Sex and gender differences in acute stroke care: metrics, access to treatment and outcome. A territorial analysis of the Stroke Code System of Catalonia

Abstract

Introduction: Previous studies have reported differences in the management and outcome of women stroke patients in comparison with men. We aim to analyze sex and gender differences in the medical assistance, access to treatment and outcome of acute stroke patients in Catalonia. Patients and methods: Data were obtained from a prospective population-based registry of stroke code activations in Catalonia (CICAT) from January/2016 to December/2019. The registry includes demographic data, stroke severity, stroke subtype, reperfusion therapy, and time workflow. Centralized clinical outcome at 90 days was assessed in patients receiving reperfusion therapy. Results: A total of 23,371 stroke code activations were registered (54% men, 46% women). No differences in prehospital time metrics were observed. Women more frequently had a final diagnosis of stroke mimic, were older and had a previous worse functional situation. Among ischemic stroke patients, women had higher stroke severity and more frequently presented proximal large vessel occlusion. Women received more frequently reperfusion therapy (48.2% vs 43.1%, p < 0.001). Women tended to present a worse outcome at 90 days, especially for the group receiving only IVT (good outcome 56.7% vs 63.8%; p < 0.001), but not for the group of patients treated with IVT + MT or MT alone, although sex was not independently associated with clinical outcome in logistic regression analysis (OR 1.07; 95% CI, 0.94–1.23; p = 0.27) nor in the analysis after matching using the propensity score (OR 1.09; 95% CI, 0.97–1.22). Discussion and conclusion: We found some differences by sex in that acute stroke was more frequent in older women and the stroke severity was higher. We found no differences in medical assistance times, access to reperfusion treatment and early complications. Worse clinical outcome at 90 days in women was conditioned by stroke severity and older age, but not by sex itself.

Sex-Based Analysis of Workflow and Outcomes in Acute Ischemic Stroke Patients Treated With Alteplase Versus Tenecteplase

“…For in-hospital times, there are conflicting results for door-to-needle times and whether women experience thrombolysis delays due to possibly slower decisionmaking in older age. 7,15,18 However, we observed no sex difference in door-to-needle times. the absolute median difference in door-to-puncture times for EVT was numerically shorter in females by 11.5 minutes similar to other Canadian registry data 19 and could indicate better performance with higher stroke severity, given that the adjusted difference reduces to 3 minutes (Table 2).…”

“…Still, our baseline differences of older age and higher rates of LVO in women are representative and consistent with established global epidemiological trends where women experience increased rates of cardioembolic strokes attributed to atrial fibrillation. 31 The disproportionately increased frequency of proximal LVOs in women is not well-reported in the literature but was also demonstrated in a large Spanish stroke registry 15 and is consistent with women experiencing more severe strokes. Reasons for why women may experience more LVOs warrant further investigation.…”

“…Among all workflow time metrics, we reassuringly found no sex differences similar to other Canadian and European studies. [7][8][9]15 Others have shown that women experience a slight delay in onset-to-arrival times explained by older age, greater stroke severity, and, importantly, single living status. 16,17 Our study did not adjust for living or socioeconomic status and showed no difference.…”

“…8 Our study, however, demonstrates improved median onset-to-needle times by nearly 30 minutes and is more indicative of contemporary clinical decision-making and practices regarding IVT. 20 More recent studies in Europe and the United States have not shown outcome differences between sexes after adjusting or matching for baseline covariates, 7,10,15 while data from joint European registries showed that women had worse functional outcomes and higher mortality rates after covariate adjustment. 21 Our findings are robust in showing that women, before accounting for differences in age, stroke severity, and occlusion site, have a worse prognosis across multiple definitions for functional outcomes, including the dichotomized mRS, ordinal mRS score, and return to the baseline function.…”

Service delivery in acute ischemic stroke patients: Does sex matter?

“…Regarding prehospital timing, several other studies reported longer onset-to-hospital times for women [17][18][19][20][21][22] whereas others did not find a sex-related difference [23,24]. One plausible reason for increased prehospital times is that women are more often widowed and living alone [25], leading to a later activation of emergency medical services [21].…”