More Young Women Having Strokes
Sometimes doctors miss the red flags.
March 4, 2012— -- In the middle of having sex with her boyfriend, Kara Jackson's* heavy breathing suddenly turned into labored breathing.
Her tongue felt swollen, like a balloon in her throat, blocking her airway. Stark naked, she bolted upright and tried to reassure her boyfriend that she was OK. But her mouth could not string together the sentence her brain was forming. "My words totally garbled, like I was tripping over my tongue," she recalls. "I tried again, but I still couldn't speak. That's when the panic set in."
She felt like crying but couldn't even do that. As her boyfriend called 911, Kara thought, I should put on some clothes before the medics arrive. But she couldn't move her left arm. Or stand up.
By the time the ambulance reached her New York City apartment building, Kara was able to speak again. But a throbbing headache had set in, one with a visual aura, as though a camera flashbulb had blinked and stayed on. She told the medics she thought she was having an allergic reaction, although to what she didn't know. Or, she speculated, it was "a really weird migraine"--but quite different from the ones she'd experienced since she was 13. "Truth is, I had no idea what was happening to me," Kara now says.
In fact, at 23, Kara had just suffered a stroke.
This past fall, the Centers for Disease Control and Prevention released a study showing an alarming rise among young adults in the number of acute ischemic strokes, by far the most common kind, in which the blood supply to part of the brain is cut off due to a blockage. From 1995 to 2008, the number of women ages 15 to 34 who were hospitalized for this type of stroke rose some 23 percent, from 3,750 a year to nearly 4,900. For the next age-group, 35 to 44, hospitalizations jumped 29 percent, from 9,400 a year to nearly 13,400. And a second study found that strokes among 20-to 44-year-old Caucasians (who are generally at lesser risk than African Americans) has more than doubled since 1993.
"This is a significant and scary change," says Brett Kissela, M.D., a neurology professor at the University of Cincinnati College of Medicine and lead author of the latter study. Stroke is commonly, and justifiably, thought of as a curse for older people: The average stroke victim is 68 years old. What's causing its rise among the young is one of the most urgent questions facing the medical community today. "The question is, are we seeing more strokes in young people or are we better at finding them?" asks Kissela. "My belief is that we're seeing more strokes. This could prove an expensive and devastating trend for society, as well as for each person who goes from healthy one second to disabled the next."
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Scarier still is how often strokes in young adults are missed--some 14 percent of the time, according to researchers at Wayne State University. Patients from that study were misdiagnosed as, among other things, being drunk, having an inner ear infection, or suffering from benign vertigo.
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"If a young person has symptoms of sudden unsteadiness, dizziness, or weakness, it's almost always considered a less dramatic event than stroke," says study coauthor Kumar Rajamani, M.D., an associate professor of neurology at Wayne State University School of Medicine.
The consequences of misdiagnosis are dire, because when having a stroke, every minute counts. "Timeliness of treatment is crucial," says Rajamani. After a stroke is diagnosed, patients generally have up to three hours (in some situations up to four and a half hours) to be injected with a clot-busting drug called tissue plasminogen activator, or TPA.
"But if the stroke is diagnosed too late, then the affected part of the brain is already dead, which is irreversible. Treatment with TPA at this late stage is futile and perhaps dangerous." And though young stroke patients can bounce back more quickly than older ones--their brains are able to compensate better for losses--they're not immune to the often-traumatic consequences.
Maureen Graves gave birth to her daughter, Simone, in September 2008. She was 38 at the time and single, living in Seattle. A nurse at the same hospital where she delivered, Maureen was soon flooded with guests and well-wishers. "She didn't sleep very much during those first couple of days," recalls her sister, Jeanne.
Before being released from the hospital two days later, Maureen started suffering from a severe headache. She was discharged, but the headache worsened. Maureen returned to the hospital's pediatric care center on Simone's third day for a routine checkup. As they were waiting for a doctor, Jeanne recalls, Maureen grew so fatigued that she lay down on the examining table to nap. "She started slurring her words. Her head was back. Her voice was barely audible," says Jeanne, who was there. On the way out of the hospital, Maureen went into the bathroom to vomit.
Yet the physician who was looking after Simone didn't seem alarmed. "I thought she was really tired. She had a headache. She hadn't eaten," says Jeanne. Yet, she admits, she was growing worried, especially as she helped her sister walk out of the clinic. "She could barely stand," says Jeanne. Just two hours later, at home, Maureen collapsed, vomited again, and was speaking gibberish.
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When the medics arrived, they asked her what year it was, and Maureen replied, "1986." She was unconscious by the time they secured her in the ambulance.
A CT scan at Virginia Mason Hospital showed a large blood clot and dangerous buildup of fluid. To relieve pressure, neurosurgeon Farrokh Farrokhi, M.D., drilled three holes into her skull and placed a tube in her brain. He then performed a craniotomy to clean the blood from her brain. "If someone over 65 came in with such a severe stroke in that area of the brain, the textbook answer would be not to operate," he says, "because the chance for survival is so slim and the chance for functional survival even less. But she was young and had a brand-new baby. We had to at least try."
Four days post-surgery, Maureen remained in a coma. "In most cases, a stroke patient should regain some function within 24 to 72 hours of surgery," says Farrokhi. Maureen had a hemorrhagic stroke, in which blood escapes from the arteries and floods the brain, acting as kryptonite to neurons, obliterating them instantly. Her stroke was so explosive that it pushed her brain from one side of her skull to the other. The doctor told her family she had a 3 percent chance of surviving. And if she did, it was unlikely she'd ever walk again. Or talk. Or cradle her baby in her arms.
On the fifth day, however, Jeanne brought Maureen's Chihuahua, Cody, into the ICU and laid him on her sister's belly. "She stroked him with her thumb," says Jeanne. Hours later she opened her eyes. "It was a freakin' miracle." A few days after that, she said her first word: "Hi."
Maureen spent the next two and a half months in the hospital, and months longer at home, relearning the simplest of tasks. Eventually, her family moved her back to New York City, her hometown, where she lives with her mother. Simone lives with Jeanne, also in New York, during the week, and Maureen sees her on weekends.
Sitting across a table from Maureen, more than three years after the stroke, she seems perfectly fine. Her conversation is lively; her wit rapier sharp. But she continues to suffer from severe short-term memory loss, chronic dizziness, and debilitating exhaustion. She still struggles in a world that often feels unfamiliar, with sounds that have become too loud, lights that are too bright, and rooms that have too many people in them to process.
Her long-term pre-stroke memory is vivid, yet she has no recollection of any aspect of her stroke. She doesn't remember giving birth to Simone, or her daughter's first step or first words. "I wasn't there for her during those critical years of her life," says Maureen. "We can't get those years back."
The damage caused by her stroke may have been worsened considerably by one fact: Most everyone she came in contact with, including medical professionals, assumed that her symptoms were just those of brand-new motherhood. "I think if someone with neurological experience had seen her, the fact that she was having speech difficulties would have clued them in that this wasn't a fatigue issue," says Farrokhi.
"Misplacing and using nonsensical words suggests brain damage."
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Farrokhi won't speculate as to what caused Maureen to have a stroke. Though overweight, she wasn't obese. Nor did she have high cholesterol, diabetes, or high blood pressure. "She had no major traumas and no indication of aneurysm," says Farrokhi. "It's impossible to predict why it happened to her and not 10,000 other women in her situation." But having just given birth is a risk factor. In fact, a CDC study reports a 54 percent rise in strokes among pregnant or post-delivery women between 1994 and 2007.
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Stroke in the young can be brought on by an injury to the neck--caused by random events such as car accidents, falls, and even certain yoga poses--which then leads to a tear in the vertebral or carotid artery. But researchers haven't seen a dramatic rise in these strokes. Many in the medical community feel the increase is in strokes caused by the collateral damage of drinking, smoking, and bad eating habits.
"The public health story here is that we're seeing stroke factors at much younger ages," says Kisella, the consequence "of this epidemic of childhood obesity and diabetes, and high blood pressure and cholesterol, that everyone is talking about." In other words, it's not just that today's young adults are fatter and sicklier than in years past.
Rather, because they are, they're more likely to die or become disabled.
What's notable to Dr. Mary George, who spearheaded the CDC study, is that these conditions--and thus stroke--are extremely preventable. Some 80 percent of strokes could be avoided with such lifestyle changes as exercising and eating a healthy diet, according to a Harvard School of Public Health study.
A stroke can be devastating at any age, but having one early in life presents unique recovery challenges. "Young people have a much longer life to live with their disabilities," says George, which may include speech deficits, paralysis in their arms or legs, or both. They may also be incapable of working, leaving them broke and dependent on others. George adds that her study "emphasizes the need for healthy lifestyle behavior from the time we are very young and then throughout our lives."
But even that doesn't provide total protection. Kara, a dietitian, knew how to eat well--and did. She is an avid runner and trained for a half-marathon; fit and toned, she says she felt very much like "a healthy person." She never used recreational drugs or smoked a single cigarette.
When Kara was discharged from the emergency room at NewYork–Presbyterian/Weill Cornell Medical Center the evening of the incident, she was given a handout about how to treat migraines. The possibility of a stroke hadn't been mentioned.
"For every young [stroke patient] like Kara who walks into an emergency room, doctors will see very many more patients with similar symptoms who aren't having a stroke," says her cardiologist, Jorge Kizer, M.D., an associate professor of medicine at Weill Cornell Medical College, who took over her care soon after her stroke. Still, he admits, "the fact that her arm went dead does raise a question as to why stroke was not considered. As does the fact that her mother had one at age 45"--something the hospital staff might have learned by reading the family and medical history form Kara filled out.
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The next day Kara told her mother, a pediatrician, what had happened, and her mom insisted that she have an MRI. The radiologist found about 10 areas of ischemia (deficient supply of blood) throughout her brain and sent Kara back to the hospital to be admitted to the stroke ward. "I felt like a ticking time bomb," she says.
So, given her healthy habits, what put her at risk? "There were several factors, actually," says Kizer, including the history of stroke in her immediate family. And, unbeknownst to her, Kara and her mother shared a common heart problem, a patent foramen ovale (PFO)--a hole between the two upper chambers of the heart--which affects 27 percent of the population.
This hole is basically a portal that seems to allow clots to get to the brain. In fact, studies indicate that PFO is often found in young people with unexplained ischemic stroke. Because Kara was straining during sex at the time of her stroke, the flap between her heart chambers may have been open, causing blood to coagulate and giving a clot the chance to travel. The same could have happened when she was running, carrying a heavy box, or even having a particularly strenuous bowel movement. "I can't prove what caused Kara's stroke," says Kizer. "But circumstantially, the cause favors her PFO."
Yet there were also other risk factors--most significantly, those debilitating migraines with auras that she suffers once or twice a month. A 2007 study shows that women who have probable migraines with visual aura are 50 percent more at risk for stroke than other women. They are at even greater risk The younger the brain, the more elastic it is and the better able to compensate for losses. if they, like Kara, take birth control pills.
Most birth control pills are estrogen-based, and doctors won't prescribe them to someone with a medical and family history like Kara's. Instead, she took a progesterone-only pill. "These are thought to be safer, but they're still very controversial, and recent evidence suggests they don't necessarily have fewer risks," says Kizer.
Kara is lucky: She has no lasting impairment. She's off blood thinners--which led to volcanic, two-month-long menstrual periods--and now takes a daily aspirin as a preventive measure. She can still run, although she's no longer medically permitted to do half-marathons. "Anyone who sees me would never know I went through this," she says.
Nor would they know how often Kara wakes up in the middle of the night and says her name out loud to make sure her speech is not scrambled, or looks closely in the mirror to check that her smile isn't lopsided--all to prove to herself that it's not happening again.
"The worst part of having my stroke?" she says. "My fear that I will have another."
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