My wife (age 35), had a stroke last year, caused by a ICAD (one of her two carotid arteries dissected -- tore -- leading to a loss of blood flow). Hers was 100% occluded. Although some ICADs are traumatic, e.g. from car crashes or bungee jumping or chiropractors, many are not. If you can't point to an obvious moment of knowing when you had one, and if you don't test positive for Ehlers-Danlos or other connective tissue problems, they just shrug and deem it idiopathic/spontaneous.

She has what the doctors say are "excellent collaterals", meaning her other blood supply routes were great, and it took less than 90 minutes from stroke to teatment. It was a wake-up stroke and it took maybe 10 minutes for us to call emergency. tPA (side note: tPA is a miracle drug; it clears your system in maybe 2-3 minutes, I'm talking about my wife going from near-death and in full stroke presentation to being alert and having a normal conversation in literally 2 minutes), thrombectomy, immediate management of blood pressure. No further episodes after the beginning of treatment being administered. Discharged after only 7 days in hospital. MRIs show 3 or 4 small dots of infarct. The neurologist characterized the dots as being unconcerning, and further noted that if she was 55 or 60, they'd expect that level of damage to have accumulated just from living. Post-discharge treatment was just blood thinners for 6 months, at the 3 month update doctor said they could easily take her off; she's banned from rollercoasters and olympic weightlifting for life and we need to talk to an obstetrician to figure out if they'll recommend a c-section for any future pregnancies. 3 month followup MRI indicates her carotid never re-opened and never will, so now she's just living with one fewer major redundancy.

TBIs are weird. My wife returned to work after about 3 weeks. I would say her work performance was unaffected. On the other hand, she had sudden and overwhelming bouts of tiredness that seemed to come on with no warning. She'd go walk 5k no problem, but then other times she'd get so exhausted from making lunch she'd have to sleep the entire day. She had a lot of random head pains. Not headaches, but weird and unknown pains in her head. The doctors say both of these things are common post-stroke symptoms and they've improved a bunch over the last six months and will likely subside. She had a work-related OT visit 4 months after stroke that showed normal cognitive function except that she got a bout of extreme tiredness half-way through the day. She's mostly coped by WFH and taking breaks or naps during the day and working extended hours to catch up.

Why should random small infarcts cause this? It's unclear. We tend to have a picture of neuroanatomy that is functionalist, with particular parts of the brain serving particular functions, and so it would seem like small dots of damage should either do nothing or else impact diffuse things weirdly, not cause big systemic problems like this.

The other component is pretty severe PTSD. She's in stroke support groups for young stroke survivors (read: 60 year olds...). She has survivor's guilt when she meets people who had it worse than her. She gets upset when stuff in the news is about people who had strokes. There's been a few times where it's felt like she didn't realize she had a near-death experience, and so when I have had to talk about my own feelings with family members or friends, I think it's been jarring for her to hear how much danger she seemed in from the outside. I can't rule out that some of the big feelings are also a result of the neuroanatomical insult, but most of it seems just processing everything.

I guess the final thing is that it seems to me like she's more forgetful. More lights left on, more stuff left out, more "what did I come to this room to do?". Could this be the symptom of a TBI? Unclear if this is a real pattern or just my hyper-vigilance, and if real if it's actually caused by the stroke or something else.

For anyone else reading: Stroke morbidity and mortality is tied ENTIRELY to the speed of response. Balance, Eye Gaze, Facial Droop, Arm Weakness, Speech. If you see a symptom that might be a stroke, call emergency services immediately. Waiting an hour will compound damage significantly, and waiting 4 closes off most avenues of treatment.