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. 2019 Aug 1;76(8):962-968.
doi: 10.1001/jamaneurol.2019.1305.

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

Amy Y X Yu  1 , Andrew M Penn  2 , Mary L Lesperance  3 , Nicole S Croteau  3 , Robert F Balshaw  4 , Kristine Votova  5 , Maximilian B Bibok  6 , Melanie Penn  2 , Viera Saly  2 , Janka Hegedus  2 , Charlotte Zerna  7 , Evgenia Klourfeld  8 , Lisa Bilston  8 , Zachary M Hong  8 , Shelagh B Coutts  7   8   9   10 ; SpecTRA Study Group
Affiliations

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

Amy Y X Yu et al. JAMA Neurol. .

Abstract

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Drs Votova, Bibok, and Hegedus reported receiving grants from Genome Canada, Genome Alberta, Genome British Columbia, and the Heart and Stroke Foundation of Canada during the conduct of the study. Dr Saly reported receiving grants from Genome Canada during the conduct of the study. Dr Klourfeld reported receiving grants from Genome Canada, Genome British Columbia, and the Heart and Stroke Foundation of Canada during the conduct of the study. Mr Hong reported receiving grants from Alberta Innovates Health Solutions during the conduct of the study. Dr Coutts reported receiving grants from Genome Canada during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. Presenting Symptoms by Sex and Final Diagnosis
Symptom distribution by sex among patients with transient ischemic attack (TIA) or minor stroke (A) or with stroke mimic (B).
See this image and copyright information in PMC

References

    1. Reeves MJ, Bushnell CD, Howard G, et al. . Sex differences in stroke: epidemiology, clinical presentation, medical care, and outcomes. Lancet Neurol. 2008;7(10):915-926. doi:10.1016/S1474-4422(08)70193-5 - DOI - PMC - PubMed
    1. Gargano JW, Wehner S, Reeves MJ. Do presenting symptoms explain sex differences in emergency department delays among patients with acute stroke? Stroke. 2009;40(4):1114-1120. doi:10.1161/STROKEAHA.108.543116 - DOI - PubMed
    1. Stuart-Shor EM, Wellenius GA, DelloIacono DM, Mittleman MA. Gender differences in presenting and prodromal stroke symptoms. Stroke. 2009;40(4):1121-1126. doi:10.1161/STROKEAHA.108.543371 - DOI - PMC - PubMed
    1. Merino JG, Luby M, Benson RT, et al. . Predictors of acute stroke mimics in 8187 patients referred to a stroke service. J Stroke Cerebrovasc Dis. 2013;22(8):e397-e403. doi:10.1016/j.jstrokecerebrovasdis.2013.04.018 - DOI - PMC - PubMed
    1. Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology. 2017;88(15):1468-1477. doi:10.1212/WNL.0000000000003814 - DOI - PMC - PubMed