“I dropped the box I was holding and thought it was because it was heavy. I didn’t realize that it was because my arm was flaccid. Right after that, I felt gravity pull the left side of my face down and my speech was garbled and slurred,” says Swanson. Despite being young — just 39 years old — she knew immediately that she was having a stroke. Swanson called her husband, who was able to figure out where she was. Then she called 911 and let the hospital know they should be ready for her. Because Swanson recognized the signs and acted quickly, her colleagues were able to administer a clot-busting drug, stopping her ischemic stroke before it caused lasting damage. “I see all kinds of patients, including some younger strokes, but you don’t ever think it will happen to you,” she says. Less than two months later, her sister-in-law, who is 38, also had a stroke without any known conditions that raised her risk. “I thought mine was a rare case until it happened to her, too. Being young doesn’t rule you out for having a stroke,” says Swanson.
More Young Women Are Having Strokes
Only around 15 percent of strokes occur in people ages 18 to 45, according to the American Heart Association (AHA). And although strokes are declining throughout the United States, strokes in young people have increased 40 percent in the past few decades, the AHA reports. Strokes have historically been, and still are, more common among older people, but a county-level analysis, published in November 2019 in the journal Stroke, found that the gap is closing. The data showed that between 2010 and 2016, strokes among middle-aged Americans increased in three times as many counties as did strokes in people older than 64. Another study, published in September 2020 in Stroke, included more than 20,000 Americans. Although strokes are typically more common in men, the researchers found that among young people ages 25 to 44, women were more likely than men to have a stroke. The data showed that women had strokes at younger ages and had fewer vascular risk factors.
Younger Women Have Additional Risk Factors for Stroke
According to Mary O’Neal, MD, the director of the women’s neurology program at Brigham and Women’s Hospital in Boston, traditional stroke risk factors still play a key role in younger patients, but young women face additional risks. “When you look at strokes in young people, the cause is usually related to cardiovascular factors. But certain autoimmune conditions, such as lupus, and migraine with aura and pregnancy can increase stroke risk for women,” says Dr. O’Neal. “So can hormonal therapy and birth control.” Hypertension doubles any person’s risk of a stroke before age 80, as does smoking cigarettes, heart disease, obesity, diabetes, high cholesterol, and not getting enough exercise, according to the National Institute of Neurological Disorders and Stroke. But certain unavoidable defects or clotting disorders may also increase a person’s risk of stroke, as was the case for Swanson, who maintains a healthy weight and doesn’t smoke or have high blood pressure or high cholesterol. While she was recovering in the hospital, Swanson’s colleagues discovered that she had a patent foramen ovale (PFO), a hole between the heart’s right and left chambers. According to the American Heart Association (AHA), about a quarter of the population have the condition, and it’s usually harmless. But the hole can provide a quick route to the brain for blood clots that cause ischemic strokes. The AHA estimates that this may account for as much as 10 percent of all strokes, and half of the roughly 30 percent of strokes that occur from no apparent cause. It’s also a likely culprit in strokes in young people. Here are some other factors that have a greater impact on women, transgender women, and people who were assigned female at birth (AFAB) than on men, and may be overlooked risks for stroke.
Lupus The autoimmune disease is nine times more common in women than in men, according to the Lupus Foundation of America. Because lupus causes significant inflammation throughout the body, people who have the disease are twice as likely to have an ischemic stroke, according to an article published in July 2018 in the European Medical Journal.Migraine with aura According to O’Neal, migraine with aura increases a person’s risk of having a stroke very slightly, but the risk factor shouldn’t be ignored. “It’s a small risk, but if you combine that with other risk factors like hormone therapy, that risk can become significant,” says O’Neal. According to the Migraine Research Foundation, women are three times more likely than men to have migraines, and during their reproductive years, as many as 43 percent of women report having migraines.Pregnancy According to the Centers for Disease Control and Prevention (CDC), stroke during or shortly after pregnancy is rare, but pregnancy does raise a person’s risk of stroke. “The things women need to watch out for are new headaches and new neurological problems, and they need to closely watch blood pressure, especially if it’s their first pregnancy or they have had preeclampsia previously,” says O’Neal, noting that high blood pressure is the leading cause of pregnancy-related stroke. Though rare, pregnancy can also trigger reversible cerebral vasoconstriction syndrome (RCVS), in which blood vessels in the brain suddenly constrict, according to the Cleveland Clinic. A hallmark sign of RCVS is a sudden, debilitating headache, and the condition is most common among females ages 20 to 50. According to O’Neal, the highest risk for pregnancy-related stroke is during the third trimester, and the risk lasts for about six weeks following delivery.Birth control Oral contraceptives that contain estrogen roughly double a woman’s risk of ischemic stroke. According to O’Neal, women are on birth control for many reasons, but if contraception is the only reason a woman is on the pill, she should talk to her doctor about nonhormonal options, especially if she has other stroke risk factors.Hormone therapy A study published in February 2019 in Stroke found stroke risk to be more than doubled in transgender women who were undergoing hormone therapy than in cisgender people. “Even for patients who are already at a higher risk of stroke, the benefit of getting hormonal therapy many times will still outweigh the concern for stroke,” says O’Neal, emphasizing that it’s important that doctors are sensitive to this.
COVID-19 May Play a Role
Although strokes among young people have been a rising trend for a few years, healthcare workers early on in the COVID-19 pandemic recognized that young patients who didn’t have any risk factors were more commonly having strokes. Research is starting to reveal that COVID-19 may cause blood clots in some people, which can travel to the brain and cause a stroke. Doctors believe multiorgan inflammation may be responsible for COVID-19-related stroke. The disease also appears to have a lasting impact on the heart. In a review based on early pandemic data, published in September 2020 in the journal Lancet Neurology, doctors highlighted that although stroke is still rare among people who have had COVID-19, the respiratory disease appears to increase some young patients’ risk of stroke when no other underlying factors are in play. The review included stroke patient data from Mount Sinai Health System in New York City, which showed that, on average, patients who were admitted for stroke and had also had COVID-19 at some point were nearly 15 years younger than those who had not been infected. The hospital also saw a sevenfold increase in strokes among patients ages 25 to 44 during the city’s two worst weeks of the pandemic. Swanson has noticed a similar trend at her hospital in Nebraska. “Time will tell,” says Swanson, noting that her input is based on her experience working as a nurse during the pandemic, rather than hard data. “But I have never seen this many strokes and this many young strokes.”
Know the Signs and Act Fast
According to a survey published in October 2020 in Stroke, one-third of young Americans don’t know all the symptoms of a stroke. Because time is crucial for treating a stroke and mitigating long-term damage, knowing the signs is very important. Use this acronym as a reminder: BE FAST. B — Balance Are you feeling wobbly or having difficulty with coordination? E — Eyes Is your vision suddenly blurred, do you have double vision, or are you unable to see in one eye? F — Face People who are having a stroke commonly experience their face drooping on one side. Trying to smile is a good test. A — Arm One of your arms may feel numb or you may not be able to move it. If you raise both your arms, one may drift downward. S — Speech Slurred speech is a telltale sign of a stroke. T — Time to call 911 If you have any of these symptoms, even if they go away, you need to go to the hospital. “There are tons of abnormal symptoms that can happen because of a stroke, so if you think, ‘Something is wrong, this is not my normal,’ it’s better to go to the hospital and be told you’re fine than not go and have lifelong disabilities from the stroke,” says Swanson.
