Mid-Life Strokes:
How to recognize and prevent a major killer


If you think stroke is a problem only in old age, think again. This year, 100,000 women between ages 30 and 65 will suffer a stroke. Women account for 43 percent of strokes, but 61 percent of stroke deaths. And a stroke can hit mid-life women without any warning.

"Acute stroke is more variable in its presentation than a heart attack," remarks Alan Z. Segal, MD, director of the Stroke Center at the Weill Cornell Medical Center. "It requires more awareness of the symptoms, so you can get help quickly."

Understanding the risks and warning signs of stroke could save your life.

Brain Attack

Experts call stroke a "brain attack." The most common type, an ischemic stroke, occurs when an artery supplying the brain is blocked by fatty deposits or a blood clot. The cutoff of oxygen to the brain can cause permanent damage; survivors may have difficulty walking, talking, thinking, or even breathing. Stroke can also be caused by bleeding in the brain (usually due to a burst blood vessel); this is called a hemorrhagic stroke.

"Stroke is a major medical problem in the United States," declares Lawrence Brass, MD, professor of neurology at Yale University School of Medicine. "It's the third-leading cause of death, and a leading cause of disability in adults. One-third of strokes occur in people under 65. We're beginning to have better therapies for acute stroke, but most people who have an acute stroke are left with some deficit."

Women's Special Risks

"In women 30 to 65, stroke risk factors mainly parallel the risk factors for heart disease: smoking, high blood pressure, and diabetes," says Dr. Segal. Even second-hand smoke is a risk factor.

Many women in their 40s and early 50s are taking low-dose oral contraceptives to regulate menstrual cycles disrupted by perimenopause. However, the combination of oral contraceptives and smoking is known to promote blood clots. "In my opinion, anyone who smokes should not be on oral contraceptives. If you can't quit smoking, then oral contraceptives are contraindicated," says Dr. Segal.

Autoimmune diseases common in women, such as lupus and antiphospholipid syndrome, can produce blood-clotting abnormalities, increasing the risk of stroke.

Research also suggests a small association between migraine and stroke. "If you often have migraines, talk to your doctor about your risk of stroke and how to reduce it," Dr. Brass advises. Migraines, more common in younger women, often stop at menopause, but can also begin in midlife.

After age 50, hormone replacement therapy (HRT) is another variable. Some recent studies find the risk of blood clots rises during the first years of HRT, increasing the chances of a heart attack or stroke (especially in women who have cardiovascular disease). So the American Heart Association recently advised women not to begin HRT hoping to reduce their risk of stroke and heart attack.

Another major risk factor is atrial fibrillation, a condition in which the upper chambers of the heart don't beat properly and blood can stagnate. If a clot forms and travels to an artery supplying the brain, it can cause a stroke. It's more common as women age, and it can be asymptomatic.

Reducing your risk

"A stroke when you're 60 or 70 starts when you're in your 30s and 40s--that's when you really have an opportunity to intervene. It's a lifetime disease process. Prevent it before it happens," urges Dr. Brass. Experts estimate that 90 percent of all strokes could be prevented if people at risk were identified and treated early enough.

"Beginning at age 40, have your cholesterol and blood pressure checked," says Dr. Brass. "If women in your family tend to have heart attacks or strokes in their 50s, you need to discuss that with your doctor. In such cases, I become much more aggressive in instituting preventive measures and screening, possibly using a magnetic resonance angiogram for someone at high risk."

Preventive measures include lowering elevated blood pressure and cholesterol, and exercising regularly. Eating fish like salmon and other foods rich in omega-3 fatty acids, getting enough calcium, and increasing fiber intake can all help reduce stroke risk.

Women diagnosed with atrial fibrillation are often prescribed blood thinners, such as aspirin or warfarin. Blood thinners are also prescribed for women with antiphospholipid syndrome.

What to do in case of stroke

A recent survey in Georgia by the federal Centers for Disease Control and Prevention found that many adults are unaware of the early warning signs of stroke--and that may delay treatment and cause brain damage. Of the more than 600 men and women surveyed, only 39% could remember one of the warning signs of stroke.

Swift treatment with clot-busting drugs (like tissue plasminogen activator t-PA) can restore blood flow to starved areas of the brain. But the window of opportunity for such treatment is within three hours of the first symptoms. So it is vital to recognize the warning signs and quickly get to a hospital or Stroke Center. Studies show the average stroke patient waits 12 to 24 hours to go to the hospital. "Today's therapies could increase our success rate by one-third--but only 1 to 2 percent of all strokes are treated with these drugs," says Dr. Brass. If you have symptoms, don't plan to phone your doctor tomorrow. Call 911 immediately, or have someone call for you, he says.

Strokes can be small or silent

Not all strokes are major, with dramatic symptoms. It's not uncommon to suffer transient ischemic attacks (TIAs), in which there's a temporary blockage in the carotid artery. The symptoms of these "mini-strokes" can be the same as for major strokes, but often the only sign may be a slight numbness or weakness on one side of the face or body.

About 20 percent of stroke patients show evidence of having had a "silent stroke" in the past, reports Dr. Brass. "This kind of stroke occurs during sleep or affects a part of the brain you are not actively using. If you notice shifts in your ability to think or use parts of your body, call your doctor."

"Stroke is where breast cancer was 15 years ago in terms of awareness. People don't really want to talk about it, and don't know they should be concerned about it," declares Sharon Geris, spokeswoman for the National Stroke Association. "But strokes kill twice as many women as breast cancer. And many strokes are preventable."

Carol Milano

Many of these articles appear on the publication's website, which are often password-protected or members-only. For your convenience, I've gathered them on my own website.