Sex Differences in Prehospital Acute Management of Suspected Stroke Patients

Current state of research in the field Acute stroke patients need an optimal prehospital management with rapid identification of their suspected stroke and high quality prehospital care to gain access to modern hyperacute stroke treatments. The fewer barriers there are to a fast response, the better the patient's outcome will be. However, research results indicate that women are disadvantaged in their prehospital care by often receiving wrong working diagnosis, delayed management and less structured prehospital acute stroke care.

This is nourished by the fact that Emergency Medical Service (EMS) clinicians, who are responsible for this rapid management are usually not specialised in stroke medicine, which results in reported numbers of missed stroke diagnosis of as high as 52% (Jones, Bray et al. 2021). Prehospital identification is additionally impeded by several factors, including the limited diagnostic equipment available at the emergency site, the broad variety of non-stroke diseases presenting with stroke-like symptoms (Gibson and Whiteley 2013) and not least the time pressure behind identification of stroke suspects following the "time is brain" concept. In many areas, stretched hospital emergency departments (ED) pushing towards pathways for admission avoidance, add further challenges by increasing the aim to manage as many as possible patients in the community. Especially those patients, who present as stroke-mimics to the EMS (patients with stroke like symptoms, that are not caused by a stroke) and patients with general symptoms like dizziness or confusion could be left behind under this pressure (Neves Briard, Zewude et al. 2018).

Further complicating is that not all acute stroke patients present with the classical face, arm (leg), speech abnormalities. Especially, women often show non-traditional stroke symptoms like the ubiquitous symptoms of altered mental status, headache, reduced consciousness, generally reduced condition or dizziness (Lisabeth, Brown et al. 2009, Girijala, Sohrabji et al. 2017, Bushnell, Howard et al. 2018, Carcel, Woodward et al. 2020, Patti and Gupta 2022, Shajahan, Sun et al. 2022). This makes the already challenging stroke diagnosis even more difficult.

Information available on gender inequality of prehospital and hyperacute stroke care is growing (Walter, Phillips et al. 2022). Some studies report patient-dependent delays as underlying factors for a later arrival at hospital (Mainz, Andersen et al. 2020), but more and more pieces of information point towards an additional impact of health system-caused sex inequity in prehospital stroke pathways. A drawback of many results is the analysis of hospital-confirmed stroke patient cohorts, which carry the selection bias of missing patients, who never got diagnosed as acute stroke victims (Volpe, Zuniga et al. 2023).

Sex-related inequality in prehospital assessment of stroke patients may have potentially devastating consequences. A very recent Australian population-based cohort study with more than 200,000 confirmed stroke patients with analysis of prehospital management, identified that women, especially those younger than 70 years of age, were less likely than men to receive immediate stroke assessment despite their more frequent admission to hospital by ambulance, which is known to be an important initiating factor for rapid specialist care (Wang, Carcel et al. 2022). In the same study, it could be identified that women with stroke were more often assessed for headache, anxiety and emotional distress and, therefore, did not receive prehospital stroke care according to standard EMS protocols. A Californian state-wide database analysis of >300,000 patients identified that the probability for women to get correctly identified as suspected stroke patients in the prehospital setting was 26% lower and this was likely caused by the different clinical presentations (Govindarajan, Friedman et al. 2015). No information about any resulting differences in the subsequent acute stroke treatment, like e.g. administration rates of recanalising therapies was analysed.