Six years ago, Todd McGee was a lean, athletic 34-year-old working in construction and living with his wife and toddler daughter on Martha's Vineyard, where he spent summer weekends surfing. A stroke changed his life forever.
Today, with one arm useless and difficulty speaking, Mr. McGee, now 40, cannot work. He devotes most of his time to keeping as healthy as possible. Though he is able to drive and care for his daughter, now 7, everything takes longer, and he has trouble concentrating even on routine activities that others take in stride, like grocery shopping.
"I definitely wish I had my old life back, building houses and boats and surfing in my spare time," he said.
His experience, complicated by a serious delay in diagnosis, is a powerful reminder that strokes can and do happen to young people. The sooner the correct diagnosis is made, the less likely the result will be lifelong impairment.
Although a vast majority of strokes occur in people over age 65 (the risk is 30 to 50 per 1,000 in this age group), 10 percent to 15 percent affect people age 45 and younger (a risk of 1 in 1,000). A study by doctors at the Wayne State University-Detroit Medical Center Stroke Program found that among 57 young stroke victims, one in seven were given a misdiagnosis of vertigo, migraine, alcohol intoxication, seizure, inner ear disorder or other problems - and sent home without proper treatment.
"Although young stroke victims benefit the most from early treatment, it must be administered within four and a half hours," said Dr. Seemant Chaturvedi, a neurologist at Wayne State who directs the program and led the study. "After 48 to 72 hours, there are no major interventions available to improve stroke outcome."
"Symptoms that appear suddenly, even if they seem trivial, warrant a meticulous work-up," he added.
Follow-up analyses of the Detroit study showed that patients seen by a neurologist in the emergency room, as well as those who were given an M.R.I. as part of the initial work-up, were less likely to receive a misdiagnosis.
"Patients, too, should be aware of the risk of stroke regardless of their age," Dr. Chaturvedi said in an interview.
The Centers for Disease Control and Prevention have reported a steep increase in strokes among people in their 30s and 40s. A rise in risk factors - obesity, diabetes, high blood pressure and sleep apnea - and improved diagnosis account for this upturn.
But younger patients are no better today at recognizing the symptoms of stroke. "Only 20 to 30 percent of patients get to the emergency room within three hours of symptom onset," Dr. Chaturvedi said. "They tend to wait to see if the symptoms will go away spontaneously, and they show up in the E.R. 12 to 24 hours later."
A Cautionary Tale
After an intense workout in the surf the day before, Mr. McGee awoke one morning with a headache and feeling out of sorts. He went to work but came home nauseated and chilled. He assumed he'd come down with the flu his family had just had.
Then in the middle of the night, a headache he described as "the worst pain of my life" prompted a trip to the emergency room. The attending doctor thought Mr. McGee had a muscle tension headache, treated him with intravenous pain medication, handed him some pain pills and sent him home.
Embarrassed that he'd gone to the hospital "for just a headache," Mr. McGee took the pills when the pain returned the next afternoon. Soon after, he suffered what he thought were side effects from the medicine. Now he knows what it really was: a transient ischemic attack, a mini-stroke, that left him briefly unable to speak and numb on one side.
That night, he fell out of bed trying to get to the bathroom and lost bladder control en route. One arm, he found, had begun flapping uncontrollably. He returned to the E.R., where two doctors ordered a CT scan that suggested either a severe migraine or a stroke. At the time the hospital had no M.R.I. equipment, which could have revealed the real problem: a stroke resulting from a tear in the carotid artery, which feeds the brain.
By the time an ambulance and ferry got Mr. McGee to Boston, where the diagnosis of stroke was confirmed, it was much too late for the clot-busting drug tPA to ameliorate the stroke's effects; the drug must be given intravenously within three or four hours. (Although some doctors are concerned that tPA can cause fatal bleeding in a person with a torn carotid, Dr. Chaturvedi said the drug is "safe and effective" in such patients.)
Repeated blows from surfing, possibly combined with an inherent arterial weakness, are believed responsible for Mr. McGee's stroke. Other activities that can cause a carotid tear are those that involve sudden neck jerks, including scuba diving, golf and tennis, as well as chiropractic manipulation and bending the head sharply back (the so-called beauty parlor stroke).
But a majority of strokes that affect young adults result from clots precipitated by the usual cardiac risk factors: obesity, high blood pressure, high cholesterol and smoking. Abuse of alcohol and drugs are also contributing factors; among women, use of birth control pills can raise the risk of stroke. People prone to migraines also have a somewhat higher risk of stroke.
When to Act Fast
The distinguishing characteristic of stroke symptoms is their sudden onset. Thus, Dr. Chaturvedi said, no matter what a person's age, the sudden appearance of any of the following symptoms should prompt a trip to the hospital as quickly as possible.
¶ Numbness or weakness of the face, arm or leg, especially on one side of the body.
¶ Confusion, trouble speaking or understanding speech.
¶ Trouble seeing in one or both eyes.
¶ Difficulty walking, dizziness or loss of balance or coordination.
¶ Sudden, severe headache with no known cause.
Unlike a heart attack, most strokes are painless. Even if the initial symptoms dissipate they must be taken seriously.
"A CT scan doesn't show strokes very well in the first 24 hours," Dr. Chaturvedi said. He recommended that if the diagnosis is uncertain, an M.R.I. should be done and a neurologist consulted in the emergency room.
"Patients may have to be proactive and insist on a thorough work-up and ask to be seen by a neurologist, and E.R. doctors should consider the possibility of stroke regardless of a patient's age," he said.