Stroke In The Young Population (Children, Adolescents and Young adults)

The last thing Chioma remembers before waking up in the hospital was trying to fit her keys into her car trunk’s lock. She’d been shopping with a friend, and was about to put her bags away, but thought the key must be broken somehow. What seemed like few seconds later, she was face down on a gurney as doctors were testing her nerves with a pin roller. “They told me I had a stroke, but I didn’t believe that”, she recalls. “I was 28 years old. Nobody has a stroke at 28. It just seemed impossible”. That was 3 years ago, and Chioma is still having some ripple effects from her stroke.

Her doctors hypothesized that the incident was related to a small hole in her heart that she had had since birth without knowing it. Independently, that might not have become dangerous but she also had high cholesterol and was living a sedentary lifestyle (no physical activity).

Chioma’s Story

I was 17 and in senior high at my local school. I was studying for my A-levels. It was around 1 am on that Saturday when I woke up suddenly with an excruciatingly painful headache. I remember needing some water, but when I tried to swallow, the water just dribbled out of my mouth. The left side of my face felt like it was on fire and when I attempted to speak it came out jumbled! I went to walk downstairs, but I couldn’t support myself so my sister had to help me. When I got to the A&E none of the doctors knew what was going on with me. They assumed it wasn’t anything neurological because of my age so the whole time I was getting worse, with no proper intervention. After an MRI scan, I later learnt that I had suffered a bilateral brainstem stroke. It had left me completely paralyzed with only the ability to blink.

More often than not, Stroke is viewed as the diseases of the elderly even amongst medical professionals due to the increasing number of middle-aged and elderly population that turn up in the clinic presenting with its symptoms and cardinal signs at onset. That is fast becoming a myth which is proven otherwise by the rising incidence and prevalence of stroke in the younger population of age bracket 18-45 even in children and newly born babies. The young adults have nonchalant attitude towards certain screening tests, thinking that they don’t need to be done until they’re older. Such tests for cholesterol, blood sugar, blood pressure gives a good idea about stroke risk. Lack of physical activity is a major risk factor for stroke.

Compared to years ago, the incidence of stroke is rising in young adults to a significant degree. A study found out that Ischaemic stroke hospitalization rates are increasing for both men and women under age 45.

• In women aged 18-34, the hospitalization rates rose 31.8% (from 4.4/10,000 to 5.8/10,000 hospitalizations in 2003-2004 and 2011-2012 respectively)
• In women aged 35-44, the hospitalizations rates rose 30% (from 27.5/10,000 to 35.8/10,000)

One factor for women in this study might be the use of contraceptive which is one of the methods of birth control and have been associated with a slightly increased risk of blood clots – and blood clots account for 87% of all strokes. Also, the act of smoking in the younger population can also be a contributive factor. However, stroke occurrence is likely due to a large increase in the common stroke risk factors like lack of physical activity, hypertension, diabetes, obesity, lipid disorders(high cholesterol), drug abuse and tobacco use. The same risk factors that are booming in young people are usually being managed in those over age 50. Older adults expect to have these kinds of issues, so they get screened and are well informed on how to prevent complications that are likely to arise. But someone in her twenties usually doesn’t think about something like blood pressure unless there’s a problem.

Asides from the aforementioned factors, strokes in young individuals are usually overlooked because of their presentation which differs to that in an adult. Although the classic acronym for spotting a stroke is FAST (that is Facial drooping, Arm weakness, Speech difficulties and Time to call for an emergency/rush to the hospital as the case may be), time is crucial because anti-stroke medication must be given within about 4 hours of stroke onset to prevent permanent disability or death. But according to Dr Greene-Chandos (a Medical Doctor, director of Neurocritical care at The Ohio State University Wexner Medical Centre) – he said: ‘not all strokes look like a classic FAST incident. Older adults tend to be affected in larger blood vessels making them more likely to have the “the big stroke symptoms” like facial drooping and incomprehensible speech while younger adults are more likely to have clots thrown from other areas of their bodies and those clots travel through smaller blood vessels’. This difference often leads to stroke symptoms like numbness or a headache. People tend to shake off these signs because we’ve all had numbness from sleeping in a funny position or sitting on a leg or an arm wrongly. Some women having a stroke are also more likely to have debilitating headaches; therefore people who suffer from regular migraines are also at a risk for strokes in general. Even hiccups that don’t resolve could be a stroke symptom.

Fortunately, stroke occurrence in children and adolescent are not as high as the rate of occurrence in young adults and the older population. However, they cause significant morbidity and mortality [2, 3]. Diagnosing stroke early in children requires the utmost attention as the burden of stroke in children is likely to be greater than in adults because children surviving stroke will have more years living with functional limitations and disability. The good news about stroke occurrence in children is that children’s brain is developing and may be more plastic than those of adults, so physiotherapy is helpful, however motivating them to do their therapy may be a challenge. They may not want to do their therapy or take their medications because they don’t see other children doing those things. Adolescent survivors have to deal with the challenge of returning to school, having to catch up with their peers because they’ve likely missed classes due to hospitalization.

According to the fact sheet from stroke studies in children, it revealed:

• Stroke as amongst the top 10 causes of death in children with the highest mortality in the first 12 months of life.
• The incidence of stroke around 2 per 100,000 populations and affects 1 in every 2,300-5,000 newborns. 5,6
• 20-40% of children have recurrent strokes. 7
• The causes and outcomes of childhood stroke are poorly understood with little-published research. However data emerging from the international paediatric stroke registry suggests that ½ of the cases are due to blood vessel problems in the brain, ¼ are due to clots travelling from the heart, but no cause can be found in another ¼ of children.

But the key issues for stroke occurrences in children are but not limited to:

• The lack of awareness amongst the community and primary care doctors about childhood stroke
• Delayed recognition of stroke in children, hence inappropriate intervention
• Lack of understanding about the causes of stroke
• Poor Rehabilitation procedures to prevent further strokes

The risk factors in children are largely different from those in adults. They include pregnancy complications, difficulties at birth, blood clotting disorders and heart problems.

According to the Canadian Paediatric Ischaemic stroke registry, it estimated an incidence of ischaemic stroke of 3.3 per 100,000 children per year. In California, a retrospective study analysis recorded 2.3 per 100,000 children per year and a prospective study across Ireland and UK reported an incidence of stroke of 2.5 per 100,000 children. 10. There are scant data from the developing world where the epidemiology is likely to be different, both in terms of incidence but also in terms of the demographic characteristics of the patients and the profile of risk factors seen in them.