The leading cause of death all around the world is cardiovascular disease.  Besides causing a devastating number of deaths every year, it also reduces the quality of life of the people affected by it.1 Ischemic stroke is a common type of cardiovascular disease known for its devastating long-term physical and cognitive effects. While it has been traditionally considered a disease affecting the elderly, it has become an increasing problem among young adults as well.¹ Schemic stroke can have detrimental effects on people. Since most of the information is traditionally focused on older individuals, it is important to understand how ischemic stroke affects younger adults, what are the risk factors associated and how it can be prevented.

What is ischemic stroke?

Stroke is a high-risk condition that affects around 15 million people globally annually. Out of these, around 5 million people affected have higher chances of dying, while a further 5 million may be permanently disabled. There are two major types of strokes:

• Ischemic stroke – this type of stroke is caused by a block or reduction of blood flow to the brain by a blood clot or other particles. Because of this, the supply of oxygen and nutrients to the brain is reduced, and the brain cells begin to die. Ischemic stroke is the most common type of stroke, accounting for around 87% of all strokes.
• Haemorrhagic stroke – this type of stroke is caused by an artery in the brain leaking blood or rupturing, with the leaked blood putting pressure on the brain and damaging it.
• Transient ischemic attack or ‘’mini-stroke’’ causes a temporary disruption of the blood supply to the brain and can cause similar symptoms to stroke. However, it is not a type of major stroke as it fully resolves within 24 hours.

Stroke used to be considered a disease of older people. However, the number of young adults affected by stroke has been increasing. It is estimated that between 10 to 15% of total cases of stroke affect young adults.² Furthermore, a population-based epidemiological study in Kentucky showed that the cases of stroke among adults aged between 20 and 54 increased by around 50%, from 12.9% to 18.6%, between 1993/1994 and 2005.³

In particular, the occurrence of ischemic stroke has been increasing among young adults while decreasing in older individuals. With ischemic stroke being the most common type of stroke, it is estimated that it affects around 2 million adolescents and young adults globally each year.²

The most common causes of ischemic stroke in older adults are large artery atherosclerosis and small-vessel disease; however, these 2 causes only account for between 10% to 20% of cases in younger adults.³ It seems that the most common cause of ischemic stroke among young adults is arterial thrombosis, which occurs as a result of an underlying blood clotting condition that increases the risk of blood clot formation.¹ It also appears that cardioembolism has a slightly higher occurrence (20%–47%) among younger adults suffering from ischemic stroke compared to all ischemic stroke patients (20%–25%).³ Another significant cause of ischemic stroke in young adults is extracranial arterial dissection, which accounts for 10–25% of strokes in patients <45 years old, while only for 2% of all ischemic strokes.¹

Signs and symptoms

In general, symptoms that affect young adults suffering from ischemic stroke are the same as the symptoms that affect older adults. These may include:

• One-sided weakness or paralysis
• Difficulty with speech (aphasia)
• Slurred speech
• Losing the ability to control muscles on one side of your face or facial droop.
• Partial or total loss of one or more senses (vision, hearing, smell, taste and touch)
• Blurred or double vision
• Problems with balance or coordination
• Dizziness or vertigo
• Nausea and vomiting
• Neck stiffness
• Sudden personality changes
• Confusion or agitation
• Memory loss
• Sudden and severe headaches
• Passing out or fainting
• Coma

Strokes are associated with certain warning signs. To recognise these signs, think FAST:

• F is for face – Ask a person to smile. Their face may have dropped on one or both sides, they might not be able to smile, or their mouth and/or eyes may have drooped.
• A is for arms – Ask a person to raise their arms, someone suffering from stroke often has muscle weakness on one side, so the person may fail to lift both arms or keep them up in the air.
• S is for speech – Someone experiencing a stroke might struggle with speech. It could become slurred or garbled. The person might struggle with speaking generally and have difficulty understanding what is being said to them.
• T is for time – if you notice these signs, then it is time to call emergency services immediately.

Risk factors for ischemic stroke in young adults

Several factors can increase the risk of having an ischemic stroke in young adults.^2,3

• Traditional cardiovascular risk factors include high blood pressure, unbalanced cholesterol levels and diabetes mellitus. Studies found that the prevalence of high blood pressure and unbalanced cholesterol levels is high among young stroke patients, 47% and 35%, respectively.²
• Lifestyle risk factors – such as smoking, physical inactivity, poor diet, heavy alcohol consumption and drug use, all of them increase the risk of ischemic stroke in young adults. The two most common risk factors in young stroke patients are smoking (56%) and physical inactivity (48%).² Additionally, a study with more than 2000 young ischemic stroke patients revealed that 32.7% were prone to excessive alcohol use, and 21.6% had a body mass index (BMI) of ≥30kg/m.^2,4 Furthermore, the use of recreational drugs amongst people aged 15-64 is increasing, with around 5% of the population using drugs at least once a year. Cocaine, amphetamine, cannabis, and opioids are all associated with an increased risk of ischemic stroke due to their effects on the cardiovascular system.²
• Pregnancy and birth control – people who are pregnant are 5 times more likely to develop a blood clot than people who are not pregnant. This is the reason why pregnancy can increase the risk of having an ischemic stroke. Additionally, using birth control containing estrogen is also associated with an increased risk of stroke. In particular, the risk increases even more if the person is a smoker.
• Blood clotting disorders – multiple blood clotting disorders can be either present from birth or develop later in life. These disorders can increase the risk of blood clot formation and, in turn, also increase the risk of stroke.
• Cancer – cancer, as well as chemotherapy and radiotherapy associated with it, can also increase the risk of stroke by causing blood clotting disorders and accelerating atherosclerosis.
• Vascular diseases – multiple rare conditions affect the arteries and increase the risk of ischemic stroke among young adults—these include:³
  • Fabry disease
  • Reversible cerebral vasoconstriction syndrome
  • Mitochondrial encephalopathy
  • Cerebral autosomal dominant arteriopathy
  • Moyamoya disease
  • Giant cell arteritis, etc.

Diagnosis and treatment

Neurological examination, brain scans and other tests can diagnose ischemic strokes. During a neurological exam, your doctor may ask you to move your arms, legs, eyes or head to observe your difficulty with these tasks.

Some of the tests your healthcare provider might order include:

• Computerized tomography (CT) scan.
• Blood tests – check clotting ability and blood sugar levels to look for infections or heart damage.
• Electrocardiogram (ECG) – to rule out a heart issue as the problem.
• Magnetic resonance imaging (MRI) scans.
• Electroencephalogram (EEG) – these are less common; however, these can be used to rule out seizures or related problems.

The treatment of ischemic stroke usually involves several different medicines, including:

• Alteplase – this is used to dissolve the blood clot and restore the blood flow to the brain. This treatment should be started as soon as possible to be the most effective.
• Thrombectomy – some cases of severe ischemic stroke can be treated by inserting a catheter into an artery, usually in the groin, to move to the artery in the brain and remove the blood clot.
• Aspirin and other antiplatelet medicines – Aspirin is an antiplatelet medicine which reduces the risk of another clot developing.
• Anticoagulants – to reduce the risk of developing new blood clots in the future
• Blood pressure medicines and statins to maintain blood pressure and cholesterol levels.

Recovery

Your recovery will depend on your age and the severity of the stroke. Your recovery will also depend on the symptoms you are experiencing; you might need help from different specialists, such as physicians, nurses, physiotherapists, speech-language therapists, social workers, and occupational therapists.²

Younger patients tend to recover faster and are more likely to achieve full recovery than older patients. However, younger patients appear to struggle more with family stress, work or school and mental health conditions like depression.²

How can it be prevented?

The effects of ischemic stroke can be devastating. Ischemic stroke is associated with up to four times higher death rates in young stroke patients compared to healthy individuals. Furthermore, up to 1/3 of stroke patients are unemployed for up to 8 years after suffering from stroke.¹ This is why it is important to prevent the stroke from occurring in the first place.

In order to reduce your risk of stroke, there are some changes you can make:^1,2

• Quit smoking
• Reduce alcohol consumption
• Improve diet – this can improve your blood pressure, your blood sugar and cholesterol levels
• Regular health checks and taking medication to regulate blood pressure and cholesterol if needed
• Try alternative birth control to the ones containing estrogen

Summary

Ischemic stroke is a devastating condition that affects not only older people but has been increasingly affecting younger adults as well. It is caused by a block or reduction of blood flow to the brain that can cause multiple symptoms. The best way to recognise stroke signs is to follow the FAST technique: check if the face is drooping on one side, check if a person can raise both arms at the same time and keep them raised, check the person's speech, and if you notice that a person is struggling with these tasks, please call for help. There are some common risk factors associated with ischemic stroke, which can be modified such as quitting smoking, reducing alcohol consumption and improving the diet.