Background and Purpose: Women have worse outcomes than men after stroke. Differences in presentation may lead to misdiagnosis and, in part, explain these disparities. We investigated whether there are sex differences in clinical presentation of acute stroke or transient ischemic attack. Methods: We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Inclusion criteria were (1) cohort, cross-sectional, case-control, or randomized controlled trial design; (2) admission for (suspicion of) ischemic or hemorrhagic stroke or transient ischemic attack; and (3) comparisons possible between sexes in ≥1 nonfocal or focal acute stroke symptom(s). A random-effects model was used for our analyses. We performed sensitivity and subanalyses to help explain heterogeneity and used the Newcastle-Ottawa Scale to assess bias. Results: We included 60 studies (n=582 844; 50% women). In women, headache (pooled odds ratio [OR], 1.24 [95% CI, 1.11–1.39]; I ² =75.2%; 30 studies) occurred more frequently than in men with any type of stroke, as well as changes in consciousness/mental status (OR, 1.38 [95% CI, 1.19–1.61]; I ² =95.0%; 17 studies) and coma/stupor (OR, 1.39 [95% CI, 1.25–1.55]; I ² =27.0%; 13 studies). Aspecific or other neurological symptoms (nonrotatory dizziness and non-neurological symptoms) occurred less frequently in women (OR, 0.96 [95% CI, 0.94–0.97]; I ² =0.1%; 5 studies). Overall, the presence of focal symptoms was not associated with sex (pooled OR, 1.03) although dysarthria (OR, 1.14 [95% CI, 1.04–1.24]; I ² =48.6%; 11 studies) and vertigo (OR, 1.23 [95% CI, 1.13–1.34]; I ² =44.0%; 8 studies) occurred more frequently, whereas symptoms of paresis/hemiparesis (OR, 0.73 [95% CI, 0.54–0.97]; I ² =72.6%; 7 studies) and focal visual disturbances (OR, 0.83 [95% CI, 0.70–0.99]; I ² =62.8%; 16 studies) occurred less frequently in women compared with men with any type of stroke. Most studies contained possible sources of bias. Conclusions: There may be substantive differences in nonfocal and focal stroke symptoms between men and women presenting with acute stroke or transient ischemic attack, but sufficiently high-quality studies are lacking. More studies are needed to address this because sex differences in presentation may lead to misdiagnosis and undertreatment.

Background and Purpose: The frequency of ischemic stroke in patients with coronavirus disease 2019 (COVID-19) varies in the current literature, and risk factors are unknown. We assessed the incidence, risk factors, and outcomes of acute ischemic stroke in hospitalized patients with COVID-19. Methods: We included patients with a laboratory-confirmed SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) infection admitted in 16 Dutch hospitals participating in the international CAPACITY-COVID registry between March 1 and August 1, 2020. Patients were screened for the occurrence of acute ischemic stroke. We calculated the cumulative incidence of ischemic stroke and compared risk factors, cardiovascular complications, and in-hospital mortality in patients with and without ischemic stroke. Results: We included 2147 patients with COVID-19, of whom 586 (27.3%) needed treatment at an intensive care unit. Thirty-eight patients (1.8%) had an ischemic stroke. Patients with stroke were older but did not differ in sex or cardiovascular risk factors. Median time between the onset of COVID-19 symptoms and diagnosis of stroke was 2 weeks. The incidence of ischemic stroke was higher among patients who were treated at an intensive care unit (16/586; 2.7% versus nonintensive care unit, 22/1561; 1.4%; P =0.039). Pulmonary embolism was more common in patients with (8/38; 21.1%) than in those without stroke (160/2109; 7.6%; adjusted risk ratio, 2.08 [95% CI, 1.52–2.84]). Twenty-seven patients with ischemic stroke (71.1%) died during admission or were functionally dependent at discharge. Patients with ischemic stroke were at a higher risk of in-hospital mortality (adjusted risk ratio, 1.56 [95% CI, 1.13–2.15]) than patients without stroke. Conclusions: In this multicenter cohort study, the cumulative incidence of acute ischemic stroke in hospitalized patients with COVID-19 was ≈2%, with a higher risk in patients treated at an intensive care unit. The majority of stroke patients had a poor outcome. The association between ischemic stroke and pulmonary embolism warrants further investigation.

This World Stroke Organization Scientific Statement highlights how sex and gender differences shape stroke risk, treatment, care, and research. Estrogen confers a relative protection before menopause, with risk increasing thereafter. Beyond shared cardiovascular determinants (hypertension, atrial fibrillation, and diabetes), women face sex-specific risks—hypertensive disorders of pregnancy, menopause, and hormone therapy, with clear implications for stroke prevention and management. Despite comparable efficacy of acute and secondary stroke therapies in women and men, women are less likely to receive timely acute treatment and often experience delays in recognition and access. The statement recommends gender-responsive prevention and care pathways; systematic consideration of pregnancy-related and menopausal factors; and public and professional education to improve stroke symptom recognition and purposeful inclusion of women across the research continuum. By integrating evidence from epidemiology, acute care, and secondary prevention, this statement provides clear and timely guidance for reducing inequities and shaping future research and policy to achieve equitable stroke care globally.

BACKGROUND: Differences in clinical presentation of acute ischemic stroke between men and women may affect prehospital identification of anterior circulation large vessel occlusion (aLVO). We assessed sex differences in diagnostic performance of 8 prehospital scales to detect aLVO. METHODS: We analyzed pooled individual patient data from 2 prospective cohort studies (LPSS [Leiden Prehospital Stroke Study] and PRESTO [Prehospital Triage of Patients With Suspected Stroke Study]) conducted in the Netherlands between 2018 and 2019, including consecutive patients ≥18 years suspected of acute stroke who presented within 6 hours after symptom onset. Ambulance paramedics assessed clinical items from 8 prehospital aLVO detection scales: Los Angeles Motor Scale, Rapid Arterial Occlusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Cincinnati Prehospital Stroke Scale, Prehospital Acute Stroke Severity, gaze-face-arm-speech-time, Conveniently Grasped Field Assessment Stroke Triage, and Face-Arm-Speech-Time Plus Severe Arm or Leg Motor Deficit. We assessed the diagnostic performance of these scales for identifying aLVO at prespecified cut points for men and women. RESULTS: Of 2358 patients with suspected stroke (median age, 73 years; 47% women), 231 (10%) had aLVO (100/1114 [9%] women and 131/1244 [11%] men). The area under the curve of the scales ranged from 0.70 (95% CI, 0.65–0.75) to 0.77 (95% CI, 0.73–0.82) in women versus 0.69 (95% CI, 0.64–0.73) to 0.75 (95% CI, 0.71–0.79) in men. Positive predictive values ranged from 0.23 (95% CI, 0.20–0.27) to 0.29 (95% CI, 0.26–0.31) in women versus 0.29 (95% CI, 0.24–0.33) to 0.37 (95% CI, 0.32–0.43) in men. Negative predictive values were similar (0.95 [95% CI, 0.94–0.96] to 0.98 [95% CI, 0.97–0.98] in women versus 0.94 [95% CI, 0.93–0.95] to 0.96 [95% CI, 0.94–0.97] in men). Sensitivity of the scales was slightly higher in women than in men (0.53 [95% CI, 0.43–0.63] to 0.76 [95% CI, 0.68–0.84] versus 0.49 [95% CI, 0.40–0.57] to 0.63 [95% CI, 0.55–0.73]), whereas specificity was lower (0.79 [95% CI, 0.76–0.81] to 0.87 [95% CI, 0.84–0.89] versus 0.82 [95% CI, 0.79–0.84] to 0.90 [95% CI, 0.88–0.91]). Rapid arterial occlusion evaluation showed the highest positive predictive values in both sexes (0.29 in women and 0.37 in men), reflecting the different event rates. CONCLUSIONS: aLVO scales show similar diagnostic performance in both sexes. The rapid arterial occlusion evaluation scale may help optimize prehospital transport decision-making in men as well as in women with suspected stroke.

Various prehospital scales have been developed to detect patients with anterior-circulation large-vessel occlusion (aLVO) ischemic stroke to enable direct transportation to a thrombectomy-capable stroke center. To guide implementation, a head-to-head comparison of aLVO stroke detection scales is needed to determine which scale is most useful for prehospital triage in different regional contexts. We aimed to systematically identify and compare these scales. Published prehospital aLVO stroke scales were identified with a systematic literature search. Scales were reconstructed from individual patient data of 2 large prospective observational cohort studies conducted between 2018 and 2019, the Leiden Prehospital Stroke Study and PREhospital triage of patients with suspected STrOke symptoms study. Both studies included consecutive adult patients suspected by paramedics of having a stroke within 6 hours of symptom onset, from 4 Dutch ambulance regions, encompassing 15 stroke centers and serving 3.7 million people. All data used for the reconstruction of scales were acquired by paramedics in the field before hospital arrival. Scales' diagnostic performance to detect aLVO stroke was compared with the area under the receiver operating characteristic curve (AUROC) of the full scale and sensitivity and specificity at the scales' original cut-point. Decision curve analysis was used to evaluate harm-benefit trade-offs between delaying IV thrombolysis and expediting endovascular thrombectomy with direct transportation of patients to a thrombectomy-capable center. We identified 63 aLVO scales, of which 14 could be reconstructed. Of 2,358 included patients (mean age 70 years; 47% female), 231 (9.8%) had aLVO stroke. The AUROC was highest for Rapid Arterial oCclusion Evaluation (RACE) (0.81, 95% CI 0.78-0.84), Los Angeles Motor Scale (LAMS) (0.80, 95% CI 0.77-0.83), Gaze-Face-Arm-Speech-Time (G-FAST) (0.80, 95% CI 0.77-0.83), and modified Gaze-Face-Arm-Speech-Time (mG-FAST) (0.79, 95% CI 0.76-0.82). The Emergency Medical Stroke Assessment had highest sensitivity (85%, 95% CI 80%-90%) but lowest specificity (58%, 95% CI 56%-61%) while Cincinnati Prehospital Stroke Scale with an adjusted cut-point of 3 + gaze had highest specificity (94%, 95% CI 93%-95%) but lowest sensitivity (35%, 95% CI 29%-41%). In decision curve analysis, RACE had the highest benefit across a clinically reasonable range of harm-benefit trade-offs. RACE, LAMS, G-FAST, and mG-FAST are the best-performing scales, with RACE being preferred in most triage settings. Our findings may support policymakers with implementing a scale suitable for their region.