Sex Differences in Stroke Diagnosis, Treatment, and Outcome

This article examines how sex and gender differences affect stroke recognition, treatment, and outcomes and identifies strategies to advance equity across the stroke care continuum.

Recent evidence highlights persistent sex-based and gender-based disparities in stroke care. Women are less likely to be identified by emergency services as having a stroke, largely because they have more frequent nonfocal presentations (eg, diffuse weakness, confusion). Standard prehospital tools often miss these signs. Although sex disparities in the administration of acute treatments such as IV thrombolysis and mechanical thrombectomy have narrowed, historical underuse in women contributed to worse outcomes. Anticoagulation in atrial fibrillation has improved with the inclusion of female sex in risk scores, although some gaps remain. Long-term, women have higher rates of poststroke disability, institutionalization, and reduced quality of life. Biological differences, health care bias, and underrepresentation in clinical trials contribute to these inequities.

Women often present with underrecognized stroke symptoms, which can lead to diagnostic delays and missed opportunities for timely intervention. Despite evidence showing equal benefit, women have historically received less reperfusion therapy than men. Poststroke outcomes are generally worse for women, particularly among older patients and racially minoritized groups. To address these disparities, targeted strategies are essential, such as implementing sex-sensitive stroke scales, providing training to reduce diagnostic bias, conducting routine sex-disaggregated audits, and improving the inclusion of women in clinical trials. Multidisciplinary care should also prioritize management of anxiety, depression, and fatigue, which disproportionately affect women after stroke. Closing these gaps is critical to achieving equitable and effective stroke care for all patients, regardless of sex or gender.