ISC 2009: Women with Stroke, TIA, More Likely Than Men to Report Mental Status Change

Caroline Cassels

February 24, 2009

February 24, 2009 (San Diego, California) — Women who suffer a stroke or transient ischemic attack (TIA) are more likely than men to report nontraditional symptoms, particularly altered mental status, new research suggests.

Presented here at the American Stroke Association International Stroke Conference 2009, the prospective, observational study found women were 43% more likely than men to report nontraditional stroke symptoms, including pain, mental-status change, lightheadedness, headache, or other neurological and nonneurological symptoms.

When researchers examined these nontraditional symptoms individually, they found mental-status change — defined as disorientation, confusion, or loss of consciousness — was the main driver of this finding.

"Twenty-three percent of women reported mental-status change in comparison with 15% of men, and this was a significant difference between the genders," study investigator Lynda Lisabeth, PhD, from the University of Michigan, in Ann Arbor, told reporters attending a press conference.

Recent evidence shows that there are a number of sex disparities in stroke care, including the fact that women take longer to get to the hospital, experience longer in-hospital delays, and are significantly less likely than men with ischemic stroke to receive tissue plasminogen activator (tPA).

Impact on Care?

"One of the ideas behind this is that perhaps women present in a different or a more atypical way and that this somehow impacts their care once they get to the hospital," she said.

Furthermore, she added, a previous study conducted by investigators at University of Texas at Houston found that, in a nonurban Texas population of stroke patients, women were more likely to present with "nontraditional" stroke symptoms than men.

"We wanted to try to build on this study and better understand whether or not these results would confirm or refute the findings of the Texas study in a different stroke population," said Dr. Lisabeth.

The study included 461 (48.6% women) cases of ischemic stroke/TIA presenting to the University of Michigan Hospital between January 2005 and December 2007. Prevalence of any nontraditional symptom and each symptom were calculated by sex.

Among women, 51.8% (116) reported the presence of at least 1 nontraditional stroke/or TIA symptom or more vs 44% (104) of men. Isolated nontraditional symptoms were extremely rare and occurred in 4% of women vs 3% of men.

Consistent Results

While the association of sex and nontraditional symptoms was of borderline significance (P = .07), Dr. Lisabeth said she believes this finding is meaningful, particularly in light of the fact that these findings support the previous results from the Texas study.

"I believe if we had a larger sample size, this finding would likely have been significant, and what convinces me is that the results were so consistent with the Texas study, which was conducted in a completely different patient population," Dr. Lisabeth told Medscape Psychiatry in a follow-up interview.

Commenting on the study, American Stroke Association spokesperson Brian Silver, MD, from Henry Ford Hospital, in Detroit, Michigan, agreed that the study sends a signal that the finding of altered mental status in women is important.

"The point in this study is that all the numbers were trending in the same direction. When you see a trend like that, the implication is that there just wasn't a large enough denominator to push it to statistical significance. Had there been a larger number of patients, it almost certainly it would have been statistically significant," Dr. Silver told Medscape Psychiatry.

Changing Messages May Be Premature

Whether the current public stroke-education messages, including the "Give Me5" message endorsed by the American Stroke Association, should be tailored to address the possibility that women may also experience less typical symptoms, possibly in conjunction with traditional symptoms, is open to debate, said Dr. Lisabeth.

However, she pointed out that although rare, isolated nontraditional symptoms still affect 4% of the female population, which is still an important proportion of the stroke population.

Dr. Silver says at this point it may be premature to change the current stroke message. However, he added, the study highlights an important issue that warrants further study.

"It would be helpful to know whether adding nontraditional symptoms, and particularly altered mental status, to the [stroke] messaging would increase the diagnostic yield clinically and increase the percentage of individuals presenting early. These are 2 key questions that we don't have the answers to at this point. However, if future data corroborate this finding, I think it would be a very reasonable change to make," he said.

The study was funded by the University of Michigan. The authors report no financial disclosures.

American Stroke Association International Stroke Conference 2009: Abstract 82. Presented February 19, 2009

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