Sex Differences in the Pre- and In-Hospital Setting of Patients With Stroke Are Driven by Higher Age and Stroke Severity

Background: Sex critically determines stroke pathophysiology and recovery. To reveal potential gaps in stroke care, we analyzed sex-specific differences in the stroke patient hospital admission and treatment process.

Methods: In this single-center retrospective analysis, we screened all patients referred to our stroke center between 2014 and 2020 with suspicion of stroke (n=7112). Patients with different cerebrovascular events and stroke mimics were included. We collected demographic hospitalization and 90-day follow-up data and stratified results according to sex. In a logistic regression analysis for 90-day functional outcome, we estimated the effect of sex corrected for the clinically most relevant confounders.

Results: Of 7102 patients, 56.7% were male and 43.3% female. Women were older (median, 76.3 years; interquartile range (IQR), 64-84, versus 70.7; IQR, 59-79; P<0.001), and lived more often in nursing homes before the event (10.5% versus 3.8%; P<0.001). Among patients with acute ischemic stroke (n=4515), women had more often a large vessel occlusion (38.6% versus 34.8%; P=0.015), a higher stroke severity (National Institutes of Health Stroke Scale score, 4; IQR, 1-12 versus 3; IQR, 1-8; P<0.001), and were treated more often with endovascular treatment (21.4% versus 17.3%; P=0.001). Onset-to-door, onset-to-treatment, and door-to-treatment times were significantly longer in women. A favorable 90-day functional outcome (modified Rankin Scale score 0-2) occurred more often in men (73.9% versus 64.9%; P<0.001). When correcting for confounders in a multivariable logistic regression, age, admission National Institutes of Health Stroke Scale, and prestroke modified Rankin Scale remained highly (P<0.001), large vessel occlusion and arterial hypertension moderately significant predictors for 90-day functional outcome (P<0.05), whereas female sex was not. This could be confirmed when analyzing different patient age groups separately in multivariable logistic regression subgroup analyses. An interaction-term analysis revealed no additional association between age and female sex (OR, 0.99; P=0.815).

Conclusions: Although treatment and outcome parameters seem to be in favor of men, most can be explained by older age, poorer prestroke independence, higher stroke severity, and more large vessel occlusion in women. Sex was not independently associated with worse 90-day functional outcome in women.