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acute stroke, prehospital delay, sex/gender differences, symptom onset, systematic review



  1. Potisopha, Wiphawadee MSN, RN
  2. Vuckovic, Karen M. PhD, APRN, ACNS-BC, FAHA
  3. DeVon, Holli A. PhD, RN, FAHA, FAAN
  4. Park, Chang G. PhD
  5. Hershberger, Patricia E. PhD, APRN, FNP-BC, FAAN


Background: In 2009, the window from symptom onset to administration of tissue plasminogen activator for acute ischemic stroke was extended from 3 to 4.5 hours. Yet no systematic review has addressed prehospital delay by sex for stroke symptoms since this change.


Purpose: We aimed to (1) compare prehospital delay times-the time from symptom onset to hospital arrival-between women and men with acute stroke or transient ischemic attack and (2) summarize factors influencing prehospital delay by sex.


Methods: The CINAHL, MEDLINE, PubMed, Scopus, and PsycINFO databases were searched using PRISMA guidelines. Inclusion criteria were as follows: (1) quantitative research articles published between May 2008 and April 2019, (2) investigation of prehospital delay among women and men 15 years or older who were given a diagnosis of acute stroke or transient ischemic attack, and (3) English-language publications. The Crowe Critical Appraisal Tool was used to evaluate the quality of studies.


Results: Fifteen publications (n = 162 856) met inclusion criteria. Most studies (n = 11) showed no sex differences in prehospital delay. Four studies from Asian-Pacific countries and the United States showed that women had significantly longer prehospital delay compared with men. Older age, minority race/ethnicity (black and Mexican American), and underuse of emergency medical services were associated with prolonged prehospital delay in women.


Conclusions: Most study authors found no differences in prehospital delay between women and men; however, women delayed longer in some Asian-Pacific and American studies. Findings of sex differences were inconclusive.