On a snowy morning in 2010, Jolene Morton headed to work early, thinking she would be safer with fewer cars on the roads. Shortly after arriving, she started slurring her words while talking on the phone and then she dropped the receiver. In a flash, everything went blank. "All I saw in my head was a dark room with dust bunnies," Morton says.
She struggled to speak as her supervisor helped her lie down on the floor. Morton, at 33, had suffered a stroke, long considered a rarity in someone so young. Ischemic strokes, which account for about 90 percent of all strokes, result when clots or fatty deposits block blood flow to the brain. Morton's doctors never found a clot, only a narrowing in an artery that feeds brain areas critical for motor control, sensory perception and speech.
Over several months, Morton, who worked at a home-nursing agency in West Chester, Pa., slowly learned how to walk, talk and feed herself again. Today she spends afternoons in bed, exhausted from seizures and chronic pain that followed the stroke.
Strokes in younger adults typically result from rare conditions, including tears in artery walls (called dissections) or defects in the heart that release clots. Strokes in older adults usually result when a lifetime of bad habits ravages the vascular system. But strokes, long on the decline among the elderly, appear to be rising among younger adults.
About 10 percent of the nearly 800,000 strokes that Americans suffer each year occur in people younger than 50, according to recent studies.
No national registry tracks strokes, leaving researchers to find trends in regional studies, hospitalization records and health surveys. But their discoveries show a troubling trend. In 2010, a study in the journal Stroke found that the stroke rate tripled in 35-to-54-year-old women between 1988 and 2004. The next year, the Centers for Disease Control and Prevention reported that hospitalizations for ischemic stroke increased by more than a third in 15-to-44-year-olds in the 14-year period that ended in 2008. In 2012, a review of hospital records in the Midwest found a 44 percent jump in strokes between 1993 and 2005 among people younger than 55. The same year, researchers at Kaiser Permanente in Northern California reported an "alarming" increase in ischemic strokes among people age 25 to 44 between 2000 and 2008.
Mary George, who led the CDC study, was troubled to see so many young stroke patients with conditions that could have been prevented or treated with medications. Nearly a third of the 15-to-34-year-olds and more than half of 35-to-44-year-olds had high blood pressure, which is the leading risk factor for stroke.
Nina Solenski, an associate professor of neurology at the University of Virginia, says that the message that exercising and eating wisely can reduce high blood pressure seems to be getting through to older people, only to be lost on the young.
When Solenski started practicing 20 years ago, she rarely saw young stroke patients. But in recent years, they have been showing up with high blood pressure, diabetes and other conditions once associated with old age. "It's actually kind of frightening," she says.
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Young men and women share the same cardiovascular risks from unhealthy behaviors. But women are more prone to migraines, and they are uniquely vulnerable to pregnancy-related complications and hormones found in birth control pills, all of which increase stroke risk.
Morton ate well and exercised, but she started smoking at 19. She got migraines soon after her first pregnancy in 2000, and had taken birth control pills and Lupron, a synthetic hormone, to control endometriosis.
Lupron comes with a warning that women with clotting disorders or a history of stroke should avoid the drug. But Morton didn't find out she was positive for factor V Leiden — a mutation linked to clotting problems — until after her stroke.
Six months later, she got pregnant. "My doctors weren't pleased about that," she recalls. Pregnancy, combined with her history of smoking, migraines and a potential clotting disorder, placed her at risk of recurrence.
At 28 weeks, Morton was put on bed rest; she delivered twins within six weeks. She slowly started feeling better, and even went back to work briefly. Then one day in the fall of 2011 she woke up feeling as though she had "been hit in the back of the head." She lost her balance and couldn't see clearly. "I went to the hospital and they said, 'Oh, you've got a migraine,' and sent me home."
Soon after leaving the hospital, Morton started having seizures. She hasn't been able to work since. She can't afford the medications to control her pain or seizures and hasn't found a doctor who can help her. "It's an invisible illness," she says. "If your ability to process information is damaged, they're so much more apt to write you off or say you have an emotional problem."
Morton, once proud to be the sole breadwinner for her family, moved her family back to her home town of Altoona, where they live with her grandmother.
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About 15 to 30 percent of stroke survivors live with permanent disabilities, according to the CDC. Previous studies found lasting disability in only 3 to 7 percent of young people, whose more resilient brains allow for better recovery. But a recent study found that 12 percent of survivors age 50 and younger failed to recover their independence after 10 years.
A major stroke can kill nearly 2 million brain cells a minute. That's why patients who receive such treatments as anti-clotting drugs within three hours of initial symptoms fare better. But the rising rates of stroke in young people and its sometimes subtle symptoms may be catching clinicians off guard.
A recent review of the hospital records of 180,000 stroke patients found that women coming to emergency rooms with complaints of headaches or dizziness were about 30 percent more likely than men with such complaints to get diagnosed with migraine or ear infection. But, compared with those 75 and older, patients younger than 45 who sought treatment for these symptoms faced a nearly sevenfold risk of misdiagnosis, according to the study, published in Diagnosis. More than a quarter of these patients returned with clear signs of stroke within 48 hours.
"We can't say with certainty that any one patient was misdiagnosed," acknowledges David Newman-Toker, the Johns Hopkins neurologist who led the study. "But we know that the risk of major stroke is greatest in the 72 hours after a minor stroke," he says.
And that's what Newman-Toker saw: Hundreds of patients who arrived at the hospital in the midst of an obvious stroke had been discharged within the previous week with diagnoses of benign headache or dizziness, suggesting that they had been having a minor stroke that was missed.
Unlike obvious stroke signs such as weakness on one side and slurred speech, headaches and dizziness can have many causes, Newman-Toker says. And stroke still strikes primarily older people, so clinicians are less likely to consider it in a young patient. "Even though we're progressively making ourselves fatter and sicker at an early age," he says, "it's the people you least suspect that are going to be missed."
Misdiagnosis is the primary complaint Kelli Smith of Cape May, N.J., hears as moderator of an online support group for young stroke survivors at StrokeNet. Two minutes after a chiropractic neck manipulation in 2009, Smith, a 35-year-old mother of two, started feeling dizzy. Glancing at her husband and the chiropractor, she saw four people. Then she passed out.
The rarity of stroke following chiropractic adjustment makes it difficult to know if the neck manipulation was to blame. Whatever the cause, Smith still suffers crippling headaches from double vision and vertigo.
Most disconcerting, Smith recalls nothing from her childhood, knows her parents by name only and can't remember the first nine years of her marriage or giving birth. She's in the midst of a divorce, but she feels lucky to be alive. Basilar artery dissections are rare but deadly: Up to 95 percent of patients die without immediate treatment. Smith is more worried about the people she counsels every day.
"I can't tell you how many times I hear stories from people who had clear signs of stroke but the doctors tell them they're too young," Smith says. Then they end up with devastating health deficits and can't go back to work but can't qualify for financial assistance to pay their bills and feed their families, she says. "It's heartbreaking."
Liza Gross, a journalist based in Kensington, Calif., blogs about science for KQED.