Stephen Davis’s Response to “Building Momentum in Young Stroke Research and Services in Australia”
By Stephen Davis, Director, Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne
Immediate Past-President, World Stroke Organization
Stroke in young adults is common. Around 15%-20% occur in young adults and adolescents. When I am the consultant on stroke service at the Royal Melbourne Hospital, I am often struck by the large number of young stroke patients, frequently with photos of their children by the bedside and poignant family discussions about prognosis and the impact on their lifestyle. The articles in this issue of “Young Stroke Editorials” highlight some of the Australian perspectives on young stroke. Nick Rushworth emphasises that stroke is more common than traumatic brain injury, but has received far less attention. He also points out the ageing paradox, namely the reduction of stroke incidence rates in high income countries, contrasting with an alarming increase in stroke incidence in young adults.
Dr Barbara Wolfenden has given a unique personal insight into the experiences of a young adult stroke patient and has emphasised the role of social media in supporting and informing young stroke survivors. Furthermore, young stroke survivors are leading efforts in education, advocacy and indeed research. Professor Julie Bernhardt is an internationally-renowned stroke expert, particularly recognised for the AVERT trial, the largest ever trial of post-stroke rehabilitation. I read with great interest the plans to develop a specialised young stroke clinic at the Austin Hospital in Melbourne. Far more attention needs to be paid to the specific challenges facing younger stroke survivors given the psychosocial and vocational impact, their longer life expectancy and the need for optimisation of secondary prevention, rehabilitation and community integration. Natasha Lannin and colleagues have shown that young stroke in Australia disproportionately affects indigenous patients.
Why is young stroke an increasing problem? Research has shown that multiple factors may account for the increased rate of stroke in young adults. Although there is a somewhat different spectrum of etiologies in young adult stroke patients, such as arterial dissection and patent foramen ovale, the risk factors usually attributed to age (such as hypertension, hyperlipidemia, diabetes, smoking, low physical activity) are in fact very prominent in young adult populations and indeed explain about 80% of the stroke risk. Most of these risk factors are modifiable and a “whole of life” perspective is needed with promotion of a healthy lifestyle and early recognition and management of risk factors.
Long term prognosis is highly relevant in younger patients because of their longer life expectancy and the impact on vocation. There has been under representation of young adult stroke patients in clinical stroke trials. Stroke is highly preventable and treatable. Recent important advances of particular relevance to young adults include the role of closure of patent foramen ovale (PFO) in selected young adults with stroke of uncertain cause, so called “cryptogenic stroke”. The major advances in stroke therapy with acute reperfusion, both intravenous tPA and endovascular thrombectomy, have a much greater impact in young adults.
In Australia, young stroke is now a major focus of the Stroke Foundation in Australia. More clinical trials are required that focus on young adults, also research across the stroke spectrum including prevention, acute treatment, rehabilitation as well as the psychosocial and vocational consequences of stroke. Young stroke should be a priority area for research funding and community awareness.
To quote President John F Kennedy, “There are risks and costs to a program of action. But they are far less than the long-range risks and costs of comfortable inaction”.
