Older Woman With Transient, Nonfocal Neurological Symptoms

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CHALLENGING CASE

A 76-year-old women presents to the emergency department (ED) for evaluation of slurred speech, dizziness, and severe headache of sudden onset. The symptoms lasted about 10 minutes and then resolved. Her son is afraid she suffered a stroke and has brought her to the ED. Two similar episodes occurred during the past 2 weeks, but she refused medical attention.

She denies shortness of breath, nausea, vomiting, syncope, and symptoms of aura, as well as focal motor weakness and loss of sensation.

The patient has had hypertension for 10 years and also has hyperlipidemia and migraine. She was formerly a one-pack-a-day smoker but quit 5 years earlier. She has no history of heavy drinking or drug abuse. She has no known drug allergies. Family history is notable for stroke in her mother at age 80.

Her medications are lisinopril 40 mg daily, aspirin 81 mg daily, and atorvastatin 10 mg daily.

Examination

The woman is resting calmly. She is slightly overweight, with a body mass index of 27. Blood pressure is 145/90 mm Hg; heart rate, 85 beats/min, with normal sinus rhythm.

Results of physical and neurological examinations are unremarkable. No carotid bruits are appreciated. ABCD2 score is 3.

Workup

Blood glucose level, complete blood cell count, electrolyte levels, blood urea nitrogen and creatinine levels, and international normalized ratio (INR) are within normal limits.

A head CT scan is normal with no evidence of bleeding. A carotid ultrasound scan shows moderate stenosis of the left internal carotid artery.

What is your diagnosis? >>

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.

Discussion

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.

References:

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.