Stroke in Women

Higher morbidity and mortality? by Neelum T. Aggarwal, MD, and Shyam Prabhakaran, MD

ON AVERAGE, every 40 seconds someone in the United States has a stroke, the nation's leading cause of disability and the fourth leading cause of death. In women, stroke is the second leading cause of death, with 425,000 women suffering from stroke each year, 55,000 more than men. Not only is the overall stroke rate higher for women than for men, women are more likely to die from stroke.

One study showed that women may experience longer delay from arrival to the emergency rooms to the time they are evaluated for stroke symptoms. This may be due to possible gender differences in the reporting of acute stroke symptoms. In a commonly referenced study of 1,189 admissions that ended with a validated stroke diagnosis in the emergency room, traditional stroke symptoms of postural imbalance (men 20% vs. 15% in women) and hemiparesis (men 24% vs. 19% in women) were more likely to be presenting symptoms for men than for women. In addition, women were more likely to present with symptoms that were more atypical for stroke, including pain, and change in cognition and level of consciousness.

Differing Treatment for Women?
Once women have been diagnosed with stroke, their medical treatment may differ from that of men. Management of stroke may differ based on gender issues, similar to the well-documented gender differences in the treatment of cardiac disease, where women are less likely to receive major diagnostic and therapeutic procedures. Differences may also exist in stroke prevention. Men with stroke are more likely to have significant co-morbidities, such as higher rates of ischemic heart disease and diabetes compared with women who have higher rates of hypertension and atrial fibrillation. This cardiovascular medical history profile noted in men may favor more aggressive preventative treatment in men than in women.

Aspirin and warfarin are effective medications for stroke prevention in men and women. Carotid endarterectomy (CEA) is another important treatment for primary and secondary prevention of stroke in patients with significant carotid stenosis. Although carotid disease is more common in men, some studies have shown a higher rate of post-operative complications in women, with post-operative stroke seen more frequently in women than men. Other studies have found no differences in morbidity and mortality. Commonly cited complication rates in women have been old age at time of presentation for CEA, presence of hypertension, and smaller carotid arteries.

For stroke and heart disease, commonly recognized risk factors of smoking, elevated cholesterol, previous stroke, and large artery atherosclerotic disease hold true for both men and women. Workup following a new stroke should be similar in both sexes. Hypertension and elevated cholesterol become more common in women as they age. Cholesterol levels typically will increase at age 45 presumably due to the onset of menopause. For women who are pre-menopausal, the stroke rate is low except when associated with hormonal contraception. Pregnancy does not appear to increase stroke rates significantly until the last trimester, although pregnancy can complicate pre-existing cerebrovascular disease. Specific differences, though, have been found in some risk factors that may predispose women to stroke. One study found that women with stroke had an elevated tissue plasminogen activator antigen, which was an independent risk factor for stroke in non-diabetic women ages 15 to 44. Other studies have shown that a significant proportion of young women have elevated homocysteine serum levels, an independent risk factor for stroke and vascular disease. Serum homocysteine levels were decreased in women who took daily multivitamins with B6, B12, and foliate. Last, oral hormone replacement used by menopausal women may increase the stroke rate.

The last four years have seen the development of Primary Stroke Centers (PSCs) in the Chicago area. These stroke centers provide state-of-the-art clinical care 24/7 to prevent stroke, minimize disability in stroke survivors, and ensure the best possible outcomes for patients following a stroke. For a list of these centers, please contact the Chicago Medical Society (312) 670-2550 or email: cfouts@cmsdocs.org.

Dr. Aggarwal is a cognitive neurologist at Rush University Medical Center, and the clinical core co-leader of the NIA-funded Rush Alzheimer's Disease Research Center. Dr. Prabhakaran is an associate professor at Northwestern University, Feinberg School of Medicine. His research focuses on acute ischemic stroke, transient ischemic attack, and intracranial stenosis.