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

Background Women with acute ischemic stroke (AIS) are older and have higher preexisting handicap than men. Given that these factors do not fully explain their poorer long-term outcomes, we sought to investigate potential sex differences in the delivery of acute stroke care in a large cohort of consecutive AIS patients. Methodss We analyzed all patients from the Acute STroke Registry and Analysis of Lausanne (ASTRAL) from 03/2003-12/2019. Multivariate analyses were performed on acute time metrics, revascularization therapies, ancillary exams for stroke work-up, subacute symptomatic carotid artery revascularization, frequency of change in goals of care (palliative care) and length of hospital stay. Results Of the 5347 analyzed patients, 45% were biologically female and the median age was 74.6 years. After multiple adjustments, female sex was significantly associated with higher onset-to-door (adjusted hazard ratio (aHR):1.09, 95% confidence interval (CI) 1.04-1.14) and door-to-endovascular-puncture intervals (aHR:1.15, 95%CI:1.05-1.25). Women underwent less diagnostic exams (adjusted odds ratio (aOR): 0.94, 95%CI:0.85-1.04), fewer subacute carotid revascularizations (aOR:0.69, 95% CI:0.33-1.18) and had longer hospital stays (aHR:1.03, 95%CI:0.99-1.07), but these differences were not statistically significant. We found no differences in the rates of acute revascularization treatments, or in the frequency of change of goals of treatments. Conclusions In this retrospective analysis of a large, consecutive AIS cohort, female sex was associated with unfavorable pre- and inhospital time metrics, and lesser diagnostic exam and carotid revascularization rates. Such indicators of less effective stroke care delivery may contribute to the poorer long-term functional outcomes in female patients and require further attention.