Can You Recognize Stroke in the Young?

“How could it happen to someone so young?”

This was the question asked by many when, late in 2012 at the age of 26, Frankie Muniz, star of TV’s Malcolm in the Middle, suffered a mini-stroke, or transient ischemic attack (TIA). Muniz never saw it coming. It began with blurred vision in his right eye, and soon he experienced dizziness, numbness in his hands, a stabbing headache and dysphagia. The young actor had no known congenital problems and few risk factors, got regular exercise and didn’t use drugs, cigarettes or alcohol. Muniz didn’t expect something like this would ever happen to him, nor would most EMS providers encountering young or very young patients exhibiting isolated symptoms of stroke.

While the assessment and treatment of stroke in young patients (under 45 years old), very young patients (under 18) and newborns present unique challenges to EMS providers, these challenges can be overcome by a knowledge and awareness of this highly underrecognized emergency.

Stroke (also known as a cerebrovascular accident, CVA, or “brain attack”) occurs when blood flow to the brain is interrupted, resulting in ischemia and damage.¹ The two basic forms of stroke are thrombotic (caused by a blood clot in a blood vessel), which accounts for approximately 87% of all strokes, and hemorrhagic (caused by a tear and bleeding in a blood vessel), which accounts for the remaining 13%.²

As the leading cause of disability in the U.S., stroke has an immense impact on our healthcare system.³ While those over 65 remain at the highest risk, healthcare has made great strides in both prevention and care for older stroke victims. In recent years stroke has fallen from the third- to the fourth-leading cause of death in the United States.⁴ Yet at the same time, according to a recent study from the CDC, the incidence of stroke is growing among the young and very young, and the rate of stroke in newborns continues at an alarming rate.⁵

Newborns: The rate of stroke in-utero and in newborns is startlingly greater than 1 in 4,000 births, primarily in full-term infants.⁶

The very young (0–18 years): Stroke is the sixth-leading cause of death for children, with overall rates of approximately 1 in 10,000 up to 18 years of age, a rate similar to that of brain tumors. Boys have approximately 1½ higher risk of stroke than girls, and black children have approximately double the risk of other groups.^7–9

The young (18–45 years): While numbers in this age group also vary dramatically based upon age, sex, race and other factors, overall rates of stroke are greater than 1 in 800.^7–9 Although this rate is lower than in geriatric patients, chances are much greater that strokes in the young, very young and newborns will go unrecognized (and untreated) by healthcare providers.

Risk and Contributing Factors

Known contributing risk factors of stroke in the young can be identified through a thorough patient history. Prehospital care providers will need to raise their index of suspicion, as a vague presentation of neurological symptoms in a young person may, in fact, be signs of a stroke.^2,10,11

Common risk factors for stroke in the newborn include:

• Defects in the structure of the heart (congenital heart disease; not germane to EMS);
• Abnormally increased blood coagulation (not for EMS);
• An unusual increase in concentration of red blood cells (polycythemia);
• Disseminated intravascular coagulopathy (pathological systemic blood clotting, then bleeding);
• Abnormal connections between arteries and veins in the central nervous system (AV malformations);
• Infections;
• Traumatic birthing events.

Risk factors for stroke in the very young include:

• Arteriopathy—diseases of the arteries of the brain (found in approximately two-thirds of cases of stroke in the very young);
• Sickle cell disease (may cause blockage of blood vessels of the brain);
• Chronic anemia;
• Clotting disorders;
• Infections;
• Blood vessel narrowing of any kind (often of unknown etiology);
• Trauma, especially head trauma.

Many of the cardiovascular risk factors for stroke in the young are similar to those for the elderly. Keep in mind that many of these factors also affect the risk of stroke in the very young:

• Obesity;
• Diabetes;
• High cholesterol;
• Smoking;
• Sedentary lifestyle;
• Recent surgery;
• Recent or ongoing infection;
• Uncontrolled high blood pressure;
• Excessive alcohol consumption;
• Women who are 1–6 months post partum;
• Women who take birth control pills;
• Cocaine and stimulant abuse.

Signs and Symptoms

While an assessment of known risks and contributing factors in a young patient’s medical history can help raise a prehospital care provider’s index of suspicion for stroke, rapid assessment of signs and symptoms will facilitate treatment, transport and coordination with the emergency department.^2,12,13

By their nature newborn patients can be difficult to assess. In addition, many of the definitive signs and symptoms of stroke in the newborn may not present for several months. Still, a keenly observant prehospital care provider may be the first person to identify the issues that will lead to comprehensive care, assessment and follow-up for newborn victims of stroke. Primary signs and symptoms to watch for include:

• A tendency of the newborn to use only one side of their body;
• Extreme sleepiness and difficulty in rousing;
• Seizures;
• Other weaknesses or neurological deficits that appear to be focal in nature (affecting only one side or area of the body).

Signs and symptoms of stroke in the very young include:

• Trouble walking due to weakness or loss of coordination;
• Problems speaking or understanding language, including slurred speech, an inability to speak at all or difficulty understanding simple directions. In children this may initially be assumed to simply be obstinate behavior;
• Severe headache, especially with vomiting and sleepiness, often described by very young patients as the worst headache or pain they have ever had;
• Trouble seeing clearly in one or both eyes;
• New-onset seizures, especially focal seizures or seizures followed by severe weakness or paralysis on the side of the seizure activity;
• As with newborn stroke, any general or vague neurological complaints that are sudden-onset and focal.

While many of the signs and symptoms of stroke in the young overlap with those for newborns and the very young, they are often more focused in young patients, sometimes even allowing for differentiation between thrombotic and hemorrhagic stroke. These include:

Thrombotic stroke

• Hemiparesis;
• Parasthesia on one side, typically involving the face, arm and leg;
• Ataxia;
• Aphasia;
• Dysarthria;
• New-onset focal seizures;
• Seizures that present with postictal focal deficits lasting more than an hour;
• Combinations of focal neurological deficits such as weakness on one side accompanied by reduced vision and gaze preference toward side of intact vision.

Hemorrhagic stroke

• While significant signs on their own, a triad of unrelenting severe headache, repeated vomiting and decreased mental status should raise suspicion in a prehospital care provider that their patient is experiencing a hemorrhagic stroke.

Ruling It Out

While many of the common signs and symptoms will be familiar to EMS providers, stroke in young patients often remains unidentified and untreated in both the field and the emergency department. This is due to a combination of factors, including a low index of suspicion for stroke in patients under 65 and an inclination to presume other causes and “rule in” for them, rather “rule out” stroke.

“I believe EMS is the key to improving treatment of childhood stroke in the acute setting,” says Timothy J. Bernard, MD, director of the pediatric stroke program at Children’s Hospital in Colorado. “I have seen multiple cases where EMS takes a child into a pediatric ER and are thinking stroke before the pediatrician. This is simply because EMS sees stroke every day, and pediatricians do not. The average time to stroke diagnosis is 24 hours. In order to offer acute therapies such as tPA (a clot buster) to children, we have to reduce that time greatly. In my opinion, EMS is the most important part of this effort.”¹⁴

While listing signs and symptoms of stroke in an article titled “Can You Recognize Stroke in the Young?” may facilitate diagnosis, keep in mind that on the street, combinations of symptoms like these in younger patients are often initially overlooked or presumed to indicate a patient who is disabled, drunk or suffering some stroke mimic. The most common of these are listed below, with factors that may help in a differential diagnosis.^15,16

Diabetes mellitus/hypoglycemia—Patient has a blood glucose level of less than 60 mg/dL and improves after the administration of dextrose.

Tumor—Slow and progressive onset.

Brain abscess—Slow and progressive onset.

Seizure—Patient describes an aura. Postictal deficits are brief (less than 1 hour) or not focal in nature.

Overdose/alcohol intoxication—While there may be evidence or patient admission of use of substances, keep in mind that chronic alcohol and stimulant abusers are also at high risk for stroke.

Migraine—While this can be extremely difficult to differentiate, a past history and particular sensitivity to light tend to indicate migraine.

Head injury—Trauma/significant mechanism of injury as part of the current injury.

Bell’s palsy—A previous diagnosis of Bell’s palsy and/or isolated deficit of the facial muscles.

Louise McCullough, MD, director of stroke research at the University of Connecticut’s John Dempsey Hospital, reminds EMS providers that it is important to keep an open mind to the possibility of stroke in the young and not presume complaints are due to stroke mimics. “All patients exhibiting potential stroke symptoms should be treated as if they were having a stroke until proven otherwise,” McCullough says.¹⁷

EMS Care and Management

As with cardiac and trauma care, EMS care for young stroke patients is focused on managing life threats while rapidly transporting to proper definitive care. Accomplishing this in the most efficient way will give your patient the best chance for a positive outcome.^3,19–21

In even the most complicated cases of stroke, you can follow five general treatment principles for the care and management of your patient.

1. First assess the ABCs and manage any life threats.
2. Evaluate for risk factors and signs and symptoms of acute stroke, regardless of patient age.
3. If you suspect stroke, triage to a designated stroke center or specialty center according to your local protocols.
4. Notify and coordinate with the stroke center or specialty center.
5. Provide ongoing supportive care for your patient as you start again at step 1.

As you work under the five general principles outlined above, keep in mind these more specific assessment and treatment recommendations to provide the best care for younger stroke patients.

Assessment—Identify the time last seen normal. This is very different from the time the patient, family or bystanders may have first noticed signs or symptoms. Treatment options for young stroke patients all have specific timetables, and the clock starts ticking with the time the patient was last known to be without signs and symptoms of stroke.

Evaluate the patient with a validated stroke scale in order to best identify the presence and acuity of stroke.^3,15,21,22 Validated stroke scales include:

• Cincinnati Prehospital Stroke Scale (CPSS);
• Los Angeles Prehospital Stroke Scale (LAPSS);
• Miami Emergency Neurological Deficit (MEND) checklist.

When time allows, complete a thorough physical assessment. Be especially observant for both focal neurological deficits and injuries the patient may have sustained as a result of the stroke but not be able to verbalize.

Provide cardiac monitoring. Identification of clot-producing arrhythmias such as atrial fibrillation may contribute to in-hospital treatment decisions.

Evaluate patient history for events such as:

• Previous stroke or transient ischemic attack;
• Myocardial infarction;
• Significant trauma or bleeding, especially head injury;
• Recent surgery.

Assess for contributing or comorbid diseases such as:

• Congenital heart disease;
• Hypertension;
• Diabetes mellitus;
• Sickle cell disease;
• Clotting disorders.

Treatment

Provide supportive oxygen if the patient’s oxygen saturation is less than 94%. Young victims of stroke have a high risk for aspiration. Do not allow the patient to consume anything by mouth. Initiate IV access if easily possible. Few fluids or medications may be needed in the field, but immediately available IV access for thrombolytic therapy or other in-hospital medications will speed patient treatment and save brain tissue.

Check for hypoglycemia. If the patient’s blood sugar is less than 60 mg/dL, administer 10%–25% dextrose according to protocol. If the patient’s blood sugar is greater than 60 mg/dL, do not administer dextrose or use IV fluids containing dextrose, as they may worsen the outcome for both thrombotic and hemorrhagic stroke.²³

Do not manage hypertension with medications. Hypertension may be an unfortunate but necessary physiological response if the intracranial pressure is increasing due to bleeding and/or swelling.

Allow the patient to rest in a position of comfort, but if possible avoid ambulating the patient or allowing them to sit upright.

The Good News

The good news for young victims of stroke is that they tend to have better outcomes than older patients with similar injuries. While we’re not sure why, hypotheses include the fact that young patients tend to have fewer comorbidities and better neuroplasticity (adaptability of the brain) and potential for regeneration. That being said, a stroke in a young person is still a critical incident, especially for very young patients. According to Bernard, 70%–80% of these patients will have a lifelong disability associated with their stroke.¹⁴ In addition, McCullough notes, they can have a worse acute period of stroke, as they have less collateral circulation and less room in the cranium to accommodate the cerebral edema that often accompanies stroke.¹⁷

There is still much we can do to improve the outcomes for young victims of stroke, both as part of a stroke system of care and as individual EMS providers.^21,24–26 Drs. Kate Amlie-Lefond and Gabrielle deVeber of the International Pediatric Stroke Study are running a trial through the National Institutes of Health called the TIPS (Thrombolysis in Pediatric Stroke) trial.²⁷ “This is the first treatment trial in childhood stroke, and it looks at the safety of tPA in the acute setting of stroke in children age 2–18 years,” says Bernard. “Since this is a time-limited trial (kids need to be enrolled within 4.5 hours of their stroke), EMS will be crucial to our success.”¹⁴

Stroke systems of care have been shown to provide the best outcomes for stroke victims of all ages. The five primary recommendations from the American Stroke Association for EMS’ role in stroke systems of care are:^20,21,28

1. Provide rapid access to the public to activate EMS resources via enhanced 9-1-1 systems in the event of a suspected stroke.
2. Use education, protocols and algorithms to assist emergency dispatchers in recognizing signs and symptoms of stroke and rapidly dispatching the highest level of available resources.
3. Improve understanding and awareness of stroke in young patients through education.
4. Utilize stroke-specific treatment, transport and communication guidelines and protocols to facilitate the most efficient delivery of young stroke patients to definitive care.
5. Use validated screening tools such as the CPSS, LAPSS, MEND or others to rapidly identify stroke in the young and communicate findings to other care providers to determine patient eligibility for acute stroke treatment therapies.

What You Can Do

Strive for the following five objectives to improve your care for young victims of stroke as an individual provider in your community.

1. Improved understanding—Know you play a significant role in the stroke system of care in your area. Your assessment, treatment and management in the field are essential to the continuum of care and ultimately the patient’s outcome.
2. Improved awareness—Know what stroke risk factors to look for in younger patients’ current and past medical histories. These will help alert you to the possibility of stroke even in complex and difficult cases.
3. Improved assessment—Know the signs and symptoms of stroke in the young. Don’t assume their source is a stroke mimic just because of the patient’s age. Be especially suspicious of new-onset focal neurological deficits.
4. Improved care—Know, understand and utilize both the general patient management and specific stroke care treatment recommendations for patients under 45 years old, under 18 years old, and newborns.
5. Improved coordination—Know and use the validated stroke scale in use in your area. This will not only improve your identification of stroke, it will assist in coordination with and hand-off to hospital staff. One of the most important things EMS can do, Bernard says, is to speak up to physicians if they think one of their patients has had a stroke.¹⁴

Remember, EMS is responsible for the first five of the “eight Ds” of stroke care.¹⁵ Our ability to rapidly detect stroke, dispatch the right resources, deliver the stroke patient to the door of the right hospital and provide the right assessment data will allow a primary stroke center to decide to administer the right drug and give our patient the best possible disposition.²⁹

References

1. Limmer DJ, et al. Emergency Care, 11^th ed. Prentice Hall, 2011.
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12. The Children’s Hospital of Philadelphia Pediatric Stroke Program. Stroke Care at CHOP: The Bare Essentials for Primary Care & ED Physicians, www.chop.edu/export/download/pdfs/articles/pediatric-stroke-pdf-bare-essentials.pdf.
13. Children’s Hemiplegia and Stroke Association. What Is a Stroke?, https://www.chasa.org/.
14. Personal interview.
15. Adams HP, del Zoppo G, et al. Guidelines for the early management of adults with ischemic stroke. Stroke, 2007; 38: 1,655–1,711.
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17. Personal interview.
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19. Suyama J, Crocco T. Prehospital care of the stroke patient. Emerg Med Clin North Am, 2002 Aug; 20(3): 537–52.
20. Schwamm LH, Pancioli A, et al. Recommendations for the establishment of stroke systems of care: Recommendations from the American Stroke Association’s Task Force on the Development of Stroke Systems. Stroke, 2005; 36: 690–703.
21. Acker JE 3^rd, Pancioli AM, et al. Implementation strategies for emergency medical services within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council. Stroke, 2007 Nov; 38(11): 3,097–115.
22. Ramanujam P, Guluma KZ, et al. Accuracy of stroke recognition by emergency medical dispatchers and paramedics—San Diego experience. Prehosp Emerg Care, 2008 Jul–Sep; 12(3): 307–13.
23. Lindsberg PJ. Brain tissue salvage in acute stroke. Neurocrit Care, 2004; 1(3): 301–8.
24. Gropen T, Magdon-Ismail Z, et al. Regional implementation of the stroke systems of care model: recommendations of the Northeast Cerebrovascular Consortium. Stroke, 2009 May; 40(5): 1,793–802.
25. Chenaitia H, Lefevre O, et al. Emergency medical service in the stroke chain of survival. Eur J Emerg Med, 2013 Feb; 20(1): 39–44.
26. Schwamm L, Fayad P, et al. Translating evidence into practice: a decade of efforts by the American Heart Association/American Stroke Association to reduce death and disability due to stroke: a presidential advisory from the American Heart Association/American Stroke Association. Stroke, 2010 May; 41(5): 1,051–65.
27. Amlie-Lefond C. Thrombolysis in Pediatric Stroke. Clinicaltrials.gov, https://clinicaltrials.gov/show/NCT01591096.
28. Crocco TJ, Grotta JC, et al. EMS management of acute stroke—prehospital triage (resource document to NAEMSP position statement). Prehosp Emerg Care, 2007 Jul-Sep; 11(3): 313–7.
29. Jauch EC, Cucchiara B, et al. Part 11: adult stroke: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2010 Nov 2; 122(18 Suppl 3): S818–28.

An emergency responder for more than 20 years with career and volunteer fire departments, public and private emergency medical services and hospital-based healthcare, Rommie L. Duckworth, LP, is an internationally recognized subject matter expert, fire officer, paramedic and educator. He is currently a career fire lieutenant, EMS coordinator and American Heart Association national faculty member.