Last fall, Aaron Parker was doing carpentry on a job site when suddenly his right arm stopped working. It was a strange sensation, like a drill that had lost power, yet the tool that was failing him was his own body. Before he knew it, he hit the ground. Lying in a ditch with a concrete wall, he wanted to call out to his coworkers for help but he couldn’t speak. The thoughts were there, yet the circuitry between mind and mouth had shorted out. “If I’d had time to be scared, I would have been,” says Parker (not his real name). “I remember thinking, ‘You’re not going to die here—get up.'” He managed to slide himself up the wall and after about five minutes he started to get his voice back, but it was different. It came out like a bear’s growl, roughly forming the words. Still, a coworker heard him and rushed over to help. A ride to the emergency room at Kingston Hospital ensued where tests confirmed that he’d had a stroke due to trauma to his left carotid artery. Parker was only 47. Ten days earlier, he recalled, he’d visited a chiropractor who had given him a forceful neck adjustment. Not long after this experience, he’d noticed that his left eye was droopy and tearing—a sign, he learned later, that a stroke was coming. A sign so subtle that he had missed it altogether.
A Younger Disease
The nation’s third leading cause of death and the first leading cause of disability, stroke is not just a disease of the elderly—in fact, it is becoming less so every year. Statistics show that the mean age of stroke incidence is declining and is 69 (down from 71 in the mid-1990s). Stroke occurrence in people under 55 is on the rise at 19 percent. Partly, credit is due to increased stroke awareness, faster response time, and improved diagnosis, with better technology and sharper imaging. Some individuals can connect their stroke back to uncommon origins like an underlying blood clotting disorder, sleep apnea, oral contraceptive use in women, or, in the case of Parker, a particular trauma to the neck (even craning your neck to paint the ceiling or tipping your head back for a salon shampoo can cause injury). Yet in a great number of cases, our unhealthy lifestyle is to blame. Earlier onset of diseases like diabetes, obesity, high blood pressure, and high cholesterol may have a lot to do with the fact that nearly one-fourth of strokes occur in people under 65 these days. High blood pressure is the single most important risk factor for stroke, while the risk of ischemic stroke (or stroke due to arterial blockage) for smokers is double that of nonsmokers.
“I think we’re seeing hypertension at a younger age,” says Ramandeep Sahni, MD, assistant director of the stroke program at Westchester Medical Center. “Young patients always feel like they’re healthy, and blood pressure is a silent killer.” Recreational tobacco, alcohol, and drug use are also culprits in stroke for younger people, who perhaps feel more invulnerable than they should to health threats like stroke and heart disease. Unexpected “brain attacks” do happen, often when people are feeling fine—though younger patients tend to have milder strokes with less incidence of disability or death. Says Sahni, “Elderly patients do have the most severe strokes. The younger ones can have more subtle symptoms, and we actually do see them on their first stroke these days. Part of this has to do with the stroke centers implemented in the 1990s. Acute care for stroke has changed and now many patients are immediately brought to hospitals that are designated stroke centers instead of to the nearest ER.”
Time Is Brain
Parker was lucky—two of his coworkers were volunteer firefighters and they knew that with stroke, as neurologists say, “Time is brain.” The faster a medical team can treat a stroke, the more cerebral tissue they can save. With a police escort, one coworker drove Parker to the hospital, where doctors diagnosed a carotid dissection—the inner lining of the artery in his neck had peeled away, creating clots that blocked blood flow to the brain. A few hours later, he was transferred to Albany Medical Center, a designated stroke facility, where physicians threaded a stent into the ailing artery via an incision in his groin. “It was a very unnerving operation,” says Parker. “I was awake and could feel the stent being placed right under my ear. I could hear it there.” Following an intensive care unit stay of a few days, he was sent home with three or four blood thinners, including one to inject in his stomach twice a day. Yet six days later, he had another stroke—a bleeder. The stent had occluded. Back to the hospital he went, this time for three-and-a-half weeks. After some debate about bypass surgery, nonintervention was the decided route and he went home to recover. Fortunately, he suffered no permanent disability from the ordeal. Yet poststroke, he’s not quite the same person. “I’m a little more jumpy, not as easygoing as I was,” says Parker. “I can’t focus as well as I used to. Everything is more intense.”
The decision about how to treat a stroke can vary depending on the type of stroke and the presentation of symptoms. Nine out of ten strokes are ischemic, while only one in ten are hemorrhagic, caused by a blood vessel that leaks or bursts. With ischemic strokes, a lifesaving drug called tPA (tissue plasminogen activator), introduced in the 1990s, can dissolve a clot that’s leading to thrombosis and restore blood flow. Yet the drug must be administered within a small window of time, only three to four hours. Since stroke symptoms are often unmistakable—such as a sudden loss of movement, sudden trouble speaking, sudden paralysis or numbness on one side on the body, or sudden trouble seeing with one eye—many patients do make it to the hospital in time for this gold-standard treatment. Yet the signs are not always as pronounced, especially in younger patients. “People have to know that stroke symptoms can be subtle and are not always severe,” says David Ober, MD, of Rockland Neurological Associates in West Nyack. “Most strokes don’t cause any pain. If someone just has numbness or tingling they might pooh-pooh it, but this isn’t a good idea, especially if they have risk factors like high blood pressure or high cholesterol.”
Lucky Stroke
When Andrew Revkin suspected that his subtle symptoms indicated a stroke, he didn’t waste any time. It was Fourth of July weekend in 2011 when Revkin, an environmental reporter for the New York Times and a resident of Garrison, was experiencing vision problems in his left eye after a tough run in the woods with his teenage son. “When I got home, initially I was still in slo-mo mode,” says Revkin, then 55. “But I had a lucky moment of deciding ‘maybe this is a stroke’ and taking five or six baby aspirin [a good idea for ischemic stroke, but not for hemorrhagic].” He headed to Hudson Valley Hospital, which, though a designated stroke center, didn’t have a stroke neurologist on site that holiday weekend. The ER doctor almost sent him home but Revkin, trusting his instinct that something wasn’t right, requested an ultrasound of his carotid arteries. That’s when a technician discovered that he had no pulse in his left carotid artery.
How could his brain be working without this crucial vessel? The answer lies in an anatomical wonder called the Circle of Willis—an arrangement of arteries in the brain that creates collateral circulation so if one artery is compromised, the others can compensate. Like Parker, Revkin had a carotid dissection; the stroke hadn’t struck yet, but it was coming. Transferred to Westchester Medical Center, he was put on intravenous heparin to prevent blood clots, though perhaps too late. He suffered a mild stroke that night and spent a week recuperating in the hospital, then went on to make a full recovery. Says Revkin, “It was like peeking through the door of a very dark place, and getting to shut the door very quickly.”
Wondering why had he suffered a stroke so young, the reporter in Revkin kicked into gear: He spent his week in the hospital researching and blogging. He learned that carotid dissection is a relatively rare form of stroke, but for youngish, healthy people without common risk factors, it’s often a suspect. He also learned about some of the most cutting-edge technology available for stroke: telemedicine. Similar to Skype, telemedicine is virtual care from an expert physician who doesn’t need to be in your emergency room to be helpful. At least three American companies have developed technology for telemedicine administered through various devices, from robots to iPads. Unfortunately, says Revkin, “this country doesn’t have policies that are friendly to telemedicine. It’s particularly important in stroke, because most of the diagnosis is done visually. So if it’s Fourth of July weekend in the Hudson Valley and there’s no stroke neurologist at the hospital, you can still have someone there.” What good is this money- and time-saving technology if it’s not widely available to help patients? “My main concern is that as much can be done as possible to change policies that get in the way of rapid diagnosis and treatment.”
Before Stroke Strikes
We’ve come a long way with stroke care, but there’s more work to be done. For now, one key to combating stroke is vigilant awareness—and, like Revkin, listening to your body and acting swiftly. “Often a patient is well aware when the symptoms start but then waits and thinks they’ll get better, or goes back to bed, or doesn’t listen to their wife,” says Sahni. “Even if it does get better it could be a TIA [transient ischemic attack], and if you have a TIA your highest risk of stroke is in the next 48 hours.” There is also the empowerment of knowing that, according to the American Stroke Association, about 80 percent of strokes are preventable. “We often have patients who know they’ve had high blood pressure for years and didn’t do anything about it, and now they have a devastating bleed in their head,” says Sahni. “Or they’ve been a smoker their whole life, but they’re going to stop smoking now that they’ve had this stroke and they’re paralyzed on one side.” Note to self: Don’t skip the annual physical. “Even if you feel healthy, you should always make sure your blood pressure is okay, your blood sugar is okay. You can’t control the fact that you’re going to get older, but there are other things you can control. You can commit yourself to having a healthy lifestyle.”
Resources
Ramandeep Sahni, MD (914) 345-1313
David Ober, MD (845) 353-4344
Andrew Revkin Twitter @revkin and @dotearth
This article appears in August 2013.
