Background Women have been reported to have worse outcomes after endovascular treatment (EVT), despite a similar treatment effect in non-clinical trial populations. We aimed to assess sex differences at hospital presentation with respect to workflow metrics, prestroke disability, and presenting clinical symptoms.
Methods We included consecutive patients from the Multicentre Randomised Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in The Netherlands (MR CLEAN) Registry (2014–2018) who received EVT for anterior circulation large vessel occlusion (LVO). We assessed sex differences in workflow metrics, prestroke disability (modified Rankin Scale (mRS) score ≥1), and stroke severity and symptoms according to the National Institutes of Health Stroke Scale (NIHSS) score on hospital admission with logistic and linear regression analyses and calculated the adjusted OR (aOR).
Results We included 4872 patients (47.6% women). Compared with men, women were older (median age 76 vs 70 years) and less often achieved good functional outcome at 90 days (mRS ≤2: 35.2% vs 46.4%, aOR 0.70, 95% CI 0.60 to 0.82). Mean onset-to-door time was longer in women (2 hours 16 min vs 2 hours 7 min, adjusted delay 9 min, 95% CI 4 to 13). This delay contributed to longer onset-to-groin times (3 hours 26 min in women vs 3 hours 13 min in men, adjusted delay 13 min, 95% CI 9 to 17). Women more often had prestroke disability (mRS ≥1: 41.1% vs 29.1%, aOR 1.57, 95% CI 1.36 to 1.82). NIHSS on admission was essentially similar in men and women (mean 15±6 vs 15±6, NIHSS <10 vs ≥10, aOR 0.91, 95% CI 0.78 to 1.06). There were no clear sex differences in the occurrence of specific stroke symptoms.
Conclusion Women with LVO had longer onset-to-door times and more often prestroke disability than men. Raising awareness of these differences at hospital presentation and investigating underlying causes may help to improve outcome after EVT in women.
Data availability statement
No data are available. Data cannot be made available to other researchers, as no patient approval has been obtained for sharing coded data. However, syntax and output files of statistical analyses are available on reasonable request.
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Collaborators MR CLEAN Registry Investigators – group authors
Diederik W.J. Dippel1; Aad van der Lugt2; Charles B.L.M. Majoie3; Yvo B.W.E.M. Roos4; Robert J. van Oostenbrugge5,44; Wim H. van Zwam6,44; Jelis Boiten14; Jan Albert Vos8.
Ivo G.H. Jansen3; Maxim J.H.L. Mulder1,2; Robert- Jan B. Goldhoorn5,6,44; Kars C.J. Compagne2; Manon Kappelhof3; Josje Brouwer4; Sanne J. den Hartog1,2,40; Wouter H. Hinsenveld5,6; Lotte van den Heuvel1,40.
Local principal investigators
Diederik W.J. Dippel1; Bob Roozenbeek1; Aad van der Lugt2; Pieter Jan van Doormaal2; Charles B.L.M. Majoie3; Yvo B.W.E.M. Roos4; Bart J. Emmer3; Jonathan M. Coutinho4; Wouter J. Schonewille7; Jan Albert Vos8; Marieke J.H. Wermer9; Marianne A.A. van Walderveen10; Adriaan C.G.M. van Es10; Julie Staals5,44; Robert J. van Oostenbrugge5,44; Wim H. van Zwam6,44; Jeannette Hofmeijer11; Jasper M. Martens12; Geert J. Lycklama à Nijeholt13; Jelis Boiten14; Sebastiaan F. de Bruijn15; Lukas C. van Dijk16; H. Bart van der Worp17; Rob H. Lo18; Ewoud J. van Dijk19; Hieronymus D. Boogaarts20; J. de Vries22; Paul L.M. de Kort21; Julia van Tuijl21; Issam Boukrab26; Jo P. Peluso26; Puck Fransen22; Jan S.P. van den Berg22; Heleen M. den Hertog22; Boudewijn A.A.M. van Hasselt23; Leo A.M. Aerden24; René J. Dallinga25; Maarten Uyttenboogaart28; Omid Eschgi29; Reinoud P.H. Bokkers29; Tobien H.C.M.L. Schreuder30; Roel J.J. Heijboer31; Koos Keizer32; Rob A.R. Gons32; Lonneke S.F. Yo33; Emiel J.C. Sturm35,47; Tomas Bulut35; Paul J.A.M. Brouwers34; Anouk D. Rozeman42; Otto Elgersma41; Michel J.M. Remmers43; Thijs E.A.M. de Jong46.
Imaging assessment committee
Charles B.L.M. Majoie3(chair); Wim H. van Zwam6,44; Aad van der Lugt2; Geert J. Lycklama à Nijeholt13; Marianne A.A. van Walderveen10; Marieke E.S. Sprengers3; Sjoerd F.M. Jenniskens27; René van den Berg3; Albert J. Yoo38; Ludo F.M. Beenen3; Alida A. Postma6,45; Stefan D. Roosendaal3; Bas F.W. van der Kallen13; Ido R. van den Wijngaard13; Adriaan C.G.M. van Es10; Bart J. Emmer3; Jasper M. Martens12; Lonneke S.F. Yo33; Jan Albert Vos8; Joost Bot36; Pieter-Jan van Doormaal2; Anton Meijer27; Elyas Ghariq13; Reinoud P.H. Bokkers29; Marc P. van Proosdij37; G. Menno Krietemeijer33; Jo P. Peluso26; Hieronymus D. Boogaarts20; Rob Lo18; Wouter Dinkelaar41; Auke P.A. Appelman29; Bas Hammer16; Sjoert Pegge27; Anouk van der Hoorn29; Saman Vinke20; Sandra Cornelissen2; Christiaan van der Leij6; Rutger Brans6; Jeanette Bakker41; Maarten Uyttenboogaart28; Miou Koopman3; Lucas Smagge2; Olvert A. Berkhemer1,3,6; Jeroen Markenstein3; Eef Hendriks3; Patrick Brouwer10; Dick Gerrits35.
Diederik W.J. Dippel1(chair); Aad van der Lugt2; Charles B.L.M. Majoie3; Yvo B.W.E.M. Roos4; Robert J. van Oostenbrugge5,44; Wim H. van Zwam6,44; Geert J. Lycklama à Nijeholt13; Jelis Boiten14; Jan Albert Vos8; Wouter J. Schonewille7; Jeannette Hofmeijer11; Jasper M. Martens12; H. Bart van der Worp17; Rob H. Lo18
Adverse event committee
Robert J. van Oostenbrugge5,44(chair); Jeannette Hofmeijer11; H. Zwenneke Flach23
Hester F. Lingsma40
Research nurses / local trial coordinators
Naziha el Ghannouti1; Martin Sterrenberg1; Wilma Pellikaan7; Rita Sprengers4; Marjan Elfrink11; Michelle Simons11; Marjolein Vossers12; Joke de Meris14; Tamara Vermeulen14; Annet Geerlings19; Gina van Vemde22; Tiny Simons30; Gert Messchendorp28; Nynke Nicolaij28; Hester Bongenaar32; Karin Bodde24; Sandra Kleijn34; Jasmijn Lodico34; Hanneke Droste34; Maureen Wollaert5; Sabrina Verheesen5; D. Jeurrissen5; Erna Bos9; Yvonne Drabbe15; Michelle Sandiman15; Nicoline Aaldering11; Berber Zweedijk17; Jocova Vervoort21; Eva Ponjee22; Sharon Romviel19; Karin Kanselaar19; Denn Barning1; Laurine van der Steen3.
Clinical/imaging data aquisition
Esmee Venema40; Vicky Chalos1,40; Ralph R. Geuskens3; Tim van Straaten19; Saliha Ergezen1; Roger R.M. Harmsma1; Daan Muijres1; Anouk de Jong1; Olvert A. Berkhemer1,3,6; Anna M.M. Boers3,39; J. Huguet3; P.F.C. Groot3; Marieke A. Mens3; Katinka R. van Kranendonk3; Kilian M. Treurniet3; Manon L. Tolhuisen3,39; Heitor Alves3; Annick J. Weterings3; Eleonora L.F. Kirkels3; Eva J.H.F. Voogd11; Lieve M. Schupp3; Sabine L. Collette28,29; Adrien E.D. Groot4; Natalie E. LeCouffe4; Praneeta R. Konduri39; Haryadi Prasetya39; Nerea Arrarte-Terreros39; Lucas A. Ramos39; Nikki Boodt1,2,40; Anne F.A.V Pirson5; Agnetha A.E. Bruggeman3; Nadinda A.M. van der Ende1,2; Rabia Deniz3; Susanne G.H. Olthuis5,44; Floor Pinckaers6,44.
List of affiliations
Department of Neurology1, Radiology2, Public Health40, Erasmus MC University Medical Center;
Department of Radiology and Nuclear Medicine3, Neurology4, Biomedical Engineering & Physics39, Amsterdam UMC, location University of Amsterdam;
Department of Neurology5, Radiology & Nuclear Medicine6, Maastricht University Medical Center+;
School for Cardiovascular Diseases Maastricht (CARIM)44 and MHeNs School for Mental Health and Neuroscience, Maastricht, the Netherlands45;
Department of Neurology7, Radiology8, Sint Antonius Hospital, Nieuwegein;
Department of Neurology9, Radiology10, Leiden University Medical Center;
Department of Neurology11, Radiology12, Rijnstate Hospital, Arnhem;
Department of Radiology13, Neurology14, Haaglanden MC, the Hague;
Department of Neurology15, Radiology16, HAGA Hospital, the Hague;
Department of Neurology17, Radiology18, University Medical Center Utrecht;
Department of Neurology19, Neurosurgery20, Radiology27, Radboud University Medical Center, Nijmegen;
Department of Neurology21, Radiology26, Elisabeth-TweeSteden ziekenhuis, Tilburg;
Department of Neurology22, Radiology23, Isala Klinieken, Zwolle;
Department of Neurology24, Radiology25, Reinier de Graaf Gasthuis, Delft;
Department of Neurology28, Radiology29, University Medical Center Groningen;
Department of Neurology30, Radiology31, Atrium Medical Center, Heerlen;
Department of Neurology32, Radiology33, Catharina Hospital, Eindhoven;
Department of Neurology34, Radiology35, Medisch Spectrum Twente, Enschede, (currently Deventer Hospital47);
Department of Radiology36, Amsterdam UMC, Vrije Universiteit van Amsterdam, Amsterdam;
Department of Radiology37, Noordwest Ziekenhuisgroep, Alkmaar;
Department of Radiology38, Texas Stroke Institute, Texas, United States of America;
Department of Neurology42, Radiology41, Albert Schweitzer Hospital, Dordrecht;
Department of Neurology43, Radiology46, Amphia Hospital, Breda.
Contributors MarA and MJHW: conception and design of the study, and drafting of the manuscript. MarA, AvdM, HJAvO, and MahA: data and statistical analysis. EWvZ: supervision of statistical analysis. AvdM, JH, WJS, MAAvW, IRvdW, and ACGMvE: acquisition of clinical data. CBLMM and DWJD: members of the trial executive committee and critical review and revision. FHMS, PJN, MCV, and NDK: critical review and revision for valuable intellectual content. MarA is guarantor of the data.
Funding The Multicentre Randomised Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in The Netherlands (MR CLEAN) Registry was partly funded by the TWIN Foundation, Erasmus MC University Medical Centre, Amsterdam University Medical Centre, and Maastricht University Medical Centre.
Competing interests MJHW reports funding from the Dutch Research Council (VIDI grant 91717337). CBLMM reports funding from the TWIN Foundation, CVON/Dutch Heart Foundation, European Commission, Health Evaluation Netherlands, and Stryker, all outside the submitted work (paid to institution); he is shareholder of Nicolab. DWJD reports funding from the Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Sciences and Health, and unrestricted grants from Penumbra Inc, Stryker European Operations BV, Medtronic, Thrombolytic Science, and Cerenovus, all paid to institution. JH reports funding from the Dutch Heart Foundation, Brain Foundation Netherlands, and ZonMw, all paid to institution. IRvdW reports funding from Jacobus Stichting. PJN reports funding from the Dutch Heart Foundation and The Netherlands Organisation for Health Research and Development, both paid to institution.
Provenance and peer review Not commissioned; externally peer reviewed.
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