Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients with Suspected Stroke

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

doi:10.1161/STROKEAHA.123.044898

Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients with Suspected Stroke

Mariam Ali^*
, Luuk Dekker
, Jasper D. Daems
, Mahsoem Ali
, Erik W. van Zwet
, Ewout W. Steyerberg
, Martijne H. C. Duvekot
, T. Truc My Nguyen
, Walid Moudrous
, Ruben M. van de Wijdeven
, Marieke C. Visser
, Karlijn F. de Laat
, Henk Kerkhoff
, Ido R. van den Wijngaard
, Diederik W. J. Dippel
, Bob Roozenbeek
, Nyika D. Kruyt
, Marieke J. H. Wermer
, Leo A. M. Aerden
, Kees C. L. Alblas

Jeannette Bakker, Eduard van Belle, Timo Bevelander, Jan Bosch, Bianca Buijck, Tamara Dofferhoff-Vermeulen, Pieter Jan van Doormaal, Kirsten R. I. S. Dorresteijn, Dion Duijndam, Roeland P. J. van Eijkelenburg, Adriaan C. G. M. van Es, Jan-Hein Hensen, Amber Hoek, Loet M. H. Kloos, Gaia T. Koster, Jan Willem Kuiper, Arnoud M. de Leeuw, Hester F. Lingsma, Aad van der Lugt, Geert Lycklama À Nijeholt, Lisette Maasland, Bruno J. M. van Moll, Laus J. M. M. Mulder, Anja Noordam-Reijm, Erick Oskam, Aarnout Plaisier, Anouk D. Rozeman, Els L. L. M. de Schryver, Esmee Venema, Annemarie D. Wijnhoud, Merel L. Willeboer, Mirjam Woudenberg, Mandy M. A. van der Zon, Egon D. Zwets, Stas A. Zylicz

^*Corresponding author for this work

Leiden University Medical Center
Erasmus MC
Albert Schweitzer Ziekenhuis
Maasstad Hospital
Vrije Universiteit Amsterdam
Haga Teaching Hospital
Haaglanden Medisch Centrum
University Neurovascular Center Leiden
University of Groningen, University Medical Center Groningen
Leiden University
Erasmus University Rotterdam
Vrije Universiteit (VU) Amsterdam and VU Medical Center
Haga Ziekenhuis
Leids University Medical Center
University Neurovascular Center Leiden-The Hague
University of Groningen

Research output: Contribution to journal › Article › Academic › peer-review

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Abstract

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.

Original language	English
Article number	doi: 10.1161/STROKEAHA.123.044898
Pages (from-to)	548-554
Number of pages	7
Journal	Stroke
Volume	55
Issue number	3
DOIs	https://doi.org/10.1161/STROKEAHA.123.044898
Publication status	Published - 1 Mar 2024

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

Keywords

acute ischemic stroke
emergency medical services
large vessel occlusion
sex
thrombectomy

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10.1161/STROKEAHA.123.044898

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Ali, M., Dekker, L., Daems, J. D., Ali, M., van Zwet, E. W., Steyerberg, E. W., Duvekot, M. H. C., Nguyen, T. T. M., Moudrous, W., van de Wijdeven, R. M., Visser, M. C., de Laat, K. F., Kerkhoff, H., van den Wijngaard, I. R., Dippel, D. W. J., Roozenbeek, B., Kruyt, N. D., Wermer, M. J. H., Aerden, L. A. M., ... Zylicz, S. A. (2024). Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients with Suspected Stroke. Stroke, 55(3), 548-554. Article doi: 10.1161/STROKEAHA.123.044898. https://doi.org/10.1161/STROKEAHA.123.044898

@article{68164bfd66bb4c09aba62192a462bba0,

title = "Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients with Suspected Stroke",

abstract = "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.",

keywords = "acute ischemic stroke, emergency medical services, large vessel occlusion, sex, thrombectomy",

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

year = "2024",

month = mar,

day = "1",

doi = "10.1161/STROKEAHA.123.044898",

language = "English",

volume = "55",

pages = "548--554",

journal = "Stroke",

issn = "0039-2499",

publisher = "American Heart Association",

number = "3",

}

Ali, M, Dekker, L, Daems, JD, Ali, M, van Zwet, EW, Steyerberg, EW, Duvekot, MHC, Nguyen, TTM, Moudrous, W, van de Wijdeven, RM, Visser, MC, de Laat, KF, Kerkhoff, H, van den Wijngaard, IR, Dippel, DWJ, Roozenbeek, B, Kruyt, ND, Wermer, MJH, Aerden, LAM, Alblas, KCL, Bakker, J, van Belle, E, Bevelander, T, Bosch, J, Buijck, B, Dofferhoff-Vermeulen, T, van Doormaal, PJ, Dorresteijn, KRIS, Duijndam, D, van Eijkelenburg, RPJ, van Es, ACGM, Hensen, J-H, Hoek, A, Kloos, LMH, Koster, GT, Kuiper, JW, de Leeuw, AM, Lingsma, HF, van der Lugt, A, Lycklama À Nijeholt, G, Maasland, L, van Moll, BJM, Mulder, LJMM, Noordam-Reijm, A, Oskam, E, Plaisier, A, Rozeman, AD, de Schryver, ELLM, Venema, E, Wijnhoud, AD, Willeboer, ML, Woudenberg, M, van der Zon, MMA, Zwets, ED & Zylicz, SA 2024, 'Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients with Suspected Stroke', Stroke, vol. 55, no. 3, doi: 10.1161/STROKEAHA.123.044898, pp. 548-554. https://doi.org/10.1161/STROKEAHA.123.044898

TY - JOUR

T1 - Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients with Suspected Stroke

AU - Ali, Mariam

AU - Dekker, Luuk

AU - Daems, Jasper D.

AU - Ali, Mahsoem

AU - van Zwet, Erik W.

AU - Steyerberg, Ewout W.

AU - Duvekot, Martijne H. C.

AU - Nguyen, T. Truc My

AU - Moudrous, Walid

AU - van de Wijdeven, Ruben M.

AU - Visser, Marieke C.

AU - de Laat, Karlijn F.

AU - Kerkhoff, Henk

AU - van den Wijngaard, Ido R.

AU - Dippel, Diederik W. J.

AU - Roozenbeek, Bob

AU - Kruyt, Nyika D.

AU - Wermer, Marieke J. H.

AU - Aerden, Leo A. M.

AU - Alblas, Kees C. L.

AU - Bakker, Jeannette

AU - van Belle, Eduard

AU - Bevelander, Timo

AU - Bosch, Jan

AU - Buijck, Bianca

AU - Dofferhoff-Vermeulen, Tamara

AU - van Doormaal, Pieter Jan

AU - Dorresteijn, Kirsten R. I. S.

AU - Duijndam, Dion

AU - van Eijkelenburg, Roeland P. J.

AU - van Es, Adriaan C. G. M.

AU - Hensen, Jan-Hein

AU - Hoek, Amber

AU - Kloos, Loet M. H.

AU - Koster, Gaia T.

AU - Kuiper, Jan Willem

AU - de Leeuw, Arnoud M.

AU - Lingsma, Hester F.

AU - van der Lugt, Aad

AU - Lycklama À Nijeholt, Geert

AU - Maasland, Lisette

AU - van Moll, Bruno J. M.

AU - Mulder, Laus J. M. M.

AU - Noordam-Reijm, Anja

AU - Oskam, Erick

AU - Plaisier, Aarnout

AU - Rozeman, Anouk D.

AU - de Schryver, Els L. L. M.

AU - Venema, Esmee

AU - Wijnhoud, Annemarie D.

AU - Willeboer, Merel L.

AU - Woudenberg, Mirjam

AU - van der Zon, Mandy M. A.

AU - Zwets, Egon D.

AU - Zylicz, Stas A.

PY - 2024/3/1

Y1 - 2024/3/1

N2 - 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.

AB - 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.

KW - acute ischemic stroke

KW - emergency medical services

KW - large vessel occlusion

KW - sex

KW - thrombectomy

UR - https://www.scopus.com/pages/publications/85186220746

U2 - 10.1161/STROKEAHA.123.044898

DO - 10.1161/STROKEAHA.123.044898

M3 - Article

C2 - 38299328

SN - 0039-2499

VL - 55

SP - 548

EP - 554

JO - Stroke

JF - Stroke

IS - 3

M1 - doi: 10.1161/STROKEAHA.123.044898

ER -

Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients with Suspected Stroke

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