Sex differences in the symptom presentation of stroke: A systematic review and meta-analysis

Abstract

Background: Early diagnosis through symptom recognition is vital in the management of acute stroke. However, women who experience stroke are more likely than men to be initially given a nonstroke diagnosis and it is unclear if potential sex differences in presenting symptoms increase the risk of delayed or missed stroke diagnosis. Aims: To quantify sex differences in the symptom presentation of stroke and assess whether these differences are associated with a delayed or missed diagnosis. Methods: PubMed, EMBASE, and the Cochrane Library were systematically searched up to January 2021. Studies were included if they reported presenting symptoms of adult women and men with diagnosed stroke (ischemic or hemorrhagic) or transient ischemic attack (TIA) and were published in English. Mean percentages with 95% confidence intervals (CIs) of each symptom were calculated for women and men. The crude relative risks (RRs) with 95% CI of symptoms being present in women, relative to men, were also calculated and pooled. Any data on the delayed or missed diagnosis of stroke for women compared to men based on symptom presentation were also extracted. Results: Pooled results from 21 eligible articles showed that women and men presented with a similar mean percentage of motor deficit (56% in women vs 56% in men) and speech deficit (41% in women vs 40% in men). Despite this, women more commonly presented with nonfocal symptoms than men: generalized nonspecific weakness (49% vs 36%), mental status change (31% vs 21%), and confusion (37% vs 28%), whereas men more commonly presented with ataxia (44% vs 30%) and dysarthria (32% vs 27%). Women also had a higher risk of presenting with some nonfocal symptoms: generalized weakness (RR 1.49, 95% CI 1.09–2.03), mental status change (RR 1.44, 95% CI 1.22–1.71), fatigue (RR 1.42, 95% CI 1.05–1.92), and loss of consciousness (RR 1.30, 95% CI 1.12–1.51). In contrast, women had a lower risk of presenting with dysarthria (RR 0.89, 95% CI 0.82–0.95), dizziness (RR 0.87, 95% CI 0.80–0.95), gait disturbance (RR 0.79, 95% CI 0.65–0.97), and imbalance (RR 0.68, 95% CI 0.57–0.81). Only one study linking symptoms to definite stroke/TIA diagnosis found that pain and unilateral sensory loss are associated with lower odds of a definite diagnosis in women compared to men. Conclusion: Although women showed a higher prevalence of some nonfocal symptoms, the prevalence of focal neurological symptoms, such as motor weakness and speech deficit, was similar for both sexes. Awareness of sex differences in symptoms in acute stroke evaluation, careful consideration of the full constellation of presenting symptoms, and further studies linking symptoms to diagnostic outcomes can be helpful in improving early diagnosis and management in both sexes.

Stroke in Women and Unique Risk Factors

“…The meta-analysis by Shajahan et al 20 also identified motor and speech deficits as the most frequent presenting symptoms in both sexes, with no differences between women and men. However, other findings varied between the 2 meta-analyses; for example, dysarthria was more frequent and paresis less frequent in women in the analysis by Ali et al, but the opposite was found in the analysis by Shajahan et al 20 Differences in study inclusion criteria likely explain some of the discrepant findings, but the authors also emphasize that a lack of consistency in the collection and classification of symptoms in existing databases hampers our ability to evaluate potential sex differences in presentation and make a case for the use of standardized measures for data collection in future studies. Other limitations of both meta-analyses include heterogeneous populations and variable methodological quality in the included studies, the limited information on potential explanatory factors such as age, and the potential for sex-based diagnostic biases where women with minor symptoms may be less likely to undergo the advanced imaging required to be included in a study of people with confirmed stroke or transient ischemic attack events.…”

“…This year, 2 new meta-analyses were published with the goal of quantifying the frequency of different presenting symptoms in women and men with stroke or transient ischemic attack. 19,20 Both studies found that women were more likely than men to present with altered level of consciousness, mental status changes, and headache. The meta-analysis by Shajahan et al 20 also identified motor and speech deficits as the most frequent presenting symptoms in both sexes, with no differences between women and men.…”

“…19,20 Both studies found that women were more likely than men to present with altered level of consciousness, mental status changes, and headache. The meta-analysis by Shajahan et al 20 also identified motor and speech deficits as the most frequent presenting symptoms in both sexes, with no differences between women and men. However, other findings varied between the 2 meta-analyses; for example, dysarthria was more frequent and paresis less frequent in women in the analysis by Ali et al, but the opposite was found in the analysis by Shajahan et al 20 Differences in study inclusion criteria likely explain some of the discrepant findings, but the authors also emphasize that a lack of consistency in the collection and classification of symptoms in existing databases hampers our ability to evaluate potential sex differences in presentation and make a case for the use of standardized measures for data collection in future studies.…”

The diversity of global stroke research in the IJS

“…9 To understand this area more fully, Shajahan and colleagues performed a systematic review and meta-analysis of sex differences in symptom presentation, which is published in this issue. 10 They pooled results from 21 studies in 36,636 patients with stroke, comprising 17,143 women and 19,493 men. While the prevalence of the more common neurological symptoms, such as motor and speech deficits, was similar between women and men, sex differences did exist.…”

Stroke is more than a hemiparesis: the pre‐hospital detection of stroke

“…In the report by Wang and colleagues in this issue of the MJA , women subsequently diagnosed in hospital with stroke were more likely than men to be assessed by paramedics as having anxiety, nausea, headache, or being unconscious, rather than stroke 1 . Two recent meta‐analyses similarly found that women with stroke exhibit non‐focal symptoms more often than men, including generalised weakness, change in mental status, confusion, headache, and loss of consciousness 2,3 …”