Minor Stroke, TIA Diagnosis More Often Missed in Women

May 31, 2019

Despite presenting with similar acute transient or minor neurologic symptoms, women were more likely than men to be diagnosed as having had a stroke mimic rather than an ischemic cerebrovascular event, but 90-day stroke recurrence rates were similar between the two sexes, according to findings from a new study.

In addition, fewer women than men were found to have evidence of stroke on MRI, but for those patients whose MRI findings were irregular, women were more likely than men to undergo incomplete assessment.

"Our findings suggest there is a greater risk of missed diagnosis of cerebral ischemia in women compared with men presenting with minor or transient neurologic symptoms, and women may be particularly vulnerable to misdiagnosis when there is no evidence of ischemia on MRI," said study author Amy Yu, MD, Sunnybrook Health Sciences Center, Toronto, Canada.

Yu presented the findings at last week's 5th European Stroke Organisation Conference (ESOC) 2019. The study was also published online in JAMA Neurology on May 22.

Yu explained to Medscape Medical News that several previous studies have suggested that women are more likely to report atypical symptoms of stroke and transient ischemic attack (TIA) than men, but this was not the case in the current study.

"We found similar symptoms in the two genders, with both men and women reporting a high frequency of nonfocal symptoms, such as headache, dizziness, confusion. Our findings throw into question the idea that women have different symptoms of a minor cerebrovascular event than men," she said.

The results also suggest that the presence of such nonfocal symptoms should not deter clinicians from assessing for possible stroke or TIA, she added. "And for the public, it's not just the typical FAST [face, arm, speech, time] symptoms that should raise alarm. Experiencing other more nonspecific symptoms, such as dizziness or confusion, is also a reason to seek medical attention," she said.

The researchers found that among patients whose MRIs showed changes indicative of a minor stroke, subsequent assessments were similar among men and women, but among those whose MRIs did not show changes — the group for whom there is the most diagnostic uncertainty — fewer women than men underwent complete assessment.

"This raises the question of whether there is an unconscious bias — if we think a woman is experiencing a stroke mimic, would we say the same thing if it was a man?" Yu commented.

She added: "I don't think this is necessarily a case of doctors not taking women seriously. It may be more related to the observation that women are more likely to have a history of migraine or other stressors which may cause them to be more frequently diagnosed with a stroke mimic rather than an ischemic cerebrovascular event."

Yu noted that this study is different from most others in that it included patients who had presented at the emergency department and who had been referred to the neurology department for a suspected stroke/TIA, rather than patients who had already received a diagnosis of stroke or TIA. "We think our approach minimizes ascertainment bias," she said.

The current prospective cohort study is a substudy of the SpecTRA (Spectrometry for Transient Ischemic Attack Rapid Assessment) trial. It involved patients with acute transient or minor neurologic symptoms who were referred for neurologic evaluation at academic emergency departments in Canada between 2013 and 2017. Patients were followed for 90 days.

Of 1648 patients who were included in the study, 46.7% were women. The median age was 70 years, and 91.6% underwent brain MRI.

Results showed that women were less likely than men to receive a diagnosis of cerebral ischemia (67.8% vs 76.8%; adjusted risk ratio [aRR], 0.88; 95% confidence interval [CI], 0.82 – 0.95), but the 90-day stroke recurrence outcome (aRR, 0.90; 95% CI, 0.48 – 1.66) and the 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 regarding presenting symptoms. Compared with patients who did not have focal neurologic symptoms, those with focal and nonfocal symptoms were more likely to receive a diagnosis of cerebral ischemia (aRR, 1.28), but the odds of receiving such a diagnosis were higher for those who only had focal symptoms (aRR, 1.45). Sex did not modify these associations.

Among those who received a diagnosis of minor ischemic cerebrovascular event, there was no MRI evidence of ischemia for 47.3% of women, compared with 39.8% of men.

Among patients for whom there was no MRI evidence of a cerebrovascular event, 25% of women underwent incomplete assessment, compared to 13% of men.

Of those patients with 90-day recurrent stroke, results of the initial MRI scan were positive for 63% of men, compared to just 33% of women.

Funding for the study was provided by Genome British Columbia, Genome Alberta, and Genome Canada. Yu has disclosed no relevant financial relationships.

J AMA Neurol. Published online May 22, 2019. Abstract

5th European Stroke Organisation Conference (ESOC) 2019. Presented May 22, 2019.

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