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Young stroke threat rising

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Even under the bright lights of A+E, and the fixed stare of the experienced doctor, stroke can go undetected.

It hides behind the mask of other problems like migraine, vertigo or drugs and alcohol.

In young people, who are generally considered low risk, this deceit can be devastating.

Death or life-changing disabilities can occur – simply because signs were missed by professionals, or patients and the people around them.

Traditionally strokes were considered a disease of the retired. But NHS figures show that the number of men aged 40 to 54 hospitalised after stroke hit 6,221 last year – 46 per cent higher than in 2000. For women in that age group there was a 30 per cent rise to 4,604.

The average age of stroke is 74 for men and 80 for women, with both figures gradually reducing in recent years, despite the UK’s ageing population.

Most strokes do occur over the age of
65, but poor lifestyle choices are putting younger generations increasingly at
risk.

The situation is exacerbated by the challenges faced in spotting symptoms by both young people themselves,
and clinicians.

The push to raise public awareness centres around the FAST acronym (Face, Arms, Speech and Time to call 999).
The Act FAST campaign reportedly contributed to a 54 per cent rise in stroke related 999 calls between 2009 and 2013, leading to around 4,500 fewer people being le disabled by stroke.

This saved the taxpayer over £332.9m in the period, against the campaign’s cost of £12.5m, Public Health England said.

Slightly dubiously, it is also claimed that FAST increased the proportion of the UK population that knows what a stroke is by 20 per cent to 65 per cent. It is unclear how this figure was reached with any accuracy, but the campaign’s overriding success is unquestionable.

Would a similar campaign specifically targeting young people be able to deliver such results in the under 40s? Certainly, finding the millions of pounds needed to push it out across the spectrum of social media sites and TV platforms would be a struggle.

Expert Liz Iveson believes a better use
of resources would be to promote stroke recognition in young people among doctors in GP surgeries and on A+E wards.

The stroke consultant, who works at York NHS Teaching Hospital and Woodlands Neurological Rehabilitation Centre, says: “Often, because of the age of the patient, doctors don’t think about stroke diagnosis until they have ruled everything else
out. They may not be showing the classic symptoms, while conditions far more common in young people than stroke,
like migraine or vertigo, are higher up the check-list.

“Stroke tends to be the thing that’s thought of last by both doctors and younger patients. As a result, we see delayed presentation and diagnosis.”

Stress and alcoholism are also red herrings that might detract from a correct stroke diagnosis in young people.

Strokes which are ischaemic (due to a blocked blood vessel rather than bleeding on the brain) and occur towards the
back of the brain are particularly hard to diagnose in young people.

Early diagnosis of posterior circulation ischaemic strokes may prevent disability and save lives; but the FAST test is less useful in detecting them, while symptoms like vision problems and vertigo can easily be confused with other less serious problems.

The vast majority (85 per cent) of strokes are ischaemic. Given the life-changing damage they can cause to the brain, treatment must be carried out within a few hours if serious consequences are to be avoided.

Misdiagnosis or delayed presentation puts young people’s lives at risk or sets them up for a lifetime of severe disability.

One treatment, thrombolysis, uses drugs to break down and disperse the clot. It is only licenced for use up to four and a half hours from the onset of stroke symptoms.

Thrombectomy – a procedure which mechanically pulls the blood clot out of the brain – must also take place in the early hours after a stroke.

Every minute a stroke is untreated,
1.9 million neurons are lost. When thrombolysis is given within three hours of stroke, one in 10 patients will go on to live independently.

The speed at which patients are diagnosed and possibly taken to theatre or given drugs can be hugely significant to the outcome of a stroke.

Iveson believes the emergence of the national ‘stroke pathway’ is helping to counter the threat of late detection
or misdiagnosis of stroke among
young people.

Over the last decade, the Royal College
 of Physicians (RCP) has driven the national rollout of a clear pathway
for stroke patients within healthcare trusts. Its regularly-updated National Clinical Guideline for Stroke states that: “Commissioning organisations should ensure their commissioning portfolio encompasses the whole stroke pathway, from prevention through acute care, early rehabilitation and initiation of secondary prevention on to palliation, later rehabilitation in the community
and long-term support.”

Before this guidance was first introduced in 2008, stroke care was inconsistent across the UK, with patients being treated in a range of settings rather than on dedicated stroke wards.

Iveson says: “We’re definitely getting
better at diagnosing stroke. Because of
the pathway, the stroke team has a greater presence in A+E. If doctors are unsure about symptoms, they can ask the stroke nurse to have a look at a patient.
This pathway is pretty consistent across the country, and is supported by the ongoing audit of stroke services.

“Through the pathway, we also give feedback when stroke diagnosis has
been missed, which also ensures lessons are learned.”

Improving diagnosis will only go so far in curbing the number of young lives damaged or devastated by stroke, however.

A more challenging task is snuffing out the stroke risk factors seemingly on the rise in younger people.
“Obesity and high blood pressure are being diagnosed at a younger and younger age and therefore arteries are aging earlier than they otherwise would have. The longer you have these risk factors, the more likely you are to have a stroke.”

Being overweight increases the risk of high blood pressure, heart disease and type 2 diabetes; all of which are stroke risk factors. Overall, obesity increases a person’s risk of stroke by 64 per cent, says The Stroke Association.

Meanwhile, British Heart Foundation (BHF) figures show that five million people in England are unaware they have high blood pressure, and therefore could be at risk
of stroke.

The western world’s obesity epidemic shows no signs of slowing, and young people are just as exposed as older generations. Around a third of UK children are reportedly overweight when they leave primary school.

More alarmingly, signs of obesity-related heart damage are now being detected in toddlers.

A study of more than 400 children in Romania found changes in the structure of the heart in obese infants – including those below the age of one.

The results, presented at the European Society of Cardiology congress in Barcelona, found obese children had 30 per cent thicker heart muscle compared to those of a healthy weight.

Stroke in children is usually linked to genetics rather than other risk factors. But such reports, and the fact that overweight children are statistically more likely to be obese as adults, offer little encouragement in the push to reduce stroke in young people.

Stress is another rising risk factor.
“Stress alone increases stroke risk,” says Iveson. “Partly this is because it can lead to changes in lifestyle that increase other risk factors like high blood pressure and obesity. For example, if you’re working long hours, you might do less exercise, smoke more and eat junk food on the go. There is also a more direct link between stress and stroke, related to inflammatory markers.”

This link was only proven earlier this year, by researchers at Harvard Medical School and Massachusetts General Hospital.

The part of the brain linked to stress, the amygdala, controls the production of white blood cells by bone marrow to fight infection and repair damage.

Its function is to prepare the body for a harmful experience, such as being attacked.
Scientists discovered, however, that
chronic stress can cause this process to
go into overdrive.

White blood cells are over-produced and can form plaques 
in the arteries, heightening the risk of cardiovascular diseases such as stroke.

Although definitive evidence that stress levels in young people are on the rise is lacking, numerous studies suggest a general surge in work-related strife.

Longer working hours, tighter budgets that encourage bosses to ‘sweat their assets’ and the culture of emails on the go,
all contribute.

The uncertainty that comes with zero hours’ employment and working in the so-called ‘gig economy’ is also linked with increased stress in younger workers.

Drug use is also a stroke risk factor which may be more prevalent in the under-40s. Iveson says: “I once saw a 24-year-old who came to hospital following a stroke which was put down to his heavy cocaine use
that had effectively aged his blood vessels prematurely.”

A 2012 study found that 20 per cent
of stroke patients aged 45 or under
had used illegal drugs. More recently, research has discovered links between methamphetamine – or ‘speed’, ‘ice’ or ‘meth’ – and increased stroke risk.

Clearly raising awareness of the many
risk factors of stroke in young people,
and continuing to improve diagnosis, are mammoth tasks requiring years of e ort and focus.

Evidence suggests that post-stroke treatment must also improve, if stroke patients are indeed getting younger.

The 2016 edition of the National Clinical Guideline for Stroke reports that some younger adults feel that general stroke services – used mostly by older people – do not meet their needs.

It reports: “Younger adults are more likely
to have an unusual cause for their stroke, rehabilitation may require specific attention to work and bringing up children, and social needs and expectations may be different.

“Thus, although all stroke services should respond to the particular needs of each individual regardless of age or other factors, it is appropriate to draw attention to this group of younger people with stroke.”

It recommends that acute stroke services should “recognise and manage the particular physical, psychological and
social needs of younger people with stroke”. It also says they must liaise with regional neuro-rehab services specialising in young adult care.

Encouragingly, the latest results of the Sentinel Stroke National Audit Programme (SSNAP), which measures stroke care standards and is informed by the National Clinical Guideline, shows general signs of improvement.

In the year to March 2017, 36 teams achieved an overall ‘A’ score, indicating world class stroke service. This was up from 25 in 2016.
Improvements were noted in areas such
as rapid scanning, thrombolysis provision, and access to a stroke units.

It also cited an “unacceptable variation” in standards across the country, however.

A major concern for Iveson is the scarcity of neuropsychology services for younger stroke patients within the NHS.

“Psychology is completely underfunded
at the moment. A lot of younger stroke patients do well in terms of physical recovery but it’s very di cult to address challenges like memory problems or other cognitive issues. They would really bene t from detailed neuropsychology that could perhaps prove they can return to work or at least help them to function better.
“But they just can’t get it on the NHS
and have to apply for funding for exceptional treatment to access it through private providers.”
In fact, getting access to any neuro-rehab services in the long term is needlessly tough for younger stroke survivors, Iveson says.

“In younger patients, the rest of the brain tends to be in good condition and can take over some of the functions that were controlled in the part that has died, through neuroplasticity.

“With the right rehabilitation, young stroke patients can do surprisingly well. I’ve had younger patients that have had very severe strokes resulting in a lot of brain damage, that have gone on to walk and recover speech.

“Rehabilitation is available for a reasonable time in the NHS but it’s really hard to get it for the prolonged period that many young people could bene t from.

“Unfortunately, long term support isn’t commissioned well at all. Yet younger people who’ve had a stroke may have many years ahead of them and require long-term support to help them in society, at work and in relationships.”

Having worked in the stroke field for over a decade, Iveson has witnessed great strides in the overall standard of care available to stroke survivors. She also sees significant room for improvement.

“Stroke care has improved massively in
the last 10 years but, until recently, resources have largely been concentrated on the beginning part of the patient journey, getting people into hospital as quickly as possible.

“What hasn’t been well funded is what happens after hospital when patients 
go back out into the community. That’s something that needs attention.”

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Interviews

Making the shift from victim to survivor

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After having a stroke two years ago at the age of 39, former international swimmer Craig Pankhurst founded the charity Stroke of Luck to support stroke survivors through activity and exercise. Jessica Brown reports.

“Stroke survivors are in one of two places – they either see themselves as a victim, with a not very positive outlook,” Pankhurst says.

“Or they see their stroke as a bump in the road, but that no one will stop them from having a fulfilled life, just one that’s different to the one they were leading before.

“We put in a halfway line to move people from the victim to survivor mentality.”

Pankhurst wanted to build the charity’s website to enable interaction between stroke survivors and experts in neuropsychology and personal trainers trained to work with special population groups.

When the coronavirus pandemic hit the UK in March, Pankhurst decided to do live sessions on social media, where he brought in guests and spoke about his experience and the charity he’s set up – and says he got good interaction with viewers.

His efforts caught the attention of the World Stroke Organisation, which partnered with Pankhurst to create videos for stroke survivors for what they can do to aid their recovery safely at home, with the help of specialist physiotherapists.

The videos are uploaded by both Stroke of Luck and the World Stroke Organisation.

“I spoke to the World Stroke Organisation over a number of weeks and we agreed to collaborate to create story-specific exercise and activity videos for stroke survivors, to start releasing over 12 weeks, to see if they get good engagement.

“Then we’ll carry on, and do some more,” he says.

The videos are now organised into a library, colour-coordinated into red, amber and green, depending on the viewer’s ability. The library also includes specific videos for carers.

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Interviews

The man who couldn’t see numbers

The unusual case of a man who can’t see numbers has led researchers to argue that the brain can process things without a person being aware of what they’re looking at.

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Researchers from Johns Hopkins University studied a 60-year-old man known as RFS, who has a rare degenerative brain disease that prevents him from seeing numbers two to nine.

He would describe seeing one of these numbers as a tangle of black lines that changed every time he looked at it. He had otherwise normal vision, and had no problem identifying letters and other symbols.

The problem would happen before he knew which number he was looking at, which meant his brain had to at least know that numbers were in the same category before something could then go wrong; study author Mike McCloskey tells NR Times.

“It didn’t matter how we presented digits to him, they were always distorted,” says McCloskey, a researcher in the Cognitive Science Department at Johns Hopkins University.

The researchers didn’t know what they were looking for when they started working with RFS, as this specific pattern has never been recorded before. The closest recorded cases are of patients who see distorted faces.

The researchers, whose findings were published in the journal, ‘Proceedings of the National Academy of Sciences,’ also found that RFS couldn’t recognise anything placed near or on top of a number.

They recorded RFS’s brainwaves while he looked at a number with a face embedded on it, and found that his brain detected the face, even though he was unaware of it.

“In one experiment, we showed him a big digit with a face on top of it and recorded EEG signals to see how his brain responded to the face.

“Even though he couldn’t see the face at all, we could pick up a response in the brain 170 milliseconds after the face was presented.

“We saw a perfectly normal brain response to the face, which told us his brain unconsciously identified the face as a face, even though he wasn’t aware of it at all.”

In another experiment, they put words next to the numbers and told him a target word. When he saw the target word, his brain had a bigger response even though he said he couldn’t see the word. They also did tests where they placed a number in front of RFS and asked him to guess what a number was, to test implicit knowledge.

“Sometimes, blind people say they can’t see a light, but can often point to it accurately when forced to make a guess,” McCloskey says.

“We did that with him and saw absolutely no indication he had any implicit knowledge. He couldn’t tell us if numbers were the same or different, odd or even – yet the EEG showed his brain was responding.

The reason it could just be numbers that are affected, he says, is because evidence suggests the brain treats categories of things differently.

“Furniture, fruit and vegetables, for example, may be treated separately, so it’s possible for some areas to be affected and some not.”

The findings demonstrated that the complex processing needed to detect words, numbers and other visual stimuli isn’t enough to make a person aware of what they’re seeing.

“We can draw conclusions about what’s necessary for you to be aware of what you’re seeing. You’d think that, if the brain has done enough work on something to know it’s a face or a particular word, you’d be aware of it.

“These results tell us the brain can do an awful lot of processing on something you’re looking at without you being aware of it at all,” McCloskey says.

“Something else needs to happen after the brain has identified what it’s looking at before you become aware of it at all. ”

And the reason these findings apply to everyone else is because the researchers assumed RFS’s brain was the same as anyone else’s, except for this one thing that went wrong.

“In order to become aware of something, you have to do more than processing to allow you to identify what you see – we think this is true for everyone.”

As for RFS, who was a geological engineer, the story has a happy ending.

“Because RFS couldn’t see regular digits, this was a real problem for him. We created a new set of symbols for him for digits, to see if he could use those,” McCloskey says, as well as a calculator on his phone using the digits.

“He learned them very easily – we wondered if they’d get distorted for him but fortunately, they didn’t. He says he’s been using the symbols ever since – he uses them in his daily life and stayed in his job two years longer than he would’ve otherwise, because of them.”

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Interviews

“Assume brain injury” after domestic violence, researcher urges

Domestic violence survivors in hospital should automatically be tested for traumatic brain injury (TBI) because they, and doctors, may not be aware of the symptoms.

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That is according to researcher Jonathan Lifshitz, director of the Translational Neurotrauma Research Programme at the University of Arizona’s college of medicine.

When a patient goes to the doctor with a cough, they’re tested for numerous diseases to rule them out, but with intimate partner violence (IPV), Lifshitz says, we should “flip the script”.

He tells NR Times: “If the individual doesn’t have encyclopaedic knowledge of what TBI is, they may not offer all the symptoms up to their healthcare provider.”

Similarly, the brain injury itself may prevent the patient from being able to detect their symptoms.

Instead, practitioners should suspect that victims of IPV have a head injury, so they can be tested.

“If we tested all people experiencing intimate partner violence for TBI, and are able to screen them using objective tests, we’re going to have far fewer people who experienced intimate partner violence and go untreated,” he says.

In one study, Lifshitz found that 62 per cent of people subject to IPV and diagnosed with TBI were unaware of their TBI when they sought treatment.

While it’s a challenge to determine that someone has TBI, the risk of missing something, Lifshitz says, is much greater. And while increased testing would incur more cost, due to additional testing, Lifshitz says it would save money.

“An individual may be able to hold down a job better, be less dependent on services and won’t need healthcare services as much in the long run,” he says.

Lifshitz is involved in the Maricopa County Collaboration on Concussion from Domestic Violence (MC3DV), a county-wide collaboration in Arizona. It aims to increase the suspicion of head injury by analysing health data for patterns and problems that can be targeted with a county-wide approach.

It educates police officers to recognise symptoms, social workers to better identify abusive relationships, emergency services to profile forensic evidence and clinical partners to assess and treat symptoms of TBI and concussion.

Also, prosecutors through the Maricopa Country attorney’s office are supported in being able to build their case against the assailant; while scientists and process developers also help to bring everything together.

Meanwhile, social workers and nurses are educated on the signs and symptoms of TBI, proposing an objective measure where head injury is implied.

Hospitals are a key area of focus for MC3DV, where one challenge is rebuilding trust between medical practitioners and patients who have previously suffered discrimination, and as a result have a lack of trust.

“It would be easier to implement this change in one crisis shelter or emergency department, when we have the opportunity to regulate and control the organisation we’re working with and we can put in new policies and procedures,” Lifshitz says.

“When trying to coordinate multiple systems in multiple organisations, it’s much more challenging.

“While everyone is receptive to the topic, the problem is having enough resources to do it.”

MC3DV is also hoping to replicate state-wide efforts made in 2012 to better detect evidence of strangulation.

As a result, Maricopa County prosecutors attributed the rise in domestic violence prosecution and decrease in domestic violence deaths to this change.

“Arizona recently changed the way the legal system deals with strangulation, in terms of how it sees evidence,” Lifshitz says.

“Prosecution is much more rapid and severe; it’s unburdened the legal system because many more cases are starting as guilty.”

Lifshitz hopes better testing and evidence gathering will act as a deterrent for abusers, and provide additional motivation for victims to step forward, although, he concedes, psychological, emotional and financial controls an intimate partner has over their victim complicates this scenario.

“A patient wanting to seek treatment is very different from the ability to seek treatment,” he says.

Lifshitz hopes there will be some real changes to come out of the research programme.

“I’ve always needed a bigger social driving force to keep me motivated. It’s unconscionable to know about this and not do anything about it.

“This programme helps to bridge the gap between social work, police work and biomedical research, to attack this problem from multiple angles.

“The majority of the work we do is stepping back, looking at what healthcare data we might have, and asking very specific questions.

“We sit around the table not necessarily with the smartest people, but with the most passionate people. It’s not any one person doing the work, but relying on a community of providers to support the victims and warn abusers.”

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