DIAGNOSIS: TRANSIENT ISCHEMIC ATTACK
The patient receives a diagnosis of transient ischemic attack (TIA) and is given a loading dose of aspirin 325 mg.
An ABCD2 score of 3 suggests a 1% risk of stroke in the next 48 hours.1 A neurology consultation is obtained, and she is deemed a candidate for expedited outpatient evaluation and management, including careful optimization of antihypertensive medication, brain MRI, CT angiography, echocardiography, and possible Holter monitoring.
Among patients with TIA, about 90% will have a stroke in the next 90 days, with the highest risk occurring in the first 24 hours after the event. Studies suggest that the risk of stroke can be decreased by up to 80% with early implementation of stroke prevention strategies after TIA.2
Women, in particular, represent a group in need of targeted stroke prevention. Stroke ranks as the third leading cause of death in women, and the fifth leading cause of death in men.3 Each year, almost 60% of stroke deaths occur in women.4 Yet women are more likely than men to receive a diagnosis of stroke mimic.
The SpecTRA (Spectrometry for Transient Ischemic Attack Rapid Assessment) Study is a multicenter prospective study that evaluated 1648 patients who presented with symptoms of TIA or minor neurologic events. Results showed that even though women and men presented with similar symptoms, women were significantly less likely than men to receive a diagnosis of TIA, and more likely to be diagnosed with stroke mimics. Yet women and men had similar 90-day stroke recurrence and risk of death.5
Several factors may contribute to misdiagnosis of TIA in women. Women are less likely than men to report typical symptoms of stroke and may be more likely to present with nonfocal findings. The same may be true of TIA. While more study is needed, a slightly higher percentage of women than men in the SpecTRA Study presented with nonfocal findings only (though the difference was not significant). Individuals who reported focal symptoms only were more likely to receive a diagnosis of TIA, compared with those who reported nonfocal symptoms only.5
Also, more women than men suffer from conditions that may suggest other diagnoses, such as migraine and anxiety. Mentioning such problems in the medical history may contribute to inherent gender bias in the workup.
Diagnosing TIA can be clinically challenging. While increasing awareness of the potential differences in symptoms of TIA between women and men may add to the clinical conundrum, failure to recognize them may represent a missed opportunity for stroke prevention in women.
1. MD+Calc. ABCD2 Score for TIA. https://www.mdcalc.com/abcd2-score-tia Accessed June 20, 2019.
2. Coutts SB. Diagnosis and management of transient ischemic attack. Continuum (Minneap Minn). 2017;23:82-92. doi: 10.1212/CON.0000000000000424
3. National Stroke Association. Women and stroke. https://www.stroke.org/understand-stroke/impact-of-stroke/women-and-stroke/ Accessed June 20, 2019.
4. CDC. Women and stroke. https://www.cdc.gov/stroke/docs/Women_Stroke_Factsheet.pdf Accessed June 20, 2019.
5. Yu AYX, Penn AM, Lesperance ML, et al. Sex differences in presentation and outcome after an acute transient or minor neurologic event. JAMA Neurol. 2019 May 22. doi: 10.1001/jamaneurol.2019.1305.