Strokes different in men vs. women

The woman had been at a financial planning conference when she suddenly had double vision. It eventually returned to normal. Still, over the next few days, she realized she was having a hard time reading. The problem ultimately led her to the office of Barbara Kostick, MD, a family physician in Freemont, Calif.

This scenario is not usually considered a stroke, but that's exactly what it was -- a small stroke.

"These were atypical symptoms," Dr. Kostick said. "And she didn't run to emergency room."

It is stories such as these, along with increasing evidence that women's stroke symptoms could be very different from men's and that this variation might contribute to significant disparities in outcomes, that have prompted scientists to start investigating the circumstances prospectively.

Researchers at the University of Michigan Health System, Ann Arbor, announced last month that they are interviewing every man and woman presenting to their emergency department with any sign of a stroke. The goal is to determine what patients felt and how they described it in hopes of confirming various stroke-related gender differences.

"Men have more classical symptoms of stroke, but women are experiencing other symptoms," said Lewis Morgenstern, MD, director of the University of Michigan Comprehensive Stroke Program. "We may have to go back and change the textbooks."

Looking for reasons

This research is in part an outgrowth of the emerging awareness that cardiovascular disease strikes women at high rates, and, much like heart attacks, how women present could play a role in higher death and disability rates. Epidemiological data suggest that women tend to take longer to get to the emergency department, if they make it there at all.

Once there, they might not receive care as quickly. Women also are more likely to die of stroke and, if they survive, have a greater degree of disability.

"If women are experiencing non-traditional stroke symptoms, they may be unaware that they're having a stroke, and this may result in a delay in seeking care and getting to the hospital," said Lynda Lisabeth, PhD, the study leader and a research investigator in Michigan's neurology department. "Once at the hospital, it could actually result in a delay in getting acute stroke therapy."

One reason for the disparity may be that when women have strokes, they are more likely to experience limb pain or a decreasing sense of consciousness than the classic sudden numbness on one side of the body. Women might not take these symptoms as a need to call their primary care physicians or go to an emergency department. And once a woman with such symptoms is in contact with the health system, physicians and other health care workers might not fully appreciate the urgency.

Researchers hope this line of inquiry will lead to improved triage, particularly when the patient makes the first call -- many times to a primary care physician.

"Primary care physicians are the most important caregivers of stroke, and often the point of first contact," Dr. Morgenstern said. "I hope every primary care physician will be able to screen for stroke, not delay in any way and tell them to call 911."

But many experts suspect the disparities could go beyond variations in symptoms. Women also might interpret those symptoms differently. For example, a severe headache might make a man think of a stroke or other catastrophic illnesses, but women often are more familiar with headache pain and not as alarmed by it.

"When my husband has a headache, he thinks brain tumor," said Louise McCullough, MD, PhD, assistant professor of neurology and neuroscience at the University of Connecticut, Farmington. She is also a grant recipient of the Hazel K. Goddess Fund for Stroke Research in Women. "I think migraine."

Women also might communicate about their symptoms differently, playing down their seriousness.

"Women don't complain about a lot of things. They say they had a little spell when they didn't speak so well, and atypical symptoms are just passed off," said Mary Elizabeth Roth, MD, a family physician and vice president of medical affairs at Sacred Heart Hospital in Allentown, Pa.

Demographic factors could play a role. Strokes tend to hit women at an older age than men when they have more co-morbidities.

"Men tend to be dragged in by a spouse, but by the time women have a stroke, they've usually outlived their partner and tend to be very isolated," Dr. Roth said.

In addition there is some evidence that even if all these hurdles are overcome, women might not get the care they need. For the only effective treatment of stroke to work, it must be administered within three hours of an event. A recent study published online in the Annals of Emergency Medicine last month suggests that even in the perfect situation, it still might not be given within the time window.

Other research also conducted at the University of Michigan Health System surveying emergency department physicians found that 40% were not likely to use the clot-busting drug recombinant tissue plasminogen activator, primarily because of the risk of hemorrhage and a perceived lack of benefit. The authors say this is an indication of the need for stronger support across disciplines for its use.

"Emergency physicians are unlikely to use rtPA unless there is an institutional commitment to deliver thrombolytic treatment to acute patients. This includes cooperation from neurology, radiology and emergency medicine," said William G. Barsan, MD, one of the authors and chair of the Dept. of Emergency Medicine.