Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients With Suspected Stroke
Authors: Ali Mariam , Dekker Luuk , Daems Jasper D. , Ali Mahsoem , van Zwet Erik W. , Steyerberg Ewout W. , Duvekot Martijne H.C. , Nguyen T. Truc My , Moudrous Walid , van de Wijdeven Ruben M. , Visser Marieke C. , de Laat Karlijn F. , Kerkhoff Henk , van den Wijngaard Ido R. , Dippel Diederik W.J. , Roozenbeek Bob , Kruyt Nyika D. , Wermer Marieke J.H. , Aerden Leo A.M. , Alblas Kees C.L. , Bakker Jeannette , van Belle Eduard , Bevelander Timo , Bosch Jan , Buijck Bianca , Dofferhoff-Vermeulen Tamara , van Doormaal Pieter Jan , Dorresteijn Kirsten R.I.S. , Duijndam Dion , van Eijkelenburg Roeland P.J. , van Es Adriaan C.G.M. , Hensen Jan-Hein , Hoek Amber , Kloos Loet M.H. , Koster Gaia T. , Kuiper Jan Willem , de Leeuw Arnoud M. , Lingsma Hester F. , van der Lugt Aad , Lycklama À Nijeholt Geert , Maasland Lisette , van Moll Bruno J.M. , Mulder Laus J.M.M. , Noordam-Reijm Anja , Oskam Erick , Plaisier Aarnout , Rozeman Anouk D. , de Schryver Els L.L.M. , Venema Esmee , Wijnhoud Annemarie D. , Willeboer Merel L. , Woudenberg Mirjam , van der Zon Mandy M.A. , Zwets Egon D. , Zylicz Stas A. 
Published: February 2024

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.