By Sarah Song, MD, MPH
In the hospital, my typical stroke patient is an older person — a grandparent — who has had a long history of high blood pressure, diabetes, high cholesterol, and other diseases associated with stroke. Families come in to see them, and I typically discuss treatment plans with not only the patient, but with their spouse, their children, and even their grandchildren.
Occasionally I will get called to see a young patient with stroke. These patients, though rare, are just as serious.
A new study in Annals of Neurology shows that hospitalization rates for stroke in young patients are rising dangerously. In addition, the prevalence of those stroke risk factors typically seen in older patients, such as high blood pressure and smoking cigarettes, are also rising.
Strokes are caused by either breakages of a blood vessels causing bleeding or blockages in blood vessels, usually due to blood clots and/or narrowed blood vessels. Subarachnoid hemorrhages are strokes that involve bleeding in between surfaces of the brain's lining, and are most likely associated with aneurysms.
Intracerebral hemorrhages are also strokes caused by bleeding, but the bleeding occurs directly in the tissue of the brain. Blocked blood vessels are termed ischemic strokes, because the blockage of the blood vessel leads to decreased oxygen delivery to the brain tissue in the region of blocked vessels.
These various kinds of stroke have slightly different associated risk factors, including high blood pressure, diabetes, high cholesterol, heart rhythm problems, and tobacco usage, among others.
In the new study , these three types of strokes — subarachnoid hemorrhages, intracerebral hemorrhages, and acute ischemic strokes — were examined through hospital discharge data in a database called the Nationwide Inpatient Sample, the largest all-payer inpatient care database in the country.
Patients in three different age ranges were of interest to the investigators: ages 5 to 14, ages 15 to 34, and ages 35 to 44. All hospitalizations for subarachnoid hemorrhages, intracerebral hemorrhages, and acute ischemic strokes from 1995-2008 were included. The investigators then selected two time periods to compare: 1995 to 1996, and 2007 to 2008.
The study investigators found that for acute ischemic strokes, males and females aged 15 to 44 and males aged 5 to 14, had a significantly higher prevalence of ischemic stroke hospitalizations in 2007 to 2008 than they did in 1995 to 1996.
Hospitalizations for intracerebral hemorrhages and subarachnoid hemorrhages varied slightly between the different time points, but not to the degree that ischemic stroke hospitalizations increased.
The prevalence of several significant preventable risk factors for ischemic strokes significantly increased, such as high blood pressure, diabetes, high cholesterol, tobacco usage, and obesity. In fact, high blood pressure was seen in almost one-third to one-half of ischemic stroke patients over age 15. Tobacco usage was also highly prevalent, in one-third to one-fourth of ischemic stroke patients over age 15.
Not all of the news was bad, however. Sickle cell disease, a blood disorder that can cause stroke if poorly controlled, declined over time, indicating improved care of these patients. HIV rates in males with ischemic stroke aged 15 to 34 declined over time as well, also suggesting improved clinical monitoring.
Similarly to patients with ischemic stroke, males and females aged 15 to 34 with subarachnoid hemorrhage had increased rates of tobacco usage and high blood pressure.
Despite our best efforts, the prevalence of traditional risk factors for ischemic stroke — high blood pressure, high cholesterol, smoking, diabetes, and obesity — are increasing in young people. And, while older people are improving their ischemic stroke hospitalization rates, hospitalizations for ischemic strokes in younger people are rising.
Although it is heartening to see reduction in sickle cell prevalence in children with ischemic strokes, and in HIV prevalence in young males, the overall message of this study is a warning. Stroke risk factors, such as tobacco usage and high blood pressure, are preventable and treatable.
When we reflect on stroke prevention, we must consider not just the aging population, but the younger population as well. Health risk behavior modification is important at every age, and given the personal and overall cost of having a stroke when young, striving for healthy behaviors at an early age is critical.
It is crucial for public health programs and initiatives to communicate to the public these rising trends in strokes and preventable stroke risk factors in our young population. Young people should be encouraged to eat a low-sodium, heart-healthy diet, avoid smoking cigarettes, and maintain a healthy weight. New techniques and innovative methods may be necessary to reach vulnerable younger populations who may be outside the realm of conventional public health initiatives for stroke.
For more information about risk factors for stroke: