The year 2016 ended with hemorrhagic stroke in the mainstream news around the world. Most of you have already heard the story of Carrie Fisher and Debbie Reynolds at this point – a daughter’s unexpected death followed by the surprise of her mother’s passing within a day.
Patients frequently ask me if stress can cause stroke, and many younger adults report that at the time they sustained their strokes, they were under a great deal of either professional or personal (or both) stress. When I was training to become a physician, I asked this question, and was told that there was no definitive evidence linking stress to stroke. Over the years, though, I question this for a number of reasons.
First of all, studying stress is more challenging than studying diabetes or high cholesterol, where there are reliable lab values that can be tracked. Some studies follow levels of cortisol, a hormone released by the adrenal glands, but cortisol levels do not necessarily reflect the degree of stress that patients subjectively report experiencing. Also, an individual may report severe levels of stress on a questionnaire in response to what may seem to be a relatively benign situation, while another could claim to have “mild” stress during a period of great hardship. Patients can underreport their levels of stress too.
Okay, so if we can’t easily study stress, what does that mean in terms of whether it is associated with stroke risk? It is probably worth deciphering the downstream effects of stress that can be measured to answer this question.
I tell patients that stress can send blood pressure surging, and high blood pressure is a risk factor for stroke. With the release of cortisol during stressful periods, this can result in an increase in blood sugar levels (glucose), and if prolonged could theoretically lead to the development of insulin resistance and/or diabetes. Stress causes sleep disruption, and insomnia can place patients at risk for health complications. So does stress cause stroke? I would say that if an ongoing level of stress that continuously leads to stroke risk factors is present, then perhaps it can.
Back to Debbie Reynolds now. There is stress, and then there is distress. To the best of my knowledge, she was not living with chronic stress, but endured a sudden, unexpected, severe form of emotional distress with the news of her daughter’s unanticipated death. I was not surprised when her death certificate revealed her cause of death as “intracerebral hemorrhage” (bleeding within the brain). I have met patients who have collapsed into unconsciousness with these hemorrhages when receiving intensely upsetting news, such as the unexpected death of a loved one, or notification of eviction from their homes. I suspect there is a sudden increase in catecholamine levels (stress hormones released as part of our fight-or-flight responses), causing a spike in blood pressure, and the rupture of a small artery in the brain under such pressure. It is difficult to study hormonally what is occurring during a time of such intense emotional distress just prior to an intracerebral hemorrhage though.