Sex Differences in Presentation and Outcome After an Acute Transient or Minor Neurologic Event

Abstract

; for the SpecTRA Study Group IMPORTANCE 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. OBJECTIVE 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). EXPOSURES 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. RESULTS 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.

Sex-Related Differences in Clinical Features, Neuroimaging, and Long-Term Prognosis After Transient Ischemic Attack

“… 27 However, in our study the proportion of migraine was similar in both sexes, the rate of atypical TIA was lower than previously described, 15 and no significant differences between sexes were observed for late SR. To the best of our knowledge, this is the first time that differences between sexes have been analyzed in a cohort of consecutive patients with TIA in long-term follow-up. Previous studies of differences between sexes in outcomes after TIA or minor strokes reported the same risk of SR after 30 days, 28 90 days, 4 and 1 year 28 of follow-up. In our study, LAA was the main predictor of SR in both sexes, with the risk of SR falling after the first five years of follow-up.…”

“… 2 , 3 Even so, only limited data are available about differences in sex relating to its clinical presentation, cause, imaging features, and prognosis after a transient ischemic attack (TIA). Yu et al 4 recently observed a similar risk of subsequent vascular events between sexes in a prospective cohort of patients with minor stroke. The early risk of stroke after a TIA is high 5 , 6 and urgent management is required 7 ; however, few studies have focused on the long-term risk of stroke after TIA.…”

Sex differences in Cerebral Small Vessel Disease: a systematic review and meta-analysis

“…Furthermore, women with stroke often present with non-traditional symptoms like altered mental status 28 , which could be overlooked or misdiagnosed in the clinical setting. 29,30 Sex differences in clinical presentations are also present in dementia 31 but none of the included studies reported these in VaCI or VaD. Moreover, informal carers of dependent persons in the UK are more likely to be middle-aged women with multiple roles until later life (70+).…”

The impact of loneliness on healthcare use in older people: evidence from a nationally representative cohort

“…For instance, there are known to be significant differences between men and women in relation to symptom reporting, with women reporting more intense, more numerous and more frequent symptoms compared to men (Barsky et al 2001). Despite this generally increased symptom reporting, however, research has also demonstrated that women may be less likely to receive diagnoses, as has been shown in the case of stroke, for instance (Yu et al 2019). In the current study, we controlled for doctor-diagnosed conditions as part of a mediation analysis to see if health might explain associations between loneliness and increased HCU, but if women were less likely to receive these diagnoses, this could have impacted our results.…”