More midlife women are coming to EDs with stroke

Look for sudden onset of symptoms

If a middle-aged woman walks into your ED complaining of sudden onset of neurological deficits, you should suspect she is having a stroke until proven otherwise, says Judy Guzy, RN, nurse director of the Brain Attack Team at the University of California — Los Angeles (UCLA) Medical Center's Stroke Center.

Women are much more likely than men to have a stroke in mid-life, according to new research.1 "This is a new finding, and emergency nurses will need to be educated," she says.

Researchers analyzed data from about 17,000 people who participated in the National Health and Nutrition Examination Survey, and of this group, 606 people experienced a stroke. Women ages 45-54 were more than twice as likely as men in the same age group to have had a stroke. "This is a new finding that has not been reported before," says Amytis Towfighi, MD, the study's author and former neurovascular fellow at the UCLA Stroke Center.

Be aware of this new trend and bear in mind that middle-aged women are indeed at risk for stroke, says Towfighi. "The prevalence of stroke in women in this age group appears to be rising in recent years," she says.

Symptoms may be downplayed

"Emergency rooms are busy places, and women do not want to be a bother," says Annette Andreoli, RN, BSN, patient care manager for University of Kentucky Medical Center's Stroke Care Unit in Lexington. A patient may not always speak up and tell a busy nurse that her headache has increased in severity or that the weakness or tingling she was experiencing on her right side has increased or spread, she says.

"Asking the right questions and assessing for the four basic symptoms of stroke will let you know whether you need to start them on the stroke protocol or pathway," says Andreoli. The four basic symptoms are:

  • sudden numbness or weakness of the face, arm, or leg, including loss of balance, dizziness, or loss of coordination;
  • sudden confusion, or trouble speaking or understanding;
  • sudden trouble seeing out of one or both eyes;
  • sudden severe headache with no known cause.

Use the acronym "FAST," which stands for "Face, Arm, Speech, and Time," advises Andreoli. "If you ask the patient to smile and it is lopsided, that is one test," she says. "If the patient holds their arms out straight ahead as if holding a pizza box, and one arm drifts down or to the side, that could be another sign." Next ask them to complete a simple sentence as "Sally ran home fast," she says.

If a woman is on birth control, hormone replacement therapy, or is a smoker, she has a greater risk for blood clots in her legs, says Andreoli. "Be aware of pains in her legs, and bring it to her physician's attention," she says. "If the woman is diabetic, overweight, has high cholesterol, or has any other risk factors for heart disease, you also have a recipe for stroke. Stress and migraines can mimic symptoms of stroke as well."

Although initial stroke symptoms may be different, women probably will have some classic symptoms on exam, says Lauren Brandt, RN, MSN, CNS, director of the Neurosciences, Brain & Spine Center at Brackenridge Hospital in Austin, TX. "The better known symptoms still are the most frequent and should be screened for," says Brandt. "Risk factors such as higher systolic blood pressure and abdominal obesity should increase suspicion for the woman who comes in with vague symptoms."

Don't waste time

Establish an accurate time frame for onset of symptoms and perform a neurological assessment, including a National of Institutes of Health Stroke Scale if symptoms warrant, says Andreoli. "Time loss is brain loss," she emphasizes.

When any patient presents at UCLA Medical Center's emergency medicine center with even a subtle neurological deficit, the stroke team is immediately paged and the patient is seen by the ED physician within 10 minutes, says Tina Riley-Gonzales, RN, CEN, administrative nurse. Many times, the ED nurse will have the patient prepared for immediate magnetic resonance imaging (MRI) prior to the stroke team's arrival, says Riley-Gonzales. "In addition, the ED nurse will also have pre-calculated the dose of tPA [tissue plasminogen activator], in the event this is the treatment of choice," she says. "Our goal for door-to-tPA administration is 20 minutes."

Suddeness is important

Always assume that a woman of any age presenting with sudden onset of any symptoms of a stroke may be having one, says Guzy.

"Suddenness is important, because a stroke happens suddenly," she says. A clot travels through the arterial system to the artery in the brain, and it blocks circulation to the area supplied by the affected artery, Guzy explains. "Suddenly, that affected area no longer has oxygen, therefore it is no longer able to perform the function that it usually performs," she says. The neurological deficits are directly correlated with the affected area, Guzy says. "Alert the stroke team early, and begin the stroke pathway," she says.


For more information on women with stroke, contact:

  • Annette Andreoli, RN, BSN, Patient Care Manager, Stroke Care Unit, University of Kentucky Medical Center, Room H813, 800 Rose St., Lexington, KY 40536. Phone: (859) 323-6669. E-mail:
  • Lauren Brandt, RN, MSN, CNS, Director, Neurosciences, Brain, & Spine Center, Brackenridge Hospital, 601 E. 15th St., Austin, TX 78701. Phone: (512) 324-7782. E-mail:
  • Judy Guzy, RN, Nurse Director, University of California—Los Angeles Medical Center, Stroke Center, 924 Westwood Blvd., No. 300, Los Angeles CA 90024-1777. Phone: (310) 794-0600. Fax: (310) 794-0599. E-mail:
  • Amytis Towfighi, MD, Stroke Center and Department of Neurology, University of California at Los Angeles, 710 Westwood Plaza, Los Angeles, CA 90095. Phone: (310) 794-6379. Fax: (310) 267-2063. E-mail: