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Young stroke threat rising



Even under the bright lights of A+E, and the fixed stare of the experienced doctor, stroke can go undetected.

It hides behind the mask of other problems like migraine, vertigo or drugs and alcohol.

In young people, who are generally considered low risk, this deceit can be devastating.

Death or life-changing disabilities can occur – simply because signs were missed by professionals, or patients and the people around them.

Traditionally strokes were considered a disease of the retired. But NHS figures show that the number of men aged 40 to 54 hospitalised after stroke hit 6,221 last year – 46 per cent higher than in 2000. For women in that age group there was a 30 per cent rise to 4,604.

The average age of stroke is 74 for men and 80 for women, with both figures gradually reducing in recent years, despite the UK’s ageing population.

Most strokes do occur over the age of
65, but poor lifestyle choices are putting younger generations increasingly at

The situation is exacerbated by the challenges faced in spotting symptoms by both young people themselves,
and clinicians.

The push to raise public awareness centres around the FAST acronym (Face, Arms, Speech and Time to call 999).
The Act FAST campaign reportedly contributed to a 54 per cent rise in stroke related 999 calls between 2009 and 2013, leading to around 4,500 fewer people being le disabled by stroke.

This saved the taxpayer over £332.9m in the period, against the campaign’s cost of £12.5m, Public Health England said.

Slightly dubiously, it is also claimed that FAST increased the proportion of the UK population that knows what a stroke is by 20 per cent to 65 per cent. It is unclear how this figure was reached with any accuracy, but the campaign’s overriding success is unquestionable.

Would a similar campaign specifically targeting young people be able to deliver such results in the under 40s? Certainly, finding the millions of pounds needed to push it out across the spectrum of social media sites and TV platforms would be a struggle.

Expert Liz Iveson believes a better use
of resources would be to promote stroke recognition in young people among doctors in GP surgeries and on A+E wards.

The stroke consultant, who works at York NHS Teaching Hospital and Woodlands Neurological Rehabilitation Centre, says: “Often, because of the age of the patient, doctors don’t think about stroke diagnosis until they have ruled everything else
out. They may not be showing the classic symptoms, while conditions far more common in young people than stroke,
like migraine or vertigo, are higher up the check-list.

“Stroke tends to be the thing that’s thought of last by both doctors and younger patients. As a result, we see delayed presentation and diagnosis.”

Stress and alcoholism are also red herrings that might detract from a correct stroke diagnosis in young people.

Strokes which are ischaemic (due to a blocked blood vessel rather than bleeding on the brain) and occur towards the
back of the brain are particularly hard to diagnose in young people.

Early diagnosis of posterior circulation ischaemic strokes may prevent disability and save lives; but the FAST test is less useful in detecting them, while symptoms like vision problems and vertigo can easily be confused with other less serious problems.

The vast majority (85 per cent) of strokes are ischaemic. Given the life-changing damage they can cause to the brain, treatment must be carried out within a few hours if serious consequences are to be avoided.

Misdiagnosis or delayed presentation puts young people’s lives at risk or sets them up for a lifetime of severe disability.

One treatment, thrombolysis, uses drugs to break down and disperse the clot. It is only licenced for use up to four and a half hours from the onset of stroke symptoms.

Thrombectomy – a procedure which mechanically pulls the blood clot out of the brain – must also take place in the early hours after a stroke.

Every minute a stroke is untreated,
1.9 million neurons are lost. When thrombolysis is given within three hours of stroke, one in 10 patients will go on to live independently.

The speed at which patients are diagnosed and possibly taken to theatre or given drugs can be hugely significant to the outcome of a stroke.

Iveson believes the emergence of the national ‘stroke pathway’ is helping to counter the threat of late detection
or misdiagnosis of stroke among
young people.

Over the last decade, the Royal College
 of Physicians (RCP) has driven the national rollout of a clear pathway
for stroke patients within healthcare trusts. Its regularly-updated National Clinical Guideline for Stroke states that: “Commissioning organisations should ensure their commissioning portfolio encompasses the whole stroke pathway, from prevention through acute care, early rehabilitation and initiation of secondary prevention on to palliation, later rehabilitation in the community
and long-term support.”

Before this guidance was first introduced in 2008, stroke care was inconsistent across the UK, with patients being treated in a range of settings rather than on dedicated stroke wards.

Iveson says: “We’re definitely getting
better at diagnosing stroke. Because of
the pathway, the stroke team has a greater presence in A+E. If doctors are unsure about symptoms, they can ask the stroke nurse to have a look at a patient.
This pathway is pretty consistent across the country, and is supported by the ongoing audit of stroke services.

“Through the pathway, we also give feedback when stroke diagnosis has
been missed, which also ensures lessons are learned.”

Improving diagnosis will only go so far in curbing the number of young lives damaged or devastated by stroke, however.

A more challenging task is snuffing out the stroke risk factors seemingly on the rise in younger people.
“Obesity and high blood pressure are being diagnosed at a younger and younger age and therefore arteries are aging earlier than they otherwise would have. The longer you have these risk factors, the more likely you are to have a stroke.”

Being overweight increases the risk of high blood pressure, heart disease and type 2 diabetes; all of which are stroke risk factors. Overall, obesity increases a person’s risk of stroke by 64 per cent, says The Stroke Association.

Meanwhile, British Heart Foundation (BHF) figures show that five million people in England are unaware they have high blood pressure, and therefore could be at risk
of stroke.

The western world’s obesity epidemic shows no signs of slowing, and young people are just as exposed as older generations. Around a third of UK children are reportedly overweight when they leave primary school.

More alarmingly, signs of obesity-related heart damage are now being detected in toddlers.

A study of more than 400 children in Romania found changes in the structure of the heart in obese infants – including those below the age of one.

The results, presented at the European Society of Cardiology congress in Barcelona, found obese children had 30 per cent thicker heart muscle compared to those of a healthy weight.

Stroke in children is usually linked to genetics rather than other risk factors. But such reports, and the fact that overweight children are statistically more likely to be obese as adults, offer little encouragement in the push to reduce stroke in young people.

Stress is another rising risk factor.
“Stress alone increases stroke risk,” says Iveson. “Partly this is because it can lead to changes in lifestyle that increase other risk factors like high blood pressure and obesity. For example, if you’re working long hours, you might do less exercise, smoke more and eat junk food on the go. There is also a more direct link between stress and stroke, related to inflammatory markers.”

This link was only proven earlier this year, by researchers at Harvard Medical School and Massachusetts General Hospital.

The part of the brain linked to stress, the amygdala, controls the production of white blood cells by bone marrow to fight infection and repair damage.

Its function is to prepare the body for a harmful experience, such as being attacked.
Scientists discovered, however, that
chronic stress can cause this process to
go into overdrive.

White blood cells are over-produced and can form plaques 
in the arteries, heightening the risk of cardiovascular diseases such as stroke.

Although definitive evidence that stress levels in young people are on the rise is lacking, numerous studies suggest a general surge in work-related strife.

Longer working hours, tighter budgets that encourage bosses to ‘sweat their assets’ and the culture of emails on the go,
all contribute.

The uncertainty that comes with zero hours’ employment and working in the so-called ‘gig economy’ is also linked with increased stress in younger workers.

Drug use is also a stroke risk factor which may be more prevalent in the under-40s. Iveson says: “I once saw a 24-year-old who came to hospital following a stroke which was put down to his heavy cocaine use
that had effectively aged his blood vessels prematurely.”

A 2012 study found that 20 per cent
of stroke patients aged 45 or under
had used illegal drugs. More recently, research has discovered links between methamphetamine – or ‘speed’, ‘ice’ or ‘meth’ – and increased stroke risk.

Clearly raising awareness of the many
risk factors of stroke in young people,
and continuing to improve diagnosis, are mammoth tasks requiring years of e ort and focus.

Evidence suggests that post-stroke treatment must also improve, if stroke patients are indeed getting younger.

The 2016 edition of the National Clinical Guideline for Stroke reports that some younger adults feel that general stroke services – used mostly by older people – do not meet their needs.

It reports: “Younger adults are more likely
to have an unusual cause for their stroke, rehabilitation may require specific attention to work and bringing up children, and social needs and expectations may be different.

“Thus, although all stroke services should respond to the particular needs of each individual regardless of age or other factors, it is appropriate to draw attention to this group of younger people with stroke.”

It recommends that acute stroke services should “recognise and manage the particular physical, psychological and
social needs of younger people with stroke”. It also says they must liaise with regional neuro-rehab services specialising in young adult care.

Encouragingly, the latest results of the Sentinel Stroke National Audit Programme (SSNAP), which measures stroke care standards and is informed by the National Clinical Guideline, shows general signs of improvement.

In the year to March 2017, 36 teams achieved an overall ‘A’ score, indicating world class stroke service. This was up from 25 in 2016.
Improvements were noted in areas such
as rapid scanning, thrombolysis provision, and access to a stroke units.

It also cited an “unacceptable variation” in standards across the country, however.

A major concern for Iveson is the scarcity of neuropsychology services for younger stroke patients within the NHS.

“Psychology is completely underfunded
at the moment. A lot of younger stroke patients do well in terms of physical recovery but it’s very di cult to address challenges like memory problems or other cognitive issues. They would really bene t from detailed neuropsychology that could perhaps prove they can return to work or at least help them to function better.
“But they just can’t get it on the NHS
and have to apply for funding for exceptional treatment to access it through private providers.”
In fact, getting access to any neuro-rehab services in the long term is needlessly tough for younger stroke survivors, Iveson says.

“In younger patients, the rest of the brain tends to be in good condition and can take over some of the functions that were controlled in the part that has died, through neuroplasticity.

“With the right rehabilitation, young stroke patients can do surprisingly well. I’ve had younger patients that have had very severe strokes resulting in a lot of brain damage, that have gone on to walk and recover speech.

“Rehabilitation is available for a reasonable time in the NHS but it’s really hard to get it for the prolonged period that many young people could bene t from.

“Unfortunately, long term support isn’t commissioned well at all. Yet younger people who’ve had a stroke may have many years ahead of them and require long-term support to help them in society, at work and in relationships.”

Having worked in the stroke field for over a decade, Iveson has witnessed great strides in the overall standard of care available to stroke survivors. She also sees significant room for improvement.

“Stroke care has improved massively in
the last 10 years but, until recently, resources have largely been concentrated on the beginning part of the patient journey, getting people into hospital as quickly as possible.

“What hasn’t been well funded is what happens after hospital when patients 
go back out into the community. That’s something that needs attention.”

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