Canadian study encourages doctors to look beyond typical symptoms for stroke
Women experiencing a minor stroke or transient ischemic attack (TIA) are less likely to be diagnosed with a stroke compared to men -- even though they describe similar symptoms in emergency departments.
"In our study, men were more likely to be diagnosed with TIA or minor stroke, and women were 10 per cent more likely to be given a non-stroke diagnosis, for example migraine or vertigo, even though men and women were equally likely to report atypical stroke symptoms," says study lead author Dr. Amy Yu, MD, a stroke neurologist at Sunnybrook Health Sciences Centre and assistant professor at the University of Toronto.
The findings of the study are published in JAMA Neurology and were presented May 22 at the European Stroke Organisation Conference in Milan, Italy.
The study found men and women equally described atypical stroke symptoms such as dizziness, tingling or confusion which are not commonly thought of as related to stroke. Typical symptoms of stroke are sudden weakness, face drooping, or speech difficulties.
A TIA occurs when there is temporary interruption of blood flow to the brain, and is often a warning sign of another stroke. TIAs can also be associated with permanent disability.
Discrepancy in diagnoses
"Our study also found the chance of having another stroke or heart attack within 90 days of the diagnosis was the same for women and men," adds senior author Dr. Shelagh Coutts, MD, a stroke neurologist with Alberta Health Services at Foothills Medical Centre, associate professor at the University of Calgary's Cumming School of Medicine (CSM) and member of the Hotchkiss Brain Institute at the CSM.
Researchers say while further research is needed, it is possible that patient reporting of symptoms, interpretation of symptoms by clinicians, or a combination of both, could explain the discrepancy in diagnosis among men and women.
"Our findings call attention to potential missed opportunities for prevention of stroke and other adverse vascular events such as heart attack or death in women," adds Coutts.
Previous studies on this topic have focused on patients diagnosed with stroke. Researchers in the current study included 1,648 patients with suspected TIA who were referred to a neurologist after receiving emergency care from 2013-2017, regardless of their final diagnosis.
Spotlight on atypical symptoms
Researchers note it is an important opportunity for the public and clinicians to be aware of atypical symptoms of TIA.
"What's important to recognize in stroke is that the brain has so many different functions and when a stroke is happening, people can feel different things beyond the typical stroke symptoms," says Yu. "Accurately diagnosing TIA and stroke would change a patient's treatment plan and could help prevent another stroke from happening."
Sex differences have been described in the presentation, care, and outcomes among people with acute ischemic strokes, but these differences are less understood for minor ischemic cerebrovascular events. The present study hypothesized that, compared with men, women are more likely to report nonfocal symptoms and to receive a stroke mimic diagnosis.
To evaluate sex differences in the symptoms, diagnoses, and outcomes of patients with acute transient or minor neurologic events.
DESIGN, SETTING, AND PARTICIPANTS:
This prospective cohort study of patients with minor ischemic cerebrovascular events or stroke mimics enrolled at multicenter academic emergency departments in Canada between December 2013 and March 2017 and followed up for 90 days is a substudy of SpecTRA (Spectrometry for Transient Ischemic Attack Rapid Assessment). In total, 1729 consecutive consenting patients with acute transient or minor neurologic symptoms were referred for neurologic evaluation; 66 patients were excluded for protocol violation (n = 46) or diagnosis of transient global amnesia (n = 20).
The main exposure was female or male sex.
MAIN OUTCOMES AND MEASURES:
The main outcome was the clinical diagnosis (cerebral ischemia vs stroke mimic). Secondary outcomes were 90-day stroke recurrence and 90-day composite outcome of stroke, myocardial infarction, or death. The association between presenting symptoms (focal vs nonfocal) and clinical diagnosis was also assessed. Research hypotheses were formulated after data collection.
Of 1648 patients included, 770 (46.7%) were women, the median (interquartile range) age was 70 (59-80) years, 1509 patients (91.6%) underwent brain magnetic resonance imaging, and 1582 patients (96.0%) completed the 90-day follow-up. Women (522 of 770 [67.8%]) were less likely than men (674 of 878 [76.8%]) to receive a diagnosis of cerebral ischemia (adjusted risk ratio [aRR], 0.88; 95% CI, 0.82-0.95), but the 90-day stroke recurrence outcome (aRR, 0.90; 95% CI, 0.48-1.66) and 90-day composite outcome (aRR, 0.86; 95% CI, 0.54-1.32) were similar for men and women. No significant sex differences were found for presenting symptoms. Compared with patients with no focal neurologic symptoms, those with focal and nonfocal symptoms were more likely to receive a diagnosis of cerebral ischemia (aRR, 1.28; 95% CI, 1.15-1.39), but the risk was highest among patients with focal symptoms only (aRR, 1.45; 95% CI, 1.34-1.53). Sex did not modify these associations.
CONCLUSIONS AND RELEVANCE:
The results of the present study suggest that, despite similar presenting symptoms among men and women, women may be more likely to receive a diagnosis of stroke mimic, but they may not have a lower risk than men of subsequent vascular events, indicating potentially missed opportunities for prevention of vascular events among women.
Amy Y. X. Yu, Andrew M. Penn, Mary L. Lesperance, Nicole S. Croteau, Robert F. Balshaw, Kristine Votova, Maximilian B. Bibok, Melanie Penn, Viera Saly, Janka Hegedus, Charlotte Zerna, Evgenia Klourfeld, Lisa Bilston, Zachary M. Hong, Shelagh B. Coutts. Sex Differences in Presentation and Outcome After an Acute Transient or Minor Neurologic Event. JAMA Neurology, 2019; DOI: 10.1001/jamaneurol.2019.1305
Content created 23 May 2019