Stroke: The Other Killer

Stroke, like heart disease, is a deadly condition related to blood flow—only here, we’re looking at blood flow to the brain rather than to the heart.
Just as with heart disease, women have their own risk factors and presentation for stroke, few of which overlap with the male model. During a stroke, men often suffer a sudden loss of function on one side of the body. They may have drooping eyelids, garbled speech, and numbness—all the things we traditionally associate with stroke. Women, on the other hand, may have a headache akin to a migraine or a sudden change in mental or emotional status—and unless their providers know what to look for, they can be misdiagnosed or not diagnosed at all.
A great example of this happened in the ED recently. Often, during a shift change, the incoming staff have the opportunity to evaluate patients who haven’t been formally diagnosed or discharged to other parts of the hospital. Earlier in the day, before I arrived, an elderly woman, whose nickname was Birdie, had been sent in by her nursing home. She’d had some mental-status changes that morning, was complaining of a headache, and had been struggling with her hand coordination. The nursing home staff thought she might have a urinary tract infection (UTI), which often causes mental-status changes and is common in elderly women. Her urine had been sent for analysis, but the test results weren’t back yet.
“Have you considered stroke?” I asked the outgoing staff.
“But she just has a headache,” someone replied—as if that excluded a stroke diagnosis.
Birdie’s urinalysis came back normal, so my team went back to examine her a second time. We called the neurologist and ordered an MRI. The images indicated that Birdie did, in fact, have signs of stroke.
Stroke is the third-leading killer of women in the United States today. It kills twice as many women as breast cancer! However, the unique manifestations of stroke in women have only recently been discovered, and many physicians still do not understand the differences in risk and symptoms when assessing men and women. Therefore, stroke is often misdiagnosed—as it almost was for Birdie.
For example, men are slightly more likely than women to have transient ischemic attack (TIA), meaning small strokes with symptoms that go away after a few minutes, hours, or days, which are often hard to diagnose after they recede. However, more than half of all stroke deaths occur in women.
I believe that this could be partially related to the fact that TIA symptoms may be described differently by women than men.
If part of the brain is not getting blood and that part of the brain is only responsible for a small part of the body or a particular cognitive function, the symptoms may not seem “stroke-like.” Women will come in with complaints like, “This weird thing happened today. I talked funny for five minutes, but now I’m fine.” Or “I had total brain fog for an hour today, but everything seems okay now.” When we look for evidence of a blood clot or impaired blood flow in the brain, we can’t find anything, because the blood clot has already dissolved. This makes TIA extremely difficult to diagnose but also contributes to the subjective perception that women are more likely to exaggerate symptoms.
Because of situations like these, women’s strokes are often misdiagnosed, brushed off, or mistaken for other common ailments, including UTIs, migraine, and—yes, you guessed it—anxiety. This can lead to a potentially deadly delay in treatment.

In general, a fear of adverse effects in women seems to pervade the medical mentality, and this affects how women are treated for stroke. For example, one study that looked at prescription of the anticoagulant dabigatran found that women were generally prescribed a lower dose, despite the fact that prescribing guidelines were the same for both men and women. Men were more likely to be given the recommended 150 mg dose for blood clot and stroke prevention, while women were more likely to receive the lower 110 mg dose.21 Women had consistently poorer outcomes on this drug—unless they were prescribed the standard 150 mg dose, at which point their results improved. When asked why they chose the lower dose for women, many prescribers cited the greater chance of women falling down and injuring themselves as a reason to give less of the anticoagulant (since any cuts or injuries could result in excessive bleeding while on this medication), despite the fact that they had no data to back up this assertion. Thus, the perception among doctors that women were more likely to fall led to routine underprescribing of a lifesaving drug.
This is indicative of a broader problem, which is the perception that women are inherently weaker than men and need to be protected. We’ll discuss this unconscious bias in more depth in Chapter 8, but it applies here in the sense that women routinely have to try far harder to get the right care and then are expected to apologize for continuing to seek the care they need when they don’t receive it on the first, second, or third try.
The best thing that women can do is to know their risk factors. For example, migraine with aura is a risk factor for ischemic stroke, and as many as 70 percent of migraine sufferers are women. Other risk factors include high blood pressure, using birth control pills or other synthetic hormones, and pregnancy.22 African American women are twice as likely to have a stroke as white women of the same age; this is due to several factors, including sickle-cell anemia (the most common genetic disorder in African Americans) and the fact that black women tend to have higher rates of high blood pressure, obesity, and diabetes.23
It’s also vital for women to know the female-specific symptoms of stroke. A standard Google search for “stroke symptoms” will produce multiple images of men having strokes but little about women’s presentation. A prospective, observational study presented at the American Stroke Association International Stroke Conference noted that “women were 43% more likely to report non-traditional stroke symptoms such as pain, changes in mental status, lightheadedness, headache, or other neurological and non-neurological symptoms.”24
Therefore, women need to be aware that any or all of the following symptoms could indicate stroke:

  •  Loss of consciousness/fainting
  • General weakness
  • Shortness of breath or difficulty breathing
  • Confusion, disorientation, or unresponsiveness
  • Sudden behavioral changes or changes in mental status
  • Agitation
  • Nausea or vomiting
  • Hiccups
  • Headache
  • Pain, including neck pain or pain in the extremities
  • Seizures

As you can see, the symptoms of stroke in women often overlap with other conditions. This creates lack of recognition, which in turn results in delayed treatment and poorer outcomes. However, the most effective treatments for stroke—like the clot-busting drug tPA—are only available if the stroke is recognized and diagnosed early; otherwise, irreversible damage to the brain or blood vessels may occur. My colleague Tracy Madsen, MD, associate director of the Division of Sex and Gender in Emergency Medicine at Brown University’s Department of Emergency Medicine and one of the country’s leading researchers of sex differences in stroke, led a study that filled a critical knowledge gap in this area. In “Analysis of Tissue Plasminogen Activator Eligibility by Sex in the Greater Cincinnati/Northern Kentucky Stroke Study,” Madsen et al. proved that although there are some small differences in individual tPA exclusion criteria, overall, women and men have similar eligibility for use of this lifesaving drug.25
This raises the question, If criteria for tPA use are similar for women and men, why did a review study published by the Journal of the American Heart Association find that women were 30 percent less likely to receive tPA than their male counterparts?26 In that study, researchers Matthew Reeves, PhD, et al. concluded, “Despite the presence of significant between-study variation, women with acute stroke were consistently less likely to receive thrombolysis treatment compared with men. Further studies to explore the origins of this sex disparity are warranted.”
Dr. Madsen’s evidence suggests that any disparities in the use of tPA are potentially related to biases in care—including delayed recognition due to lack of information about female-pattern stroke. Such bias might contribute to other issues as well—such as why women have consistently worse recovery times after stroke than men and why they are more likely to live in a long-term healthcare facility after a stroke event.
TO ME, all of this information fits into a pattern.
1. Women have worse outcomes in this area, including heart attack and stroke. Why? →
2. Do both men and women get the same treatments? No? →
3. Why don’t men and women receive the same treatments? Is it because they are not eligible for those treatments? Did they undergo the same diagnostic tests? No? →
4. Do healthcare providers recognize the same disease in women as they do in men? Do women present differently? Yes? →
5. Why do women present differently? Is it because of an actual physical difference in disease pathology or because of a gender or cultural norm?
We should be asking this series of questions every time we are asked to diagnose or treat a woman.
My research division studies these patterns. We try to work backward to find the root cause and ultimately make a change in the foundational educational materials and treatment protocols for the condition. There’s no question that women are biologically different and unique; we need to keep digging up all the areas where this difference is at play and adjust our conclusions accordingly.

References:

  • Meytal Avgil Tsadok, PhD, et al., “Sex Differences in Dabigatran Use, Safety, and Effectiveness in a Population-Based Cohort of Patients with Atrial Fibrillation,” Circulation: Cardiovascular Quality and Outcomes 8 (2015): 593–599. doi: 10.1161/CIRCOUTCOMES. 114.001398.
  • “Women and Stroke,” CDC.gov, https://www.cdc.gov/stroke/docs/women_stroke
  • “Women and Stroke.”
  • Caroline Cassels, “ISC 2009: Women with Stroke, TIA, More Likely Than Men to Report Mental Status Change,” Medscape, February 24, 2009, https://www.medscape.com/viewarticle/588640.
  • T. E. Madsen et al., “Analysis of Tissue Plasminogen Activator Eligibility by Sex in the Greater Cincinnati/Northern Kentucky Stroke Study,” Stroke 46, no. 3 (2015): 717–721. doi: 10.1161/STROKEAHA.114.006737.
  • Mathew Reeves, PhD, et al., “Sex Differences in the Use of Intravenous rt-PA Thrombolysis Treatment for Acute Ischemic Stroke: A Meta-Analysis,” Stroke 40 (2009): 1743–1749, https://www.ahajournals.org/doi/pdf/10.1161/STROk

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