More Young Adults Are Suffering Strokes, While Rates Fall For Older Americans. What’s Behind It?

Stroke has long carried a reputation as an older person’s problem, something that happens to grandparents. A study spanning nearly three decades in Ohio and Kentucky shows that reputation slipping out of date. Between the early 1990s and 2020, the stroke rate among adults ages 20 to 54 nearly doubled. Over the same stretch, the rate among people 55 and older went down.

In 1993 and 1994, the region recorded about 34 strokes a year for every 100,000 adults in that younger age range. By 2020, the figure had climbed to about 62. Older adults moved in the opposite direction, from roughly 619 strokes per 100,000 to about 453. Older people still have far more strokes overall, but the gap between the generations is closing from both ends.

Younger patients are also slightly more likely to survive their stroke than they were 30 years ago, which means more people will spend decades living with its aftermath. Writing in the journal Neurology, researchers from the University of Cincinnati and partner institutions describe the rise in young-adult strokes as “a worrisome trend.”

Tracking stroke in young adults across three decades

Researchers drew on the Greater Cincinnati/Northern Kentucky Stroke Study, a long-running project covering five counties in southern Ohio and northern Kentucky. About 1.4 million people live in the area, and its population closely matches the country as a whole in age, share of Black residents, education and income.

Rather than following a fixed group of volunteers, the team counted every stroke that put someone in a hospital in the region during six one-year windows: mid-1993 to mid-1994, then 1999, 2005, 2010, 2015 and 2020. Trained research nurses combed through hospital records for stroke-related diagnosis codes. Doctors with specialized stroke training then reviewed each case to confirm it and sort it by type. Mini-strokes, in which symptoms fade within 24 hours, were left out. Every period used the same definition of a stroke, so cases from 2020 were judged by the same yardstick as cases from 1993.

To learn who died within 30 days, the researchers checked medical records against the National Death Index, a federal database that captures deaths across the country, whether they happen in a hospital or at home.

Across all six windows, they identified 2,076 first-ever strokes in people ages 20 to 54. Almost exactly half of those patients (49.6%) were women, and just over a third (35.6%) were Black. Typical patients were in their mid-to-late 40s. To compare years fairly, the team used census data and adjusted the rates so that shifts in the region’s age makeup over time would not skew the results.

Stroke in young adults: clot-type strokes behind the rise

Strokes come in two broad kinds. Ischemic strokes happen when a clot or narrowed artery cuts off blood flow to part of the brain. Hemorrhagic strokes happen when a blood vessel in or around the brain bursts and bleeds. Most of the increase among younger adults came from the clot-type strokes, whose rate roughly doubled, from about 24 to about 47 cases per 100,000 people a year. Bleeding strokes showed no clear trend in either direction.

People in their 40s and early 50s were not the only ones affected. Adults ages 20 to 39 saw their stroke rate climb from about 12 to about 21 per 100,000 a year. Among those 40 to 54, it rose from about 72 to about 125.

An obvious question is whether doctors are simply finding more strokes than they used to. MRI scans, which can spot small strokes that older imaging misses, went from being used in about a third of young stroke patients in 1993/94 to nearly 80% in 2020. Researchers offer three reasons better scanning does not explain the trend. Earlier work in this same population found that MRI confirmed strokes and ruled out false alarms at roughly equal rates, so its effect on the overall count was small. If scans were catching more mild strokes, the share of clot-type stroke patients who died should have dropped, and it did not. And if sharper imaging were inflating the numbers, rates among older adults should have gone up too. Instead, they fell.

Rising risk factors among younger stroke patients

Young people who had strokes in 2020 looked different on paper from their counterparts in the 1990s. Six in 10 had high blood pressure, up from just under half. About a quarter had diabetes, up from 19%. Atrial fibrillation, an irregular heartbeat that allows clots to form in the heart and travel to the brain, climbed from about 1% of patients to about 6%. In line with that rise, strokes caused by clots from the heart grew from about 10% of clot-type strokes to about 18%, the only cause whose share of cases climbed over time.

Drug use showed the biggest jump. In 1993/94, fewer than 5% of young stroke patients had documented use of cocaine, marijuana, methamphetamine, heroin, nonprescribed opioids or other illegal drugs. By 2020, about 40% did. Marijuana accounted for much of that change, with documented use rising from under 1% of patients to nearly 31%. Tobacco smoking and heavier drinking, by contrast, held fairly steady.

Those figures come with a large asterisk. Because the study tracked only people who had strokes, it cannot show whether drug use, blood pressure or anything else caused the increase. Hospitals may also be asking about and recording drug use more carefully than they did 30 years ago, although the authors point out that national surveys show drug use climbing as well. Cocaine and methamphetamine are widely accepted as stroke risk factors. Marijuana is less settled, and the authors call it “at least a modest stroke risk factor, although additional study is needed.”

Other pieces of the puzzle sit outside the study’s data. Researchers cite national figures showing that high blood pressure and diabetes have grown more common in younger adults without a matching rise in treatment. They also flag obesity, which is widespread among young adults and rising nationally, though the study did not collect weight information.

More young stroke survivors, more years of recovery

Survival offers the one hopeful thread. After accounting for age, race and sex, the share of young stroke patients who died within 30 days fell from 11.7% to 9.4%. Among older adults, that number barely budged: 14.3% in 1993/94 and 14.2% in 2020.

Most of the improvement came among people with bleeding strokes. Deaths within a month of bleeding inside the brain fell from 27.5% to 21.2%. For bleeding in the space surrounding the brain, often from a burst bulge in an artery, deaths dropped from 27.9% to 18.6%, though that decline was not strong enough to rule out chance. Over the years, more of these patients were treated at hospitals with neurological intensive care units, while rates of surgery stayed flat. Better brain imaging and catheter-based procedures for repairing burst arteries may also have helped, according to the authors.

Those survival gains also help explain recent headlines about rising stroke deaths among younger Americans. According to the researchers, that rise most likely reflects more strokes happening, not strokes becoming deadlier. A stroke at 40 can mean decades of living with stroke-related disability, a toll the authors note also falls on families and society.

Adults 55 and older in the region saw their stroke rates fall over the same years. Younger adults there did not share in that progress. Researchers urge doctors to identify and treat risk factors aggressively, “even among well-appearing young adults.” A high blood pressure reading at 35 deserves the same attention it would get at 65, because in Cincinnati, stroke is no longer waiting for retirement.

---