Dr Sultana Shajahan

Australian researchers investigating potential sex differences in presenting symptoms of acute stroke have found that women are more likely to have more generalised symptoms, such as confusion and weakness.

However the data was too limited to be able to say whether these differences are linked to delays in stroke diagnosis or a misdiagnosis in women, according to a team at the George Institute for Global Health.

Study investigator Dr Sultana Shajahan said it was already known that women who experience stroke were more likely than men to face delays in diagnosis or be initially given a non-stroke diagnosis. Women also experienced worse post-stroke disability and were more than three times as likely to be institutionalised after a stroke than men.

“One of the possible reasons for a delay could be sex differences in stroke symptoms when first presenting to a healthcare professional, but there is a limited number of studies that have analysed these sex differences,” she said.

To examine this more closely, George Institute researchers conducted a systematic review and meta-analysis of data from 36,636 people diagnosed with stroke from 21 studies mostly from the US or Europe, with results published between 2002 and 2020. Between 45–55% of participants in most studies were women, and they were generally older than men when presenting with stroke (an average age of 62 to 79 years versus 58 to 70 years for men).

The results showed that women and men presented with a similar percentage of classic symptoms of acute stroke such as motor deficit (56% in women vs 56% in men) and speech deficit (41% in women vs 40% in men).

However, women more commonly presented with nonfocal symptoms than men, including generalised nonspecific weakness (49% vs 36%), mental status change (31% vs 21%), and confusion (37% vs 28%).

In contrast, men more commonly presented with ataxia (44% vs 30%) and dysarthria (32% vs 27%).

Women also had a higher risk of presenting with some nonfocal symptoms of stroke including generalised weakness (RR: 1.49, 95% CI: 1.09–2.03), mental status change (RR: 1.44, 95% CI: 1.22–1.71), fatigue (RR: 1.42, 95% CI: 1.05–1.92), and loss of consciousness (RR: 1.30, 95% CI: 1.12–1.51).

The study also showed that women had a lower risk of presenting with dysarthria (RR: 0.89, 95% CI: 0.82–0.95), dizziness (RR: 0.87, 95% CI: 0.80–0.95), gait disturbance (RR: 0.79, 95% CI: 0.65–0.97), and imbalance (RR: 0.68, 95% CI: 0.57–0.81).

The researchers said the findings showed the need for careful consideration of the full constellation of presenting symptoms for acute stroke in both men and women.

“While there wasn’t enough data available to see whether these differences do actually result to delays in or missed diagnosis, greater awareness of sex differences in symptom presentation amongst healthcare providers involved in the initial evaluation of acute stroke would be helpful,” said Dr Shajahan.

The researchers called for further epidemiological studies using consistent data collection methods to explore a possible link between symptom differences and missed or delayed stroke diagnosis outcomes.

The findings are published in International Journal of Stroke.