Stroke in middle age



Did you know that middle aged Americans are the fastest rising age group for stroke risk? Let’s look at what causes a stroke and the risk factors involved, especially if you are between the age of 35 and 64 years of age.


Some statistics[1]

Annually more than 795,000 Americans have a stroke. Worse, stroke kills about 133,000 Americans each year— ranking No. 5 among all causes of death in the US—that’s approximately 1 out of every 20 deaths. We also know that stroke risk increases with age.


What is surprising to me is the increasing stroke risk in the middle age group. In 2009, 34% of people hospitalized for stroke were less than 65 years old. And according to an American Stroke Association conference presentation (no source for this), results from a national study revealed that stroke rates among young men had increased by 51 percent since the mid-1990s.[2] In males aged 35 to 44, stroke occurrence had increased by 47 percent; for females in the same age bracket it rose by 36 percent.


We’ll look closer at the risk factors a bit later.


First signs of a stroke

The first five major signs of stroke are the following:


1) sudden weakness in an arm, leg, or face (e.g. drooling, facial paralysis) that lasts longer than 10 minutes. In the case of facial paralysis, know that Bell’s Palsy (almost always temporary for weeks only) is a far more common cause of facial droop than a stroke in the brain. A brain stroke can cause paralysis to the lower face only, while Bell's palsy causes paralysis to the entire side of your face. Bell’s palsy patients cannot close their affected eyelid completely and also show paralysis of the affected forehead muscles.


2) sudden numbness in an arm, leg or your faced that lasts longer than 10 minutes


3) sudden confusion; or difficulty speaking and/or comprehending speech


4) sudden visual changes in one or both eyes; this often takes an ophthalmologist to distinguish between a stroke in the brain from a retinal or intrinsic eye problem


5) sudden balance or coordination change


A sudden severe headache could be associated with a stroke, but would not generally be the reason for a stroke work up in the emergency department.


Of course, it is best when a victim of stroke symptoms can get to an Emergency Department (ED) as fast as they can. Why? Every minute counts! The sooner you get to the ED for a computed tomography (CT) scan to rule out bleeding or masses, and get clot busters, the better your prognosis will be. It could mean the difference between complete resolution and permanent disability. That’s because after 3 hours from the onset of stroke symptoms, clot busters begin to lose their effectiveness rapidly and are not effective at all after 6 hours. The thrombolytic medicine Tissue Plasminogen Activator (TPA) works to totally reverse stroke symptoms in more than 33 percent of patients, but can also cause bleeding in 6% which worsens a stroke. As you can see, stroke prevention is super important. Let’s look further into that.


The mechanism of stroke

Let me first describe how a stroke or cerebrovascular accident (CVA) occurs. Blood supply to a part of the brain is disrupted and brain cells to die. This happens in two general ways. Clot (embolism) from the heart (e.g. in atrial fibrillation) or an artery that travels to the brain accounts for approximately 85 percent of strokes. Bleeding (hemorrhage) into the brain from a broken blood vessel (usually related to atherosclerosis, or hardening of the arteries) accounts for the other 15 percent and is considered more deadly—resulting in about 40% of all stroke deaths.[3]


A transient ischemic attack (TIA, mini-stroke) is on the other end of the stroke spectrum. It is similar to stroke but is only a short-lived (less than 24 hours) impairment of brain function that resolves without any permanent disability.


The risk factors for a stroke

Major risk factors for stroke at any age are also the major risk factors for coronary artery (heart) disease. These include:

  • Tobacco smoking. This doubles your risk of stroke

  • High blood pressure. This is caused by inflammatory foods, stressful lifestyle, smoking, obesity, and sedentary lifestyle.

  • Type 2 diabetes mellitus. This is promoted by inflammatory foods, stressful lifestyle, obesity, sedentary lifestyle.

  • High total cholesterol[4] (above 200 mg/dl) high LDL cholesterol[5] (above 100) or low HDL cholesterol (below 45). Remember: more important than the level of cholesterol are the factors that cause inflammation and sticky cholesterol.

  • Lack of physical activity or exercise. Even independent from body weight, exercise and activity is antioxidant and anti-inflammatory.

  • Obesity


The risk factors for stroke in the middle years of life are just a bit different, however.

Apparently, in younger and middle-age patients who suffer from a stroke, there is more intense pressure from swelling after the event because the brain hasn’t shrunk as it does in older people. The thought is that younger adults have less space available to alleviate this building pressure.


An interesting study[6]done on middle-age men in Eastern Europe (Lithuania) revealed that serum cholesterol and body mass index were not even related to the risk of death from stroke. They followed 2295 men for an average of 17.5 years and found it was high systolic blood pressure, diabetes, and smoking that were the strongest risk factors for stroke deaths in these middle-age men. Twenty-five percent of strokes in this age group were attributed only to hypertension and 19% of stroke deaths were attributed only to smoking.

Another similar study[7]among middle age men and women in Finland followed 8077 men and 8572 women prospectively for an average 16.4 years. It revealed that diabetes was the top risk factor for stroke, especially in women.


More risk factors to consider

There are some other factors that contribute to atherosclerosis of stroke. Some are environmental exposures; others are lifestyle habits you will want to change, especially if you are already at known increased risk for a stroke. I’ll look at these in detail, along with ways to reduce these other risk factors in my next article.


To longevity and feeling good,


Michael Cutler, M.D.


_______________________

[1] https://www.cdc.gov/stroke/facts.htm [2] Associated Press [3] https://www.stroke.org/understand-stroke/what-is-stroke/hemorrhagic-stroke/ [4] Ridker PM, Rifai N, Rose L, Buring JE, Cook NR. Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med. 2002 Nov 14;347(20):1557-65. [5] Guize L, Benetos A, Thomas F, Malmejac A, Ducimetiere P. Cholesterolemia and total, cardiovascular and cancer mortality. Study of a cohort of 220,000 people. Bull Acad Natl Med. 1998 182(3):631-47. [6] Rastenyte D, Tuomilehto J, Domarkiene S, Cepaitis Z, Reklaitiene R. Risk factors for death from stroke in middle-aged Lithuanian men: results from a 20-year prospective study. Stroke. 1996 Apr;27(4):672-6. PubMed PMID: 8614928. https://www.ncbi.nlm.nih.gov/pubmed/8614928 [7] Tuomilehto J, Rastenyte D, Jousilahti P, Sarti C, Vartiainen E. Diabetes mellitus as a risk factor for death from stroke. Prospective study of the middle-aged Finnish population. Stroke. 1996 Feb;27(2):210-5. PubMed PMID: 8571411. https://www.ncbi.nlm.nih.gov/pubmed/8571411

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