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Stroke’s other side

Susan Gray works on a patient’s surgically repaired foot recently at Northside Physical Therapy in Spokane. Gray, 46, had a stroke nine years ago and uses a cane and leg brace. (Dan Pelle)
Susan Gray works on a patient’s surgically repaired foot recently at Northside Physical Therapy in Spokane. Gray, 46, had a stroke nine years ago and uses a cane and leg brace. (Dan Pelle)

‘Old man’s disease’ kills more women; one factor may be subtler symptoms

Here’s a statistic to ponder on the heels of Breast Cancer Awareness Month and temporary markdowns on breast cancer-pink lip balm online: Strokes kill twice as many women as breast cancer.

That’s probably surprising news to many, said Lynn Goddess, who founded the Hazel K. Goddess Fund for Stroke Research in Women after her mother died of complications from stroke.

“Stroke has really gotten very little attention,” Goddess said. “Sixty-one percent of the people who (die from) stroke are women, and it is really perceived as an old man’s disease. And it isn’t.”

With still much to learn about how men’s and women’s brains may be injured differently during a stroke, scientists point to a number of factors when considering women’s higher death rates and worse quality of life after a “brain attack.” Women tend to be older when they suffer their strokes. Hormone- replacement therapy prescribed for post-menopausal women has been linked to strokes, and pregnant women and those who’ve just given birth also face higher risk. But some doctors and researchers point to another factor, too: Women report different symptoms from men when they’re having one, which can lead to delays in treatment.

When it comes to treating stroke, speed is critical. The most common type, called ischemic stroke, occurs when a blood clot blocks blood supply to the brain, causing brain cells to die rapidly.

Health advocates often teach easily recognizable signs that someone is having a stroke: If one side of their face or one arm droops or their speech is affected, call 911, they advise. But women, especially, report other symptoms along with those obvious ones – or instead of them – that can make a stroke difficult to spot.

“The traditional ones you can recognize across the room,” said Dr. Madeleine Geraghty, who runs the stroke center at Providence Sacred Heart Medical Center in Spokane. “It’s when they just have the nontraditional or nonspecific stroke symptoms by themselves (that a stroke is more difficult to recognize) – isolated confusion, isolated dizziness, isolated agitation. ‘Grandma’s real cranky, and she won’t talk to me, and she’s never like this. And she’s hitting. She doesn’t do that.’

“Well, who would think that’s a stroke? But sometimes a right parietal-lobe stroke can do that.”

A study published in 2009 in the journal Stroke found that women are more likely to report “nontraditional” symptoms as men.

Classifying nontraditional symptoms as pain, mental status change, lightheadedness and headache, the study found that nearly 52 percent of women reported at least one of them, especially “altered mental status.”

The research validated the findings of a similar study published in 2002, said Dr. Lewis Morgenstern, a co-author of both studies and director of the stroke program at the University of Michigan School of Public Health.

As a medical student decades ago, Morgenstern said, he learned the “traditional” symptoms of stroke: weakness or numbness on one side, difficulty speaking or understanding, sudden unexplained clumsiness or falling.

“We label them traditional because that’s what was published,” he said. “But most of the early studies that were done in the last century … were done in men. The traditional symptoms, for the most part, come from men.”

Women are more likely to report pain and, especially, an “altered” consciousness or mental state, the 2009 study found.

“Altered consciousness means people are very sleepy or they can’t wake up. They’re somewhere between the awake state or comatose state,” Morgenstern said. Altered mental status can include those symptoms, but also mean stroke victims “may not be understanding, they may not say things right, they may be confused. Their personality may be affected.”

Morgenstern cautioned that researchers don’t know whether the women in the study actually experienced different symptoms from men or just reported or described them differently. Another possible explanation for differences: Because women are more likely to live alone in old age, having outlived male partners, their symptoms are more likely to be described to doctors by people who don’t know the women well.

Some strokes ‘slip through your fingers’

Because the drug usually used to treat ischemic strokes must be given within a few hours, a stroke that goes unrecognized can be catastrophic.

There’s a whole system in place to catch obvious strokes, Geraghty said. In Washington, the Department of Health is working to expand that system to reach people in rural areas, particularly in Central Washington, far from hospitals equipped to treat strokes.

But the scale used by doctors to assess patients for stroke is designed to catch obvious signs, Geraghty said.

“ ‘Show me your teeth – does your face droop? Show me your arm – does your arm droop? Talk to me – do you talk like this?’ ” she said, slurring her words. “It doesn’t have points for wobbly walking. It doesn’t have points for feeling dizzy. It’s got a few points for mild confusion.”

That causes some strokes to be overlooked. “The nontraditional strokes do slip through your fingers,” Geraghty said. “They don’t get activated (recognized) in the field, and they don’t get activated in the ER sometimes. That’s not a fault of the paramedics, and it’s not a fault of the ER doctors, and they even get missed by neurologists, because they’re tricky sometimes.”

The immediate problem is that “tissue plasminogen activator,” or tPA, should be given within three hours to stroke victims 80 or older or 4.5 hours for younger people, she said. The sooner it’s given, the more effective it can be. TPA is the main drug used to treat ischemic strokes, which account for about 90 percent of cases.

“The sooner you do it, the better it is,” Geraghty said. “Because every minute, you’re losing 2 million neurons.”

Compared to men who receive tPA, female stroke patients who get the drug fare better over the long term, Geraghty said. Forty percent suffer just minimal symptoms after 90 days, compared with 30 percent of men.

But female stroke victims who don’t receive t-PA fare worse than men who don’t get it, Geraghty said: “We’re more likely to end up in nursing homes. We’re more likely to have post-stroke depression. We’re more likely to fall afterwards.” She added that in “quality of life assessments’ after a stroke, women rated their lives as less happy.

She wants to get t-PA to everyone who could benefit from it, Geraghty said. “Boy,” she said, “I really want to give it to the women.”

Dr. James Grotta, chairman of the neurology department of the University of Texas Medical School at Houston, said women’s worse quality of life after stroke has a lot to do with their lack of support systems. Women are frequently the caregivers for elderly male stroke victims. By the time women have strokes, they’re often widows, he said. “There’s no one to take care of them.”

While he trusts studies showing that women experience nontraditional symptoms, and that may affect their treatment, “I don’t know how big an impact that really has,” Grotta said. “Even if they come in with typical symptoms, there’s evidence that our systems respond less quickly and aggressively when women come in with symptoms than when men do. Maybe it’s, again, because they don’t have people coming in with them, taking care of them.”

Consider the context of ‘nonspecific’ signs

Still, Morgenstern said he thinks it’s important for potential stroke victims, the people around them and medical professionals to know that “nontraditional symptoms may be a predominant feature of stroke.”

The Goddess Fund, based in West Palm Beach, Fla., distributes cards listing traditional along with nontraditional symptoms of stroke. The National Stroke Association also lists stroke risk factors and symptoms unique to women on its website.

Consider potential symptoms in context, Morgenstern said: “Obviously it would be completely wrong to have every woman who has a pain in her left arm to think she’s having a stroke.” Nontraditional symptoms are also called “nonspecific” – they could be caused by other problems, too. Said Morgenstern: “If somebody seems that they’re not acting right and may be complaining of pain (people around them should also determine) whether they have weakness or numbness on one side of the body, difficult speaking or understanding – any of the other, traditional stroke symptoms that may clue us into it being a stroke.”