Discoveries Magazine

Cedars-Sinai

Unbreakable

Chelsy Colangelo knows her brain is dying.

“I’ve had a stroke! You have to help me!”

stroke1

Chelsy Colangelo, 29, had worked a shift behind the bar at her neighborhood Marie Callender’s the night she was blindsided by a stroke. Photo: Max Gerber

But the plea collapses before reaching her lips. Instead, Chelsy’s frantic thoughts spin circles in a smoldering maze of circuits in her brain — only to crash, crumble, or vaporize in the glare of emergency room lights. Her brain is dying, and no one knows but her.

The doctor in the small community hospital thinks she may be drunk, or perhaps drugged. Otherwise why would a seemingly healthy 28-year-old woman collapse in a bar at 11:30 at night?

Tests. Wait. Exams. Wait. Lab work. Wait for results.

Chelsy spots a clock on the emergency room wall, where harrowing seconds and then minutes tick away, casually, methodically, defiantly. Terrified that the window of time to save her brain is closing, still unable to form words, she repeatedly points to the clock.

Now 29, Chelsy is 40 years younger than the average stroke sufferer’s age. But today strokes are occurring earlier in life than ever before. According to a 2012 Neurology article, the average age of stroke onset was 71.2 in 1994, but 69.2 by 2005. The study also found that 19 percent of all strokes — nearly one in five — occur in people younger than 55. That’s a 6 percent increase over the study’s 11-year span.

“We have to stop thinking of stroke as a disease of only the elderly,” says Patrick Lyden, MD, chair of the Department of Neurology, director of the Stroke Program, and the Carmen and Louis Warschaw Chair in Neurology. “Stroke is still more common among older people, but the greatest increase has occurred in the middle-aged and pre-retirement group. A stroke can happen at any age.”

Dr. Lyden calls the increase alarming because stroke is the No. 1 cause of adult disability. According to a 2014 article in the journal Stroke, 32 percent of young stroke patients — those 18 to 50 — need long-term assistance with daily activities or even lose the ability to live independently.

“Strokes in younger people, who are in the prime of their productive and wage-earning years, put enormous strains on families and society in a one-two punch: Just at the time patients lose their ability to make a living — temporarily or permanently — they are hit with the costs of acute treatment, rehabilitation, and, often, long-term care.”

The trend is alarming but not entirely surprising, according to Dr. Lyden and Laurie Paletz, board-certified registered nurse, public health nurse, and coordinator of the Stroke Program at Cedars-Sinai (see sidebar on causes and prevention). The same major risk factors that lead to strokes in the elderly — such as diabetes, obesity, high cholesterol, high blood pressure, and smoking — increase risk at any age. Many young people were introduced to a steady stream of high-calorie, high-sugar, low-nutrient fast foods at an early age, giving them a head start on stroke-producing habits.

“We tell our doctors to be on the lookout for stroke in young people because it often isn’t the first thing people consider.”
— Shlee Song, MD

“We’re seeing 24-year-olds with high cholesterol levels because they’ve been eating fast food for years,” says Paletz, who often presents stroke awareness information at health fairs and community events. “We have to get the message out to young people that strokes do happen, and choices they make can affect their risk.”

To the traditional risk factors, add a few that affect younger generations in particular, such as hormone fluctuations from birth control pills or pregnancy, undetected heart defects, drug abuse, and brain artery injuries called dissections.

Some risks are well-documented. Others — including migraine headaches, the use of some over-the-counter dietary supplements, and the consumption of sodas and even diet sodas — are increasingly seen by stroke experts in clinics, Dr. Lyden says, although solid scientific evidence is only now taking shape and more research is needed.

“It is important to note that not every stroke is preventable or caused by poor health habits,” he adds. “Chelsy was fit and athletic, but she had a stroke anyway.”

Chelsy learned the symptoms of stroke while earning her bachelor’s degree in sports medicine at California State University, Fullerton, where she also received a bachelor’s degree in radio, television, and film. She graduated in 2012 but continues working as a bartender at her neighborhood Marie Callender’s. She loves the job, the pay is good, and she has a group of loyal customers who can’t mistake the hearty laugh and good-natured energy that is delivered with their drinks.

She is outgoing and active, a Boston Red Sox and New England Patriots fan who played competitive softball in her adolescent years.

Chelsy had worked a shift at the restaurant that night in December 2014 before meeting a few friends at a bar for a drink. After sipping a beer, she excused herself to go to the restroom.

“My brain got fuzzy and I couldn’t open the stall door,” she recalls. “I couldn’t move my left hand. I thought: ‘What the heck is going on?’ It was really scary. I slid under the door, went out to my friends, and paid my tab. But when I tried to sit on the chair, I collapsed.”

stroke2

Cedars-Sinai’s stroke team was able to save Chelsy from grave disability. Although she is frustrated at the halting pace of recovery, she has returned to the job she loves, where she can work on improving her speech and movement. Photo: Max Gerber

Paramedics arrived quickly after the 911 call, but they took Chelsy to the closest hospital instead of one that specializes in stroke care.

“It’s a tough job for an emergency room doctor because they have to be a jack-of-all-trades, thinking of all the common ailments from gastrointestinal issues to heart attacks, strokes, toxicities, and drugs. A 28-year-old usually does not present with a stroke, so it probably didn’t even hit the community hospital’s radar,” says Shlee Song, MD, associate director of the Cedars-Sinai Stroke Program and director of the Vascular Neurology Fellowship, which trains the next generation of stroke experts. “We tell our doctors to be on the lookout for stroke in young people because it often isn’t the first thing people consider.”

In a study published in the Journal of Stroke & Cerebrovascular Diseases, investigators at Wayne State University/Detroit Medical Center found that eight of 57 stroke patients between 16 and 50 years of age were initially misdiagnosed. All eight were evaluated at hospitals that were not certified Primary Stroke Centers, and seven were actually discharged from the emergency department before the correct diagnosis was made.

“Our study demonstrates the increasing need for ‘young stroke awareness’ among emergency department personnel,” the authors wrote. “Initial misdiagnosis can potentially lead to a lost opportunity for thrombolysis — administration of a drug that dissolves clots — in otherwise good candidates.”

It also demonstrates the need for more research. One promising study shows that when the clot-busting drug called tissue plasminogen activator, or tPA, is given within about three hours of the start of an ischemic stroke — by far the most common type, caused by narrowing or blockage of an artery — the stroke’s effects may be completely reversed. In fact, giving tPA increases the number of strokes cured by 11 percent, according to Dr. Lyden, who was a key contributor to the pivotal clinical trial that led to Food and Drug Administration (FDA) approval of the drug in 1996.

But stroke treatments — with tPA or new devices that in some cases can be threaded through blood vessels to grab and remove a clot — only work if they are started before too much irreversible damage is done.

In her community education programs, Paletz urges people to learn the symptoms of stroke and realize that “time is brain,” and time lost is brain lost.

A friend and colleague of Dr. Lyden’s — Jeffrey Saver, MD, director of the Stroke Program at UCLA — published results of a systematic literature review in the journal Stroke in 2006: “The typical patient loses 1.9 million neurons each minute in which stroke is untreated,” he wrote.

Chelsy had been staring at the emergency room clock for an hour when her mom, Kathy, arrived.

“I took one look at her and said to the doctor, ‘She’s had a stroke,’ and he said, ‘No, no. I don’t think so.’” I called her father and said, ‘Get down here. This is serious,’” Kathy recalls.

Precious hours crept by. The doctor came and went. Nurses shuffled in and out. Exams were done. Tests were ordered. Blood was drawn. Still no answers.

In the early morning hours, results of a CT head scan looked abnormal, and a follow-up CT with contrast — which provides greater detail — was later performed. The first piece of Chelsy’s puzzle finally started to come into focus: Blood and oxygen were choked off from a large area on the right side of her brain.

As dawn began to break, the emergency staff scrambled to make plans to transfer Chelsy to Cedars-Sinai, a Comprehensive Stroke Center with advanced technology and experts available around the clock every day of the year. Chelsy’s father, Tom, went with her in the ambulance, and a large stroke team, led by Dr. Song, met them at the Neuroscience Intensive Care Unit at 8:27 a.m. — nine hours after her collapse and well beyond the traditional treatment window.

“We know the brain can create new connections, and this is especially true in young people. Sometimes we see amazing recoveries.”
— Michael Alexander, MD

But neurosurgeon Michael Alexander, MD — professor and vice-chair of the Neurosurgery Department, and director of the Neurovascular Center — wasn’t ready to give up. An expert in the use of innovative instruments guided through blood vessels to the brain, Dr. Alexander currently leads a large clinical trial studying an angioplasty balloon and stent system that opens plaque-narrowed brain arteries. Interventions in the brain are trickier than similar treatments for clogged heart arteries because the less muscular, more delicate arteries of the brain are especially vulnerable to nicks and tears.

Beginning at 9 a.m., he used 3-D angiographic imaging to confirm the presence of a clot in the territory fed by the right middle cerebral artery. He maneuvered a state-of-the-art “thrombectomy” device through vessels to grab the clot and take it out, and blood flow was fully restored by 10:15 a.m.

“At first, Chelsy literally could not speak,” Kathy recalls. “She couldn’t write the alphabet. Zilch. But by the very next day, she could write the alphabet with only three mistakes — that’s how quickly she was making progress. We used pictures to figure out what she was communicating because her words would come out randomly. She couldn’t speak on command.”

After three days in the Neuroscience Intensive Care Unit, Chelsy transferred to the Stroke Recovery Unit, but only for the weekend. She started inpatient rehabilitation Monday morning and went home 12 days later to continue outpatient physical, speech, and occupational therapies. Kathy estimates her vocabulary consisted of about 20 words. The first word she spoke: “mom.”

Three months later, Chelsy was back at work.

When a patient like Chelsy arrives at Cedars-Sinai, the code brain team’s first priority is confirming the diagnosis and taking action to quickly open the vessel. When the immediate crisis is resolved, neurologists and other experts search for causes or contributing factors to help prevent a recurrence.

During the intensive exams Chelsy underwent following her stroke, doctors discovered a congenital heart defect. In March, she returned to Cedars-Sinai, where cardiologist Saibal Kar, MD, director of Cardiovascular Intervention Research, performed a minimally invasive procedure to repair it.

“We don’t know for certain where Chelsy’s clot came from or how it ended up in the artery in her brain, but a hole between the two upper chambers of her heart — an atrial septal defect — is one possibility where a clot could have passed through to get to the brain,” Dr. Song says.

Normally, oxygen-depleted blood from the veins flows into the right atrium and goes out to the lungs. The left atrium then pumps oxygen-rich blood to the body. But if a hole exists between the chambers, a clot that comes in with the venous blood flow can enter the left atrium and quickly be pumped to the brain.

A similar heart defect that increases the risk of stroke is called a patent foramen ovale (PFO). A small hole that allows blood to flow between the atria in the fetus should close at birth, but in about 25 percent of people, the flap fails to seal properly. This defect usually causes no symptoms or consequences, but the gap can allow an otherwise harmless clot to be pumped to a brain artery. PFOs are found in about 40 percent of patients who have strokes of unknown cause, and although PFO-related strokes can occur in the older population, they are more commonly seen among younger patients.

Chelsy had several other risk factors, including using birth-control pills and having a job that required standing for long periods of time. Birth-control pills alter hormone levels and increase clotting risk. Long stretches of sitting or standing in place can contribute to formation of clots in deep veins, usually in the legs. This type of clot, called a deep vein thrombosis, or DVT, is more common in older people, but the young are not immune. Dr. Song theorizes that the combination of these two could create “the perfect storm” to bring on the stroke.

Yet another scenario — the likeliest one, in Dr. Alexander’s view — holds that Chelsy had a spontaneous tear, or dissection, in her brain artery that December night. Arterial walls consist of three layers — inner, middle, and outer. If the inner layer tears and separates, the damaged tissue can obstruct blood flow. But even if the artery stays open, the body tries to heal the injury by initiating a cascade of events that leads to clotting.

“Where there is a dissection, there is clotting, and the end result is often a stroke,” Dr. Song says. On the other hand, she adds, arterial tissue is so fragile that even emergency clot-removing intervention can lead to a dissection. “It isn’t always possible to know which came first, but we are sure that without the intervention, Chelsy would have had a much different outcome.”

Dr. Alexander says Chelsy’s youth is on her side. “We know the brain can create new connections, and this is especially true in young people. Sometimes we see amazing recoveries. At the very least, we hoped to prevent significant swelling in Chelsy’s brain and give her a fighting chance.”

Chelsy regained about 70 percent of her vocabulary within a few months. One day she went in for lunch at the Marie Callender’s where she used to bartend, and her boss said, “You’re doing great. You can come back to work now.”

“Her regular customers have been like one huge supportive family,” says Kathy. “That has been a big help.”

Chelsy says everyday activities like counting money or texting remain tough. She feels frustrated when she has to pause for words or when she utters them out of order or not in the tense she intended. But going back to work was good for her rehabilitation.

“I’m moving and I’m talking to people, which helps my speech. But it’s hard now,” admits Chelsy, who sometimes stops in mid-sentence to say, “I can’t say it.” It’s easier when she slows down her speech. She sometimes questions the progress others see in her recovery, but then laughs about her own impatience.

Physically, she’s strong. She can bowl and golf with no problem. And although she hasn’t regained normal sensation on her left side, she has learned to adapt. At work, Chelsy carries trays of drinks on her left hand and serves with her right. But since she can’t feel the tray, she uses her eyes to track its position.

The words “at work” are a key part of Chelsy’s story, says Dr. Lyden: “Her stroke was quite severe, and it would not have reversed without intervention. If she had not been treated, she would be gravely disabled and probably living in a nursing home today, if she lived this long.”

Dr. Lyden acknowledges that scientists don’t know all the reasons for the increased incidence of stroke among younger people. Dozens of rare causes may be to blame, but arterial dissections are definitely a significant factor.

Unlike Chelsy’s probable dissection, which occurred within the more protective confines of the skull, many are found in an artery of the neck. In a small number of cases, an underlying connective tissue disorder contributes, but dissections can occur spontaneously, for no apparent reason. Spontaneous dissections are estimated to cause only about 2 percent of all strokes — but possibly up to 25 percent of those in people of young and middle age.

“I think many Baby Boomers are hesitant to accept the physical limitations of getting older,” Dr. Lyden says. “I’ve treated men in their 50s who fell while surfing, skiing, or playing basketball and suffered strokes caused by arterial dissections. With more people remaining active — and maybe imagining themselves eternally young — we’re seeing more injuries, more dissections, and more strokes.” He adds that even yoga moves, chiropractic manipulations, and leaning back into a beauty parlor sink have been known to precede dissections.

According to Dr. Lyden, another insidious risk factor is the migraine headache. While risk is only slightly increased and the reasons are unclear, experts are seeing more migraine-related strokes — especially when the headaches include visual or other sensory disturbances.

“Headaches go by different names, such as tension, sinus, and cluster, but any headache that occurs regularly — weekly, monthly, or four or five times a year — is a form of migraine, and migraines cause chemical changes in the brain that we believe increase risk for stroke,” Dr. Lyden says.

A 2007 study found that using cocaine or methamphetamines increases stroke risk — and the rising abuse of these substances is leading to more strokes among young people. A study presented at the 2013 International Stroke Conference also showed a strong link between marijuana smoking and suffering a stroke. And although there are claims that marijuana can actually improve stroke recovery, a recent report published in Stroke shows a causal link between marijuana use and the incidence of stroke.

“We still have much more to learn about many of the substances we ingest and their impact on stroke risk.”
— Patrick Lyden, MD

Dr. Lyden cautions that drugs don’t have to be illegal to be ill-advised. Synthetic marijuana, sometimes referred to as “spice” or “legal weed,” can be found in the guise of potpourri on store shelves, although federal and many state regulations have been enacted to prohibit the sale or possession of some synthetic substances. A report by the Substance Abuse and Mental Health Services Administration linked synthetic marijuana to 11,406 emergency department visits in 2010. That number more than doubled to 28,531 the following year. Adverse effects included severe agitation, anxiety, nausea, vomiting, racing heartbeat, elevated blood pressure, tremors, seizures, hallucinations, paranoid behavior, unresponsiveness, and even death.

Recently, concerns have been raised about weight-loss and energy-gain dietary supplements with a so-called natural ingredient that contains the chemical BMPEA, which is considered nearly identical to amphetamine. The Canadian government removed such supplements from stores and issued a health alert to consumers: “Amphetamine stimulants can increase blood pressure, heart rate, and body temperature; lead to serious cardiovascular complications (including stroke) at high doses; suppress sleep and appetite; and be addictive.” In the U.S., the FDA has yet to recall the products or issue a public health alert.

Dr. Lyden says even common health food store products and energy drinks can contain ingredients mimicking the effects of amphetamines. “Guarana, ginseng, and gingko can affect heart rate, blood pressure, and blood clotting. For healthy people, and in limited amounts, herbs may be harmless or even beneficial, but people with medical problems and those taking other medications should be especially wary.”

Even those innocent-looking cans of soda in your refrigerator may not be so harmless.

“Surprisingly, a recent study found an association between daily drinking of soda — even diet soda — and increased stroke risk,” Dr. Lyden says. “The research appears sound, although it needs to be substantiated in larger studies. All of this evidence seems to underscore two things: There’s something to be said for moderation, and we still have much more to learn about many of the substances we ingest and the impact they have on stroke risk.”

Chelsy’s family is set for a cruise to Alaska soon — consolation for the Christmas missed when attention was focused on her survival and recovery. She looks forward to baseball season and hopes to find time to catch a Red Sox game or two on TV.

Chelsy’s strides toward recovery have taken a family team effort with Kathy often at the center. When Chelsy falters in finding a word, Kathy assists, but she also encourages her daughter to push herself to complete her own sentences. What Chelsy learns in rehabilitation, she practices with her mom at home. And when her daughter feels discouraged, cheerleader Kathy provides perspective.

“Chelsy doesn’t see the recovery as much as the rest of us do, and ‘patience’ is not one of her words,” says Kathy. “But the brain is such an amazing thing to behold.” She wraps an arm around her daughter’s shoulder and adds: “After just a few months, look at you! I just can’t get over it.”

  • The average stroke lasts 10 hours
  • 25% increased incidence of stroke in those aged 20 to 64 between 1990 and 2010 worldwide
  • 80% of strokes can be prevented
  • Every hour without treatment, the brain ages effectively by 3.6 years
  • 90% of strokes are ischemic, caused by a narrowing or blockage of blood vessels in the brain
  • 10% of strokes are hemorrhagic, caused by bleeding in the brain
  • Every minute a typical stroke goes untreated, a person loses:
    1.9 million neurons
    14 billion synapses
    7.5 miles of myelinated fibers

Drop the bowl of sodium-rich, nutrient-lacking noodle soup and nobody gets hurt — or how to prevent a stroke

Your grandparents don’t have to worry about the stroke risks associated with birth control pills or pregnancy. They’re probably not involved in kickboxing, surfing, or other strenuous activities that can lead to a tear in the lining of a neck artery, which can bring about a stroke. And chances are that if a congenital heart defect was going to allow a clot to travel to their brains, it would have already happened.

Laurie Paletz, board-certified registered nurse, public health nurse, and coordinator of the Stroke Program at Cedars-Sinai, says that some conditions that raise the risk of a stroke — such as heart defects — cannot be avoided or even detected, but, luckily, young people can take steps to reduce other risk factors. Many are the same health-conscious measures their grandparents have already adopted.

“We call high cholesterol, high blood pressure, and diabetes the trifecta because this combination puts people at high risk for stroke at any age,” says Paletz.

In a 2011 article in Annals of Neurology, a group of experts analyzed hospital records of young stroke patients over a 13-year span. “Hypertension, diabetes, obesity, lipid disorders, and tobacco use were among the most common coexisting conditions, and their prevalence increased from 1995 to 2008 among adolescents and young adults (aged 15 to 44) hospitalized with acute ischemic stroke.”

Paletz urges young people to review their health habits and take the following steps:

  • Avoid alcohol and drugs.
  • If you smoke, stop. And don’t assume that electronic cigarettes and “vaping” — inhaling small amounts of vaporized nicotine — are without risk.
  • If you don’t exercise, start. Aim for 30 minutes a day, most days.
  • If you eat sugary, salty, high-calorie foods, cut back — way back. Fruits, vegetables, and whole grains are a healthier foundation for your heart and brain.
  • If you get migraines or other recurring headaches, see a doctor and follow up regularly.
  • Even if you don’t get headaches, make a doctor’s appointment if you haven’t had one in a while.

“How many college students go to the doctor? They saw doctors when they were kids, and maybe they got physicals if they were involved in sports, but young adults tend to take their health for granted,” says Paletz, who chairs a task force for the national Comprehensive Stroke Centers certification program and who recently published an article on preventing strokes related to deep vein thrombosis. “Young people can have stroke risk factors and never know until it’s too late,” she adds.

Although about one-third of such stroke survivors end up with long-term disabilities, it’s not all bad news.

“When young people suffer strokes, they have healthy vessels around the dead brain tissue that can create new synapses and new fibers much faster than in elderly patients, so functional outcomes in the young population are better,” she says. “We also have new therapies that didn’t exist even a few years ago. Still, by far the best way to deal with a stroke is to prevent it from happening in the first place.”

Tags: , , , ,

Comments do not necessarily reflect the opinions of Cedars-Sinai. Cedars-Sinai does not endorse any product, service, or views posted here.

Leave a Comment