Sex differences in clinical presentation, severity and outcome of stroke: results from a hospital-based registry

Predictors of functional outcome after stroke: Sex differences in older individuals

BACKGROUND

Sex differences in stroke are well documented, with females being older at onset, with more severe strokes and worse outcomes than males. Females receive less comprehensive stroke unit treatment. Similarly, older individuals receive poorer quality care than younger ones. There is limited research on sex differences in factors that impact 3-month poststroke functional outcome in people older than 80 years.

METHODS

This register-based and cross-sectional study analyzed data from two stroke quality registers in Sweden from 2014 through 2019. The study included patients aged ≥80 with a diagnosis of ischemic or hemorrhagic stroke. Sociodemographic features, prestroke condition, stroke severity on admission (National Institutes of Health Stroke Scale [NIHSS]), stroke unit care, rehabilitation plans, and 3-month poststroke functional outcome measured with the modified Rankin Scale were analyzed. Ordinal regression analyses stratified by sex were conducted to assess sex differences in factors that impact poststroke functional outcome 3 months after the stroke.

RESULTS

A total of 2245 patients were studied with the majority (59.2%) being females. Females experienced more severe strokes (NIHSS median 4 vs. 3, p = 0.01) and were older at stroke onset than males (87.0 vs. 85.4, p < 0.001). Females were also less independent prestroke (69.9% vs. 77.4%, p < 0.001) and a higher proportion of females lived alone (78.2% vs. 44.2%, p < 0.001). Males received intravenous thrombolysis more often than females (16.3% vs. 12.0%, p = 0.005). Regarding 3-month functional outcome, males benefited more from thrombolysis (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.30-0.83), whereas females benefited more from thrombectomy (OR 0.40, 95% CI 0.20-0.71).

CONCLUSION

Stroke care should be adapted to sex disparities in older individuals, while clinicians should be aware of these sex disparities. Further research could clarify the mechanisms behind these disparities and lead to a more personalized approach to stroke care of the older population.

The Association Between National Institutes of Health Stroke Scale Score and Clinical Outcome in Patients with Large Core Infarctions Undergoing Endovascular Treatment

INTRODUCTION

This study aimed to analyze the association between baseline National Institutes of Health Stroke Scale (NIHSS) scores and clinical outcomes in patients with large core infarctions undergoing endovascular treatment (EVT), a relationship that remains unclear.

METHODS

Data were obtained from the MAGIC study, a prospective multicenter cohort study focusing on patients with acute large core ischemic stroke. This analysis evaluated the impact of NIHSS scores on EVT outcomes in patients with large core infarctions. Primary outcome metrics included favorable outcomes (modified Rankin Scale [mRS] of 0-3 at 90 days), while secondary outcomes encompassed shifts in mRS scores, functional independence (mRS score of 0-2), mRS score of 0-4, and successful recanalization rates. Adverse events considered were symptomatic intracranial hemorrhage (sICH) and mortality.

RESULTS

A total of 490 patients were enrolled in this study. Higher baseline NIHSS scores were inversely correlated with favorable outcomes (adjusted odds ratio [OR] in model 3, 0.848 [0.797-0.903], P < 0.001), particularly in patients with NIHSS scores above 20 (adjusted OR in model 3, 0.518 [0.306-0.878] vs. 0.290 [0.161-0.523]). Regarding adverse events, higher baseline NIHSS scores significantly correlated with increased 90-day mortality rates (adjusted OR in model 3, 1.129 [1.072-1.189], P < 0.001). This correlation became insignificant when baseline NIHSS scores exceeded 22. Additionally, baseline NIHSS scores partially mediated the association between age (indirect effect = - 0.0005, 19.39% mediated) and sex (indirect effect = 0.0457, 25.08% mediated) with the primary outcome.

CONCLUSIONS

The findings indicate that higher baseline NIHSS scores correlate with poorer outcomes and increased mortality, particularly when scores exceed 20. Moreover, age and sex indirectly influence favorable outcomes through their association with baseline NIHSS scores.

From Admission to Discharge: Predicting National Institutes of Health Stroke Scale Progression in Stroke Patients Using Biomarkers and Explainable Machine Learning

As a result of social progress and improved living conditions, which have contributed to a prolonged life expectancy, the prevalence of strokes has increased and has become a significant phenomenon. Despite the available stroke treatment options, patients frequently suffer from significant disability after a stroke. Initial stroke severity is a significant predictor of functional dependence and mortality following an acute stroke. The current study aims to collect and analyze data from the hyperacute and acute phases of stroke, as well as from the medical history of the patients, in order to develop an explainable machine learning model for predicting stroke-related neurological deficits at discharge, as measured by the National Institutes of Health Stroke Scale (NIHSS). More specifically, we approached the data as a binary task problem: improvement of NIHSS progression vs. worsening of NIHSS progression at discharge, using baseline data within the first 72 h. For feature selection, a genetic algorithm was applied. Using various classifiers, we found that the best scores were achieved from the Random Forest (RF) classifier at the 15 most informative biomarkers and parameters for the binary task of the prediction of NIHSS score progression. RF achieved 91.13% accuracy, 91.13% recall, 90.89% precision, 91.00% f1-score, 8.87% FNrate and 4.59% FPrate. Those biomarkers are: age, gender, NIHSS upon admission, intubation, history of hypertension and smoking, the initial diagnosis of hypertension, diabetes, dyslipidemia and atrial fibrillation, high-density lipoprotein (HDL) levels, stroke localization, systolic blood pressure levels, as well as erythrocyte sedimentation rate (ESR) levels upon admission and the onset of respiratory infection. The SHapley Additive exPlanations (SHAP) model interpreted the impact of the selected features on the model output. Our findings suggest that the aforementioned variables may play a significant role in determining stroke patients' NIHSS progression from the time of admission until their discharge.

Sex Differences in Intensity of Care and Outcomes After Acute Ischemic Stroke Across the Age Continuum

BACKGROUND AND OBJECTIVES

Sex differences in stroke care and outcomes have been previously reported, but it is not known whether these associations vary across the age continuum. We evaluated whether the magnitude of female-male differences in care and outcomes varied with age.

METHODS

In a population-based cohort study, we identified patients hospitalized with ischemic stroke between 2012 and 2019 and followed through 2020 in Ontario, Canada, using administrative data. We evaluated sex differences in receiving intensive care unit services, mechanical ventilation, gastrostomy tube insertion, comprehensive stroke center care, stroke unit care, thrombolysis, and endovascular thrombectomy using logistic regression and reported odds ratios (ORs) and 95% CIs. We used Cox proportional hazard models and reported the hazard ratios (HRs) and 95% CI of death within 90 or 365 days. Models were adjusted for covariates and included an interaction between age and sex. We used restricted cubic splines to model the relationship between age and care and outcomes. Where the p-value for interaction was statistically significant (p < 0.05), we reported age-specific OR or HR.

RESULTS

Among 67,442 patients with ischemic stroke, 45.9% were female and the median age was 74 years (64-83). Care was similar between both sexes, except female patients had higher odds of receiving endovascular thrombectomy (OR 1.35, 95% CI [1.19-1.54] comparing female with male), and these associations were not modified by age. There was no overall sex difference in hazard of death (HR 95% CI 0.99 [0.95-1.04] for death within 90 days; 0.99 [0.96-1.03] for death within 365 days), but these associations were modified by age with the hazard of death being higher in female than male patients between the ages of 50-70 years (most extreme difference around age 57, HR 95% CI 1.25 [1.10-1.40] at 90 days, p-interaction 0.002; 1.15 [1.10-1.20] at 365 days, p-interaction 0.002).

DISCUSSION

The hazard of death after stroke was higher in female than male patients aged 50-70 years. Examining overall sex differences in outcomes without accounting for the effect modification by age may miss important findings in specific age groups.

Sex Differences in Stroke Risk Factors, Clinical Profiles, and In-Hospital Outcomes Among Stroke Patients Admitted to the Medical Ward of Dessie Comprehensive Specialized Hospital, Northeast Ethiopia

BACKGROUND

A stroke is a vascular accident that affects both men and women. The threat of stroke and outcome status differ between the sexes. Such data are lacking in Ethiopia. Therefore, this study assessed sex differences in stroke risk factors, clinical profiles, and outcomes in the medical ward of Dessie comprehensive specialized hospital.

METHODS

A retrospective cross-sectional study was employed among stroke patients. Medical records with complete information and a confirmed diagnosis of stroke using imaging techniques were included in the study. Using simple random sampling, 344 medical records were selected, 312 of which fulfilled the inclusion criteria. Bivariate and multivariate logistic regression analyses and a chi-square test were employed. The frequency, percentage, and mean and standard deviation of the variables were described using descriptive statistics. Findings with a P-value <0.05 were considered statistically significant.

RESULTS

Most of the patients were above or equal to 45 years old in both sexes. A significantly higher number of male than female patients were aged less than 45 years (p-value-0.001). Younger age (AOR: 2.998, p = 0.000), cigarette smoking (AOR: 2.911, p = 0.009), and Khat chewing (AOR: 3.650, p = 0.001) were risk factors for stroke in males. A higher number of males presented with hemiplegia/hemiparesis 89 (28.5%), aphasia 45 (14.4%), and facial palsy 19 (6.1%). However, more females were unconscious (15.1%). Significant differences were not seen in the stroke outcomes. Furthermore, there were no apparent differences in risk factors for stroke-related mortality.

CONCLUSION

Males developed stroke at a younger age. Women were older at the time of stroke onset and presented unconscious. More males experienced hemiplegia/hemiparesis, aphasia, and facial palsy. Smoking, drinking, and khat chewing were risk factors for stroke in men. There were no gender differences in the stroke death rate. Therefore, educating the public about stroke risk factors, lifestyle modification, and conducting prospective research is required.

Gender differences in mortality of hospitalised stroke patients. Systematic review and meta-analysis

OBJECTIVE

Gender differences in mortality after stroke remains unclear in the current literature. We therefore aimed to systematically review the gender differences in mortality up to five years after ischaemic (IS) or haemorrhagic stroke (HS) to address this evidence gap.

METHODS

The literature was systematically searched using Ovid EMBASE, Ovid Medline, and Web of Science databases, from inception-November 2021. The quality of evidence was appraised using the CASP Cohort-study checklist. Unadjusted and adjusted odds and hazard ratios were meta-analysed, separately for IS and HS and a subgroup analysis of age-stratified mortality data was conducted.

RESULTS

Forty-one studies were included (n = 8,128,700; mean-age 68.5 yrs; 47.1% female). 37 studies were included in meta-analysis (n = 8, 8008, 110). Compared to men, women who had an IS had lower mortality risk in-hospital (0.94; 95%CI 0.91-0.97), at one-month (0.87; 95%CI 0.77-0.98), 12-months (0.94; 95%CI 0.91-0.98) and five-years (0.93 95%CI 0.90-0.96). The subgroup analysis showed that this gender difference in mortality was present in women ≥ 70 years up to one-month post-IS (in-hospital: 0.94; 95%CI 0.91-0.97; one-month: 0.87; 95% CI 0.77-0.98), however, in women < 70 years this difference was no longer present. Nevertheless, analysis of crude data showed women were at higher risk of mortality in-hospital, at 12-months and five-years (in-hospital: 1.05; 95%CI 1.03-1.07, 12-months: 1.10; 95%CI 1.06-1.14, five-years: 1.06; 95%CI 1.02-1.10). After HS, women had higher mortality risk in-hospital (1.03; 95%CI 1.01-1.04) however, no gender differences were found post-discharge.

CONCLUSION

The gender differences in post-stroke mortality differ by stroke type, age group and follow-up. Crude stroke mortality in women is higher than in men and this appears to be driven by pre-existing comorbidities. In adjusted models, women have a lower mortality risk following IS, independent of duration of follow-up. After HS, women had higher mortality in hospital however, no gender differences after hospital discharge were found.

Demographic and clinical characteristics of inpatient stroke patients in Turkey

Objectives

This study aims to assess the stroke rehabilitation facilities provided by university hospitals (UHs) and training and research hospitals (TRHs) and to evaluate the geographical disparities in stroke rehabilitation.

Patients and methods

Between April 2013 and April 2014 a total of 1,529 stroke patients (817 males, 712 females; mean age: 61.7±14.0 years; range, 12 to 91 years) who were admitted to the physical medicine and rehabilitation clinics in 20 tertiary care centers were retrospectively analyzed. Demographic, regional and clinical characteristics, details of rehabilitation period, functional status, and complications were collected.

Results

The median duration of stroke was five (range, 1 to 360) months. The ratio of the patients treated in the TRH in the Marmara region was 77%, but only 25% of the patients were living in the Marmara region. Duration of hospitalization was longer in the TRHs with a median of 28 days compared to those of UHs (median: 22 days) (p<0.0001). More than half of the patients (55%) were rehabilitated in the Marmara region. Time after stroke was the highest in the Southeast region with a median of 12 (range, 1 to 230) months and the lowest in the Aegean region with a median of four (range, 1 to 84) months.

Conclusion

This study provides an insight into the situation of stroke rehabilitation settings and characteristics of stroke patients in Turkey. A standard method of patient evaluation and a registry system may provide data about the efficacy of stroke rehabilitation and may help to focus on the problems that hinder a better outcome.

Analysis of Prognostic Risk Factors for Ischemic Stroke in China: A Multicentre Retrospective Clinical Study; A National Survey in China

BACKGROUND

Stroke is a serious disease that threatens human health both in China and worldwide. Identifying and establishing its risk factors are prerequisites for intervention and evaluation of prognosis. Over the years, risk factors, such as age, diabetes, and hypertension, have gradually been established. However, at present, there is no consensus on the influence of sex on the prognosis of ischaemic stroke.

AIMS

The aims of our research was to analyse the correlation between sex and poststroke prognosis based on the results of the Third China National Stroke Registry [CNSR-III], as well as the influence of other risk factors that may be confounded by sex on ischaemic stroke and potential interventions.

METHODS

The CNSR-III recruited 14146 acute ischaemic stroke [AIS] patients between 2015 and 2018. Our study included 13,972 patients who had complete follow-up information. This research analysed basic information, socioeconomic status, lifestyle habits, medical history, and poststroke prognosis.

RESULTS

There was a conspicuous relationship between sex and functional prognosis, stroke recurrence and all-cause death due to ischemic stroke in univariate analysis. Male stroke patients had a better prognosis than female patients. In multivariate analysis, we found that age, atrial fibrillation [AF], diabetes, hypertension and the severity of stroke had adverse effects on ischemic stroke prognosis. After adjustment for other risk factors, the functional prognosis of female patients at 3 months was worse than that of male patients [odds ratio [OR] 1.16, 95% confidence interval [CI], 1.025- 1.314]. Sex had a nonsignificant association with stroke recurrence at 3 months [hazard ratio [HR] 1.141, 95% CI, 0.975-1.336]. Furthermore, compared to male patients, female stroke patients had a lower cumulative death rate at 12 months [HR 0.777, 95% CI, 0.628-0.963].

CONCLUSION

Our study identified sex differences in stroke-related disability, recurrence, and death and attempted to explain the causes of these differences. Our study clearly showed that a large proportion of this difference could be attributed to age, socioeconomic factors, lifestyle habits, and medical history, confounded by sex differences rather than sex per se.

Sexual dimorphism in the cerebrovascular network: Brain MRI shows lower arterial density in women

BACKGROUND AND PURPOSE

Accumulating evidence suggests that there is a sexual dimorphism in brain health, with women exhibiting greater disability following strokes of comparable size and having a higher prevalence of cognitive impairment later in life. Despite the critical implication of the cerebrovascular architecture in brain perfusion and brain health, it remains unclear whether structural differences in vessel density exist across the sexes.

METHODS

In this study, we used high-density MRI imaging to characterize the intracerebral arterial and venous density of 28 (14 women) sex-matched healthy young volunteers in vivo. Using an in-house vessel segmentation algorithm, we quantified and compared these vascular features across the cortical and subcortical deep gray matter, white matter, and periventricular white matter.

RESULTS

We found that, on average, women have reduced intracerebral arterial density in comparison to men (F 2.34 ± 0.48%, M 2.67 ± 0.39%; p<.05). This difference was most pronounced in the subcortical deep gray matter (F 1.78 ± 0.53%, M 2.38 ± 0.82%; p<.05) and periventricular white matter (F 0.68 ± 0.15%, M 1.14 ± 0.33%; p<.0005), indicating a potential sex-specific vulnerability to hypoperfusion in areas critical to core cerebral functions. In contrast, venous density did not exhibit a significant difference between sexes.

CONCLUSIONS

While this research remains exploratory, it raises important pathophysiological considerations for brain health, adverse cerebrovascular events, and dementia across the sexes. Our findings also highlight the need to take into account sex differences when investigating cerebral characteristics in humans.

The Long-Term Functional Effect of Thrombectomy on Patients with Middle Cerebral Artery Occlusion Who Exhibit Moderate to Severe Disability

Background and Objectives: Endovascular thrombectomy (EVT is an emerging gold standard treatment for acute cerebral infarction and may allow functional improvement after subacute cerebral infarction. However, the long-term functional benefits of EVT in patients with moderate to severe disability remain unclear. We investigated the effects of EVT on the activities of daily living (ADL), handicap, gait, and eating in patients with middle cerebral artery (MCA) occlusion who exhibited moderate to severe disability (score of 3-5 on the modified Rankin scale (mRS)) due to stroke, up to six months after onset. Materials and Methods: This retrospective longitudinal case-control study assessed 45 patients with MCA occlusion who exhibited moderate to severe disability (mRS score ≥ 3): 15 underwent EVT and 30 served as controls. Clinical assessments were conducted at two weeks (12-16 days), four weeks (26-30 days), and six months (180-210 days) after stroke onset. Functional assessments comprised the Korean version of the modified Barthel index (MBI), mRS, functional ambulation category (FAC), and dysphagia outcome severity scale (DOSS) to assess disability, handicap, gait, and eating. Results: The MBI, mRS, FAC, and DOSS scores all improved significantly (all p < 0.05) in the EVT group, compared to the controls. Conclusions: EVT has favorable effects on performing routine ADL, the handicap itself, walking, and eating. Therefore, EVT is recommended for patients with acute MCA occlusion, including those with severe disability at the initial assessment.

Trends in prevalence of acute stroke impairments: A population-based cohort study using the South London Stroke Register

BACKGROUND

Acute stroke impairments often result in poor long-term outcome for stroke survivors. The aim of this study was to estimate the trends over time in the prevalence of these acute stroke impairments.

METHODS AND FINDINGS

All first-ever stroke patients recorded in the South London Stroke Register (SLSR) between 2001 and 2018 were included in this cohort study. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted prevalence of 8 acute impairments, across six 3-year time cohorts. Prevalence ratios comparing impairments over time were also calculated, stratified by age, sex, ethnicity, and aetiological classification (Trial of Org 10172 in Acute Stroke Treatment [TOAST]). A total of 4,683 patients had a stroke between 2001 and 2018. Mean age was 68.9 years, 48% were female, and 64% were White. After adjustment for demographic factors, pre-stroke risk factors, and stroke subtype, the prevalence of 3 out of the 8 acute impairments declined during the 18-year period, including limb motor deficit (from 77% [95% CI 74%-81%] to 62% [56%-68%], p < 0.001), dysphagia (37% [33%-41%] to 15% [12%-20%], p < 0.001), and urinary incontinence (43% [39%-47%) to 29% [24%-35%], p < 0.001). Declines in limb impairment over time were 2 times greater in men than women (prevalence ratio 0.73 [95% CI 0.64-0.84] and 0.87 [95% CI 0.77-0.98], respectively). Declines also tended to be greater in younger patients. Stratified by TOAST classification, the prevalence of all impairments was high for large artery atherosclerosis (LAA), cardioembolism (CE), and stroke of undetermined aetiology. Conversely, small vessel occlusions (SVOs) had low levels of all impairments except for limb motor impairment and dysarthria. While we have assessed 8 key acute stroke impairments, this study is limited by a focus on physical impairments, although cognitive impairments are equally important to understand. In addition, this is an inner-city cohort, which has unique characteristics compared to other populations.

CONCLUSIONS

In this study, we found that stroke patients in the SLSR had a complexity of acute impairments, of which limb motor deficit, dysphagia, and incontinence have declined between 2001 and 2018. These reductions have not been uniform across all patient groups, with women and the older population, in particular, seeing fewer reductions.

Stroke in the adult Qatari population (Q-stroke) a hospital-based retrospective cohort study

BACKGROUND

Studies assessing the burden of stroke in Qataris are limited. We aim to study stroke in the Qatari population.

METHODS

A retrospective review was undertaken of all Qatari adults presenting with stroke to Hamad Medical Corporation over a 5-year period. Descriptive statistics were used to summarize demographic and all other clinical characteristics of the patients. The primary outcome was the incidence of stroke in the Qatari patients. Comparison was made between the sexes.

RESULTS

862 patients were included, with 58.9% being male. The average incidence of stroke over the 5-year period was 92.04 per 100,000 adult Qatari population. The mean age of the cohort was 64.3±14.4 years, (range 19-105 years). The mean age of first ever cerebrovascular event was 63.2±14.5 years. The diagnosis was ischemic stroke in (73.7%), transient ischemic attack in (13.8%), intracerebral hemorrhage (ICH) in (11.6%), subarachnoid hemorrhage in (0.7%) and (0.2%) cerebral venous sinus thrombosis. Small vessel disease was the most common cause of ischemic stroke accounting for (46.5%), followed by large artery atherosclerosis (24.5%). Hypertension (82.7%) and diabetes (71.6%) were particularly prevalent in this cohort. Females were older (65.8±14.1 vs 63.4±14.5 years), had more hypertension and diabetes and more disability or death at 90 days (p<0.05) compared to Qatari males.

CONCLUSION

Stroke occurs at a significantly lower age in Qataris compared to the western population. This study has uncovered sex differences that need to be studied further.

In acute ischemic stroke patients with smoking incidence, are more women than men more likely to be included or excluded from thrombolysis therapy?

Background:

Clinical factors associated with exclusion from recombinant tissue plasminogen activator in both men and women are not completely understood. The aim of this study is to determine whether there is a gender difference in clinical risk factors that excluded ischemic stroke patients with a history of smoking from recombinant tissue plasminogen activator.

Methods:

Retrospective data from a stroke registry were analyzed, and multivariable linear regression models were used to determine gender differences. Logistic regression models determined exclusion clinical risk factors for thrombolysis in male and female acute ischemic stroke patients with a history of smoking, while sequentially adjusting for sociodemographic, clinical, and stroke-related variables. The Kaplan–Meier survival analysis was used to determine the exclusion probabilities of men and women with a history of smoking within the stroke population.

Results:

Of the 1,446 acute ischemic stroke patients eligible for recombinant tissue plasminogen activator, 379 patients with a history of smoking were examined, of which 181 received recombinant tissue plasminogen activator while 198 were excluded from receiving recombinant tissue plasminogen activator. Of the 198 patients, 75 females and 123 males were excluded from receiving recombinant tissue plasminogen activator. After multivariable adjustment for age, National Institutes of Health scores, and stroke-related factors, females who present with weakness/paresis on initial examination (OR = 0.117, 95% CI, 0.025–0.548) and men who present with a history of previous transient ischemic attack (OR = 0.169, 95% CI, 0.044–0.655), antiplatelet medication use (OR = 0.456, 95% CI, 0.230–0.906), and weakness/paresis on initial examination (OR = 0.171, 95% CI, 0.056–0.521) were less likely to be excluded from recombinant tissue plasminogen activator (thrombolysis therapy).

Conclusions:

In an ischemic stroke population with a history of smoking, female smokers are more likely to be excluded from thrombolysis therapy in comparison to men, even after adjustment for confounding variables.

A hospital-based study on ischaemic stroke characteristics, management, and outcomes in Sarawak: Where do we stand?

BACKGROUND

Located on the Borneo Island, Sarawak is the largest state of Malaysia and has a population distinctive from Peninsular Malaysia. The ischaemic stroke data in Sarawak had not been reported despite the growing number of patients annually. We aimed to investigate patient characteristics, management, and outcomes of ischaemic stroke in Sarawak and benchmark the results with national and international published data.

METHODS

We included ischaemic stroke cases admitted to Sarawak General Hospital between June 2013 and August 2018 from Malaysia National Stroke Registry. We performed descriptive analyses on patient demographics, cardiovascular risk factors, prior medications, smoking status, arrival time, thrombolysis rate, Get With The Guidelines (GWTG)-Stroke measures, and outcomes at discharge. We also numerically compared the results from Sarawak with the published data from selected national and international cohorts.

RESULTS

We analysed 1435 ischaemic stroke cases. The mean age was 60.1±13.2 years old; 64.9% were male; median baseline National Institute of Health Stroke Scale was seven points. Hypertension was the most prevalent risk factor of ischaemic stroke; 12.7% had recurrent stroke; 13.7% were active smokers. The intravenous thrombolysis rate was 18.8%. We achieved 80-90% in three GWTG-Stroke performance measures and 90-98% in four additional quality measures in our ischaemic stroke management. At discharge, 57% had modified Rankin Scale of 0-2; 6.7% died during hospitalisation. When compared with selected national and international data, patients in Sarawak were the youngest; Sarawak had more male and more first-ever stroke. Thrombolysis rate in Sarawak was higher compared with most studies in the comparison. Functional outcome at discharge in Sarawak was better than national cohort but still lagging behind when compared with the developed countries. In-hospital mortality rate in Sarawak was slightly lower than the national data but higher when compared with other countries.

CONCLUSION

Our study described characteristics, management, and outcomes of ischaemic stroke in Sarawak. We achieved high compliance with most of GTWG-Stroke performance and quality indicators. Sarawak had better outcomes than the national results on ischaemic stroke. However, there is still room for improvement when compared with other countries. Actions are needed to reduce the cardiovascular burdens for stroke prevention, enhance healthcare resources for stroke care, and improve intravenous thrombolysis treatment in Sarawak.

Texture analysis based on ADC maps and T2-FLAIR images for the assessment of the severity and prognosis of ischaemic stroke

OBJECTIVES

To explore the feasibility of texture analysis based on T2-weighted fluid-attenuated inversion recovery (T2-FLAIR) images and apparent diffusion coefficient (ADC) maps in the assessment of the severity and prognosis of ischaemic stroke using the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) scores, respectively.

METHODS

Overall, 116 patients diagnosed with subacute ischaemic stroke were included in this retrospective study. Based on T2-FLAIR images and ADC maps, 15 texture features were extracted from the ROIs of each patient using grey-level co-occurrence matrix (GLCM) and local binary pattern histogram Fourier (LBP-HF) methods. The correlations of NIHSS score on admission (NIHSS_baseline), NIHSS score 24 h after stroke onset (NIHSS_24h) and mRS score with the texture features were evaluated using Spearman's partial correlations. The receiver operating characteristic (ROC) curve was used to compare the performance of the selected texture features in the evaluation of stroke severity and prognosis.

RESULTS

Texture features derived from the T2-FLAIR images and ADC maps were correlated with NIHSS score and mRS score. Entropy_ADC and 0.75Quantile_T2-FLAIR showed the best diagnostic performance for assessing stroke severity. The combination of Entropy_ADC and 0.75Quantile_T2-FLAIR achieved a better performance in the evaluation of stroke severity (AUC = 0.7, p = 0.01) than either feature alone. Only 0.05Quantile_T2-FLAIR was found to be correlated with mRS score, and none of the texture features were predictive of mRS score.

CONCLUSION

Texture features derived from T2-FLAIR images and ADC maps might serve as biomarkers to evaluate stroke severity, but were insufficient to predict stroke prognosis.

Sex differences in IV thrombolysis treatment for acute ischemic stroke

Objective

A prior meta-analysis of reports published between 2000 and 2008 found that women were 30% less likely to receive IV recombinant tissue plasminogen activator (rtPA) treatment for stroke than men; we updated this meta-analysis to determine if this sex difference persisted.

Methods

We identified studies that reported sex-specific IV rtPA treatment rates for acute ischemic stroke published between 2008 and 2018. Eligible studies included representative populations of patients with ischemic stroke from hospital-based, registry-based, or administrative data. Random effects odds ratios (ORs) were generated to quantify sex differences.

Results

Twenty-four eligible studies were identified during this 10-year period. The summary unadjusted OR based on 17 studies with data on all ischemic stroke patients was 0.87 (95% confidence interval [CI], 0.82–0.93), indicating that women had 13% lower odds of receiving IV rtPA treatment than men. However, substantial between-study variability existed. Lower treatment odds in women were also observed in 7 studies that provided data on the subgroup of patients eligible for IV rtPA treatment, although the summary OR of 0.95 (95% CI, 0.88–1.02) was not statistically significant. Examination of time trends across 33 studies published between 2000 and 2018 found evidence that the sex difference had narrowed in more recent years.

Conclusions

Although there is considerable variability in the findings of individual studies, pooled data from recent studies show that women with acute stroke are less likely to be treated with IV thrombolysis compared with men. However, the size of this difference has narrowed compared to studies published before 2008.

Can initial sarcopenia affect poststroke rehabilitation outcome?

This study investigated the association between the presence of sarcopenia, measured by nonhemiplegic grip strength, and the level of functional recovery, measured by the modified Rankin Scale (mRS) at six months after stroke. We performed a retrospective cohort analysis of a prospectively maintained database of 194 hemiplegic poststroke patients, who had been admitted to the Department of Rehabilitation Medicine of a university-affiliated hospital. At 6 months after stroke, 72.2% of patients had mRS score >3, with more women (81.0% vs. 66.0%, p = 0.024) showing poor recovery. Both men (51.3% vs. 35.9%, p = 0.041) and women (42.2% vs. 6.7%, p = 0.022) with mRS score >3 had a higher rate of sarcopenia. Univariate analysis revealed that the presence of sarcopenia was associated with a 2.71-fold higher risk of poor recovery at six months. In addition, women had a 2.18-fold higher risk of poor outcome. Multivariable logistic regression analysis revealed that the presence of sarcopenia was associated with poor functional outcome (odds ratio [OR] = 2.61, 95% confidence interval [CI]: 1.14-5.98, p = 0.024) in men, but this association was notably stronger in women (OR = 9.93, 95% CI: 1.22-81.19, p = 0.032). This study suggests that the presence of sarcopenia two weeks after stroke may increase the risk of poor functional outcome six months after stroke. Most notably, women with sarcopenia within 2 weeks from stroke onset were more significantly likely to have a poor modified Rankin Scale after 6 months.

Management of acute ischemic stroke, thrombolysis rate, and predictors of clinical outcome

BACKGROUND AND AIMS

Monitoring the quality of acute ischemic stroke (AIS) management is increasingly important since patient outcome could be improved with better access to evidence-based treatments. In this scenario, the aim of our study was to identify thrombolysis rate, reasons for undertreatment, and factors associated with better outcome.

METHODS

From January to December 2016, individuals diagnosed with AIS at the Policlinic San Martino Hospital in Genoa, Italy, were prospectively included. Severity of stroke, site of occlusion, rate and time related in-hospital management of systemic thrombolysis, and mechanical thrombectomy were recorded. Safety and clinical outcomes were compared between different subgroups.

RESULTS

Of 459 AIS patients (57.3% females, mean age 78.1), 111 received i.v. thrombolysis (24.4%) and 50 received mechanical thrombectomy (10.9%). Apart from arrival behind the therapeutic window, which was the first limitation to thrombolysis, the main reason of undertreatment was minor stroke or stroke in rapid improvement. Baseline NIHSS ≥ 8 was associated with unfavorable clinical outcome (mRS > 2) (OR 20.1; 95% CI, 1.1-387.4, p = 0.047). Age older than 80 years (OR 5.0; 95% CI, 1.4-64.1, p = 0.01), baseline NIHSS ≥ 7 (OR 20.1; 95% CI, 1.1-387.4, p = 0.047), and symptomatic intracranial hemorrhage (OR 22.9; 95% CI, 2.0-254.2, p = 0.01) proved independently associated with mortality.

CONCLUSIONS

i.v. thrombolysis and mechanical thrombectomy rate was higher than that of previous reports. Minor stroke or stroke in rapid improvement was a major reason for exclusion from thrombolysis of eligible patients. Higher NIHSS proved an independent predictor of unfavorable clinical outcome and death. Strategies to avoid in-hospital delays need to be enforced.

Genetics of stroke recovery: BDNF val66met polymorphism in stroke recovery and its interaction with aging

Stroke leads to long term sensory, motor and cognitive impairments. Most patients experience some degree of spontaneous recovery which is mostly incomplete and varying greatly among individuals. The variation in recovery outcomes has been attributed to numerous factors including lesion size, corticospinal tract integrity, age, gender and race. It is well accepted that genetics play a crucial role in stroke incidence and accumulating evidence suggests that it is also a significant determinant in recovery. Among the number of genes and variations implicated in stroke recovery the val66met single nucleotide polymorphism (SNP) in the BDNF gene influences post-stroke plasticity in the most significant ways. Val66met is the most well characterized BDNF SNP and is common (40-50 % in Asian and 25-32% in Caucasian populations) in humans. It reduces activity-dependent BDNF release, dampens cortical plasticity and is implicated in numerous diseases. Earlier studies on the effects of val66met on stroke outcome and recovery presented primarily a maladaptive role. Novel findings however indicate a much more intricate interaction between val66met and stroke recovery which appears to be influenced by lesion location, post-stroke stage and age. This review will focus on the role of BDNF and val66met SNP in relation to stroke recovery and try to identify potential pathophysiologic mechanisms involved. The effects of age on val66met associated alterations in plasticity and potential consequences in terms of stroke are also discussed.

Sex Differences in Stroke Incidence in a Portuguese Community-Based Study

BACKGROUND AND AIM

Stroke is a major health problem. Several studies reported sex differences regarding stroke. We aim to study this issue in an incidence stroke study.

METHODS

Data were retrieved from a community-based prospective register of patients that had a first ever stroke in a life time between October 2009 and September 2011. We studied sex differences regarding demographic data, vascular risk factors, stroke type, stroke severity (NIHSS), disability at 28days (modified Rankin scale (mRS)), and case fatality at 30 and 90days.

RESULTS

From 720 stroke patients, 45.3% were men. Women were older (75.0 ± 13.6 versus 67.2 ± 14.9 years), had a worse premorbid mRS (39.3% versus 25.5%, P < .001), and a higher prevalence of hypertension (P = .004) and atrial fibrillation (P < .001). Previous myocardial infarction was more frequent in men (P = .001), as well as smoking habits (P < .001). Ischemic stroke was more common in women than men (87.6% versus 81.3%, P = .038). The 28 days' outcome was worse in women (mRS ≥ 2, 77.2% versus 70.6%, P = .044). No differences were found in initial stroke severity (median NIHSS = 4) and case fatality at 30 and 90days, after adjusting for age and premorbid mRS.

CONCLUSION

No differences were found in stroke initial severity and mortality at 30 and 90days between men and women, despite the sex differences pertaining to the stroke profile-age, vascular risk factors, stroke type, and outcome. Our results are somewhat discrepant from those described in the literature; more research is needed to understand if this may be due to changes in stroke standard of care.

Sex as predictor for achieved health outcomes and received care in ischemic stroke and intracerebral hemorrhage: a register-based study

BACKGROUND

Differences in stroke care and health outcomes between men and women are debated. The objective of this study was to explore the relationship between patients' sex and post-stroke health outcomes and received care in a Swedish setting.

METHODS

Patients with a registered diagnosis of acute intracerebral hemorrhage (ICH) or ischemic stroke (IS) within regional administrative systems (ICD-10 codes I61* or I63*) and the Swedish Stroke Register during 2010-2011 were included and followed for 1 year. Data linkage to multiple other data sources on individual level was performed. Adjustments were performed for age, socioeconomic factors, living arrangements, ADL dependency, and stroke severity in multivariate regression analyses of health outcomes and received care. Health outcomes (e.g., survival, functioning, satisfaction) and received care measures (regional and municipal resources and processes) were studied.

RESULTS

Study population: 13,775 women and 13,916 men. After case-mix adjustments for the above factors, we found women to have higher 1-year survival rates after both IS (OR_female = 1.17, p < 0.001) and ICH (OR_female = 1.65, p < 0.001). Initial inpatient stay at hospital was, however, shorter for women (β_{female, IS} = - 0.05, p < 0.001; β_{female, ICH} = - 0.08, p < 0.005). For IS, good function (mRS ≤ 2) was more common in men (OR_female = 0.86, p < 0.001) who also received more inpatient care during the first year (β_female = - 0.05, p < 0.001).

CONCLUSIONS

A lower proportion of women had good functioning, a difference that remained in IS after adjustments for age, socioeconomic factors, living arrangements, ADL dependency, and stroke severity. The amount of received hospital care was lower for women after adjustments. Whether shorter hospital stay results in lower function or is a consequence of lower function cannot be elucidated. One-year survival was higher in men when no adjustments were made but lower after adjustments. This likely reflects that women were older at time of stroke, had more severe strokes, and more disability pre-stroke-factors that make a direct comparison between the sexes intricate.

Gender-Related Differences and Short-Term Outcome of Stroke: Results from a Hospital-Based Registry in Sub-Saharan Africa

BACKGROUND

Studies suggest that sex differences have an impact on patients with stroke, but existing data in Africa remain inconclusive about this inference.

OBJECTIVES

To study sex differences in terms of the clinical profile and short-term outcome of stroke in the Douala General Hospital, Cameroon.

METHODS

A hospital-based prospective cohort study was carried out in a tertiary care hospital over an 8-year period, which included all patients admitted for confirmed acute stroke. Information about the history of stroke with emphasis on clinical profile and outcome was collected. Descriptive statistics, t test, and chi square test were used for comparisons, while the Kaplan-Meier curve was used for survival rate analysis.

RESULTS

Of the 818 patients included, 455 (55.6%) were male patients. When compared to males, female patients are more likely to experience a stroke at an older age (mean age 62.3 ± 14.1 vs. 58.4 ± 12.9 years, p < 0.001), to be unmarried, to remain unemployed, and to have higher rates of cardio-embolic stroke (p = 0.049), body mass index (p = 0.031), altered levels of consciousness at presentation (p = 0.005), higher mean HDL cholesterol levels (p = 0.001), and in-hospital complications (p = 0.011), especially urinary tract infections (p = 0.018). Males were more likely to have health insurance, to smoke, to consume alcohol (p < 0.001), and to have higher rates of dysarthria (p = 0.004), higher mean uric acid (p = 0.013), and creatinine (p < 0.001) concentrations. Ischemic and hemorrhagic strokes were more prevalent in men (p = 0.003). There are no sex differences in terms of stroke severity, length-of-hospital stay, case fatality, and functional outcome on admission.

CONCLUSIONS

Sex differences exist in the clinical profile of stroke but not in the outcome. Knowledge of these differences could help influence stroke prevention, thereby improving stroke burden in Africa.

Characteristics of hospitalizations due to acute stroke in the Silesian Province, Poland, between 2009 and 2015

INTRODUCTION

The available data on acute stroke (AS) in Poland come mainly from non-representative cohorts or are outdated. Therefore, the current study was done to access the most recent data on AS in the industrial region that covers 12% (4.6mln) of the country's population.

OBJECTIVE

To evaluate the epidemiological data of AS in the Silesian Province, Poland.

PATIENTS AND METHODS

Analysis of the data from stroke questionnaires, obligatory for all patients hospitalized due to AS and administered by the only public health insurer in Poland (the National Health Fund) between 2009 and 2015 (n=81,193).

RESULTS

The annual number of hospitalizations due to AS in the analyzed period was between 239 and 259 per 100,000 inhabitants of the Silesian Province. Haemorrhagic stroke constituted 13.3%, ischaemic stroke - 85.5%, and unspecified stroke - 1.2%. The average age of patients was 71.6±12.2 years (M 68.2±11.9, F 74.8±11.9, P<0.05). The mean duration of hospitalization was 17±16 days for haemorrhagic stroke, and 14±11 days for ischaemic stroke. Large-artery atherosclerosis (36.1%) and cardioembolism (18.7%) constituted the main causes of ischaemic stroke. Overall hospital mortality for AS was 18% (haemorrhagic - 40.8%, ischaemic - 14.9%). A decreasing trend in mortality was observed in ischaemic but not in haemorrhagic stroke. In-hospital mortality was significantly higher in women than in men (P<0.05).

CONCLUSIONS

This comprehensive long-term analysis of the epidemiological situation related to AS in the industrial region of Poland should encourage further development of educational and treatment programmes for improvement in the health status of the population.

Confounding by Pre-Morbid Functional Status in Studies of Apparent Sex Differences in Severity and Outcome of Stroke

BACKGROUND AND PURPOSE

Several studies have reported unexplained worse outcomes after stroke in women but none included the full spectrum of symptomatic ischemic cerebrovascular events while adjusting for prior handicap.

METHODS

Using a prospective population-based incident cohort of all transient ischemic attack/stroke (OXVASC [Oxford Vascular Study]) recruited between April 2002 and March 2014, we compared pre-morbid and post-event modified Rankin Scale score (mRS) in women and men and change in mRS score 1 month, 6 months, 1 year, and 5 years after stroke. Baseline stroke-related neurological impairment was measured with the National Institutes of Health Stroke Scale.

RESULTS

Among 2553 patients (50.6% women) with a first transient ischemic attack/ischemic stroke, women had a worse handicap 1 month after ischemic stroke (age-adjusted odds ratio for mRS score, 1.35; 95% confidence interval, 1.12-1.63). However, women also had a higher pre-morbid mRS score compared with men (age-adjusted odds ratio, 1.58; 95% confidence interval, 1.36-1.84). There was no difference in stroke severity when adjusting for age and pre-morbid mRS (odds ratio, 1.10; 95% confidence interval, 0.90-1.35) and no difference in the pre-/poststroke change in mRS at 1 month (age-adjusted odds ratio, 1.00; 95% confidence interval, 0.82-1.21), 6 months, 1 year, and 5 years. Women had a lower mortality rate, and there was no sex difference in risk of recurrent stroke.

CONCLUSIONS

We found no evidence of a worse outcome of stroke in women when adjusting for age and pre-morbid mRS. Failure to account for sex differences in pre-morbid handicap could explain contradictory findings in previous studies. Properties of the mRS may also contribute to these inconsistencies.

Sex-related differences in the risk factors for in-hospital mortality and outcomes of ischemic stroke patients in rural areas of Taiwan

Background and purpose

Sex-related differences in the clinical presentation and outcomes of stroke patients are issues that have attracted increased interest from the scientific community. The present study aimed to investigate sex-related differences in the risk factors for in-hospital mortality and outcome in ischemic stroke patients.

Methods

A total of 4278 acute ischemic stroke patients admitted to a stroke unit between January 1, 2007 and December 31, 2014 were included in the study. We considered demographic characteristics, clinical characteristics, co-morbidities, and complications, among others, as factors that may affect clinical presentation and in-hospital mortality. Good and poor outcomes were defined as modified Ranking Score (mRS)≦2 and mRS>2. Neurological deterioration (ND) was defined as an increase of National Institutes of Health Stroke Score (NIHSS) ≥ 4 points. Hemorrhagic transformation (HT) was defined as signs of hemorrhage in cranial CT or MRI scans. Transtentorial herniation was defined by brain edema, as seen in cranial CT or MRI scans, associated with the onset of acute unilateral or bilateral papillary dilation, loss of reactivity to light, and decline of ≥ 2 points in the Glasgow coma scale score.

Results

Of 4278 ischemic stroke patients (women 1757, 41.1%), 269 (6.3%) received thrombolytic therapy. The in hospital mortality rate was 3.35% (139/4278) [4.45% (80/1757) for women and 2.34% (59/2521) for men, p < 0.01]. At discharge, 41.2% (1761/4278) of the patients showed good outcomes [35.4% (622/1757) for women and 45.2% (1139/2521) for men]. Six months after stroke, 56.1% (1813/3231) showed good outcomes [47.4% (629/1328) for women and 62.2% (1184/1903) for men, p < 0.01]. Atrial fibrillation (AF), diabetes mellitus, stroke history, and old age were factors contributing to poor outcomes in men and women. Hypertension was associated with poor outcomes in women but not in men in comparison with patients without hypertension. Stroke severity and increased intracranial pressure were associated with increased in-hospital mortality in men and women. AF was associated with increased in-hospital mortality in women but not in men compared with patients without AF.

Conclusion

The in-hospital mortality rate was not significantly different between women and men. Functional outcomes at discharge and six months after stroke were poorer in women than in men. Hypertension is an independent factor causing poorer outcomes in women than in men. AF is an independent factor affecting sex differences in hospital mortality in women.

Stroke in women - from evidence to inequalities

Stroke is the second largest cause of disability-adjusted life-years lost worldwide. The prevalence of stroke in women is predicted to rise rapidly, owing to the increasing average age of the global female population. Vascular risk factors differ between women and men in terms of prevalence, and evidence increasingly supports the clinical importance of sex differences in stroke. The influence of some risk factors for stroke - including diabetes mellitus and atrial fibrillation - are stronger in women, and hypertensive disorders of pregnancy also affect the risk of stroke decades after pregnancy. However, in an era of evidence-based medicine, women are notably under-represented in clinical trials - despite governmental actions highlighting the need to include both men and women in clinical trials - resulting in a reduced generalizability of study results to women. The aim of this Review is to highlight new insights into specificities of stroke in women, to plan future research priorities, and to influence public health policies to decrease the worldwide burden of stroke in women.

Age- and sex-specific analysis of patients with embolic stroke of undetermined source

OBJECTIVE

To investigate whether the correlation of age and sex with the risk of recurrence and death seen in patients with previous ischemic stroke is also evident in patients with embolic stroke of undetermined source (ESUS).

METHODS

We pooled datasets of 11 stroke registries from Europe and America. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group. We performed Cox regression and Kaplan-Meier product limit analyses to investigate whether age (<60, 60-80, >80 years) and sex were independently associated with the risk for ischemic stroke/TIA recurrence or death.

RESULTS

Ischemic stroke/TIA recurrences and deaths per 100 patient-years were 2.46 and 1.01 in patients <60 years old, 5.76 and 5.23 in patients 60 to 80 years old, 7.88 and 11.58 in those >80 years old, 3.53 and 3.48 in women, and 4.49 and 3.98 in men, respectively. Female sex was not associated with increased risk for recurrent ischemic stroke/TIA (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.84-1.58) or death (HR 1.35, 95% CI 0.97-1.86). Compared with the group <60 years old, the 60- to 80- and >80-year groups had higher 10-year cumulative probability of recurrent ischemic stroke/TIA (14.0%, 47.9%, and 37.0%, respectively, p < 0.001) and death (6.4%, 40.6%, and 100%, respectively, p < 0.001) and higher risk for recurrent ischemic stroke/TIA (HR 1.90, 95% CI 1.21-2.98 and HR 2.71, 95% CI 1.57-4.70, respectively) and death (HR 4.43, 95% CI 2.32-8.44 and HR 8.01, 95% CI 3.98-16.10, respectively).

CONCLUSIONS

Age, but not sex, is a strong predictor of stroke recurrence and death in ESUS. The risk is ≈3- and 8-fold higher in patients >80 years compared with those <60 years of age, respectively. The age distribution in the ongoing ESUS trials may potentially influence their power to detect a significant treatment association.

Does early onset cataract increase the risk of ischemic stroke? A nationwide retrospective cohort study

This study was attempted to address the association between early onset cataract (EOC) and ischemic stroke. Using the Longitudinal Health Insurance Database 2000, we established an EOC cohort and a comparison cohort by using 4-fold propensity score matching according to age, gender and comorbidities to detect the incidence of ischemic stroke. A Cox model was used to express the risk of ischemic stroke for the EOC patients compared with the comparison cohort. After adjusting for age, gender and comorbidities of hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, asthma, chronic obstructive pulmonary disease, chronic kidney disease, heart failure, obesity, and atrial fibrillation, the EOC patients had a 1.48-fold higher risk of ischemic stroke than the comparison cohort, but it was not statistically significant. A non-significant increase in the risk of subsequent ischemic stroke development for the EOC patients is demonstrated in this study.

Sex-related differences in risk factors, type of treatment received and outcomes in patients with atrial fibrillation and acute stroke: Results from the RAF-study (Early Recurrence and Cerebral Bleeding in Patients with Acute Ischemic Stroke and Atrial Fibrillation)

Introduction

Atrial fibrillation is an independent risk factor of thromboembolism. Women with atrial fibrillation are at a higher overall risk for stroke compared to men with atrial fibrillation. The aim of this study was to evaluate for sex differences in patients with acute stroke and atrial fibrillation, regarding risk factors, treatments received and outcomes.

Methods

Data were analyzed from the “Recurrence and Cerebral Bleeding in Patients with Acute Ischemic Stroke and Atrial Fibrillation” (RAF-study), a prospective, multicenter, international study including only patients with acute stroke and atrial fibrillation. Patients were followed up for 90 days. Disability was measured by the modified Rankin Scale (0–2 favorable outcome, 3–6 unfavorable outcome).

Results

Of the 1029 patients enrolled, 561 were women (54.5%) (p < 0.001) and younger (p < 0.001) compared to men. In patients with known atrial fibrillation, women were less likely to receive oral anticoagulants before index stroke (p = 0.026) and were less likely to receive anticoagulants after stroke (71.3% versus 78.4%, p = 0.01). There was no observed sex difference regarding the time of starting anticoagulant therapy between the two groups (6.4 ± 11.7 days for men versus 6.5 ± 12.4 days for women, p = 0.902). Men presented with more severe strokes at onset (mean NIHSS 9.2 ± 6.9 versus 8.1 ± 7.5, p < 0.001). Within 90 days, 46 (8.2%) recurrent ischemic events (stroke/TIA/systemic embolism) and 19 (3.4%) symptomatic cerebral bleedings were found in women compared to 30 (6.4%) and 18 (3.8%) in men (p = 0.28 and p = 0.74). At 90 days, 57.7% of women were disabled or deceased, compared to 41.1% of the men (p < 0.001). Multivariate analysis did not confirm this significance.

Conclusions

Women with atrial fibrillation were less likely to receive oral anticoagulants prior to and after stroke compared to men with atrial fibrillation, and when stroke occurred, regardless of the fact that in our study women were younger and with less severe stroke, outcomes did not differ between the sexes.

Prestroke CHA2DS2-VASc Score and Severity of Acute Stroke in Patients with Atrial Fibrillation: Findings from RAF Study

BACKGROUND AND PURPOSE

The aim of this study was to investigate for a possible association between both prestroke CHA₂DS₂-VASc score and the severity of stroke at presentation, as well as disability and mortality at 90 days, in patients with acute stroke and atrial fibrillation (AF).

METHODS

This prospective study enrolled consecutive patients with acute ischemic stroke, AF, and assessment of prestroke CHA₂DS₂-VASc score. Severity of stroke was assessed on admission using the National Institutes of Health Stroke Scale (NIHSS) score (severe stroke: NIHSS ≥10). Disability and mortality at 90 days were assessed by the modified Rankin Scale (mRS <3 or ≥3). Multiple logistic regression was used to correlate prestroke CHA₂DS₂-VASc and severity of stroke, as well as disability and mortality at 90 days.

RESULTS

Of the 1020 patients included in the analysis, 606 patients had an admission NIHSS score lower and 414 patients higher than 10. At 90 days, 510 patients had mRS ≥3. A linear correlation was found between the prestroke CHA₂DS₂-VASc score and severity of stroke (P = .001). On multivariate analysis, CHA₂DS₂-VASc score correlated with severity of stroke (P = .041) and adverse functional outcome (mRS ≥3) (P = .001). A logistic regression with the receiver operating characteristic graph procedure (C-statistics) evidenced an area under the curve of .60 (P = .0001) for severe stroke. Furthermore, a correlation was found between prestroke CHA₂DS₂-VASc score and lesion size.

CONCLUSIONS

In patients with AF, in addition to the risk of stroke, a high CHA₂DS₂-VASc score was independently associated with both stroke severity at onset and disability and mortality at 90 days.

Using Qualitative Methods to Assess the Conceptual Equivalence of the Spanish and English Stroke Action Test (STAT)

Members of racial/ethnic minorities, in contrast to majority groups, experience disparities in stroke risk factors, recognition, evaluation, and treatment. This article describes the use of qualitative methods to examine the cultural and lifestyle appropriateness, clarity of item-wording, comprehension of item intent, and conceptual equivalence of the developed Spanish and the revised English Stroke Action Test (which includes three additional atypical stroke symptoms more common in women). Thirty in-depth cognitive interviews were conducted (10 in Spanish) using concurrent structured probes. The desired ultimate outcome was to obtain conceptually equivalent measures in both languages. Four sources of variability in comprehension were identified: unfamiliar and/or idiosyncratic Spanish words used in translation; phrases in the original (English) and in the literal (Spanish) translation that were not understood; and unclear intended meaning of the original (English) items. Cognitive interviews helped identify problematic items, highlighted potential response errors, and provided insight regarding putative causes for inconsistent interpretation.

Anti-ApoA-1 IgG serum levels predict worse poststroke outcomes

BACKGROUND

Autoantibodies to apolipoprotein A-1 (anti-ApoA-1 IgG) were shown to predict major adverse cardiovascular events and promote atherogenesis. However, their potential relationship with clinical disability and ischaemic lesion volume after acute ischaemic stroke (AIS) remains unexplored.

MATERIALS AND METHODS

We included n = 76 patients admitted for AIS and we investigated whether baseline serum anti-ApoA-1 IgG levels could predict (i) AIS-induced clinical disability [assessed by the modified Rankin Scale (mRS)], and (ii) AIS-related ischaemic lesion volume [assessed by Computed Tomography (CT)]. We also evaluated the possible pro-apoptotic and pro-necrotic effects of anti-ApoA-1 IgG on human astrocytoma cell line (U251) using flow cytometry.

RESULTS

High levels of anti-ApoA-1 IgG were retrieved in 15·8% (12/76) of patients. Increased baseline levels of anti-ApoA-1 IgG were independently correlated with worse mRS [β = 0·364; P = 0·002; adjusted odds ratio (OR): 1·05 (95% CI 1·01-1·09); P = 0·017] and CT-assessed ischaemic lesion volume [β = 0·333; P < 0·001; adjusted OR: 1·06 (95% CI 1·01-1·12); P = 0·048] at 3 months. No difference in baseline clinical, biochemical and radiological characteristics was observed between patients with high vs. low levels of anti-ApoA-1 IgG. Incubating human astrocytoma cells with anti-ApoA-1 IgG dose dependently induced necrosis and apoptosis of U251 cells in vitro.

CONCLUSION

Anti-ApoA-1 IgG serum levels at AIS onset are associated with poorer clinical recovery and worse brain lesion volume 3 months after AIS. These observations could be partly explained by the deleterious effect of anti-ApoA-1 IgG on human brain cell survival in vitro and may have clinical implication in the prediction of poor outcome in AIS.

Homozygous ALDH2*2 Is an Independent Risk Factor for Ischemic Stroke in Taiwanese Men

Background and Purpose—

The * 2 allele of the aldehyde dehydrogenase 2 gene (ALDH2 ) is the most common variant in Asian populations. The variant resulting in enzyme dysfunction was highly related to coronary artery disease. Recently, genome-wide association studies also discovered that the 12q24 locus near ALDH2 gene was associated with hypertension and ischemic stroke. This study intended to further investigate whether the above variant of ALDH2 increases the risk for ischemic stroke in Taiwanese.

Methods—

A case–control study was conducted on 914 patients with acute ischemic stroke and 746 nonstroke controls. Polymerase chain reaction and sequencing were used to identify the ALDH2 genotype. Vascular risk factors, stroke subtypes, vascular stenosis, and stroke outcomes were analyzed.

Results—

ALDH2 genotypes differed significantly between male controls (* 1/*1 versus * 1/*2 versus * 2/*2 =53.8% versus 39.9% versus 6.4%) and male patients with ischemic stroke (* 1/*1 versus * 1/*2 versus * 2/*2 =51.5% versus 37.3% versus 11.2%; P =0.048). No significant difference was found between groups for female patients ( P =0.228). Multivariate logistic regression analysis revealed that the ALDH2*2/*2 genotype was an independent risk factor for ischemic stroke in male patients (odds ratio, 1.93 [95% confidence interval, 1.07–3.46]; P =0.028). Further analysis of men with ischemic stroke demonstrated that the polymorphism of ALDH2 was not related to vascular risk factors, severity of vascular atherosclerosis, stroke subtypes, and stroke functional outcomes.

Conclusions—

The study demonstrated that ALDH2*2/*2 may be an independent risk factor for ischemic stroke in Taiwanese men, but not in Taiwanese women.

Transcranial Motor Evoked Potentials of Lower Limbs Can Prognosticate Ambulation in Hemiplegic Stroke Patients

OBJECTIVE

To examine the association between motor evoked potentials (MEPs) in lower limbs and ambulatory outcomes of hemiplegic stroke patients.

METHODS

Medical records of hemiplegic patients with the first ever stroke who received inpatient rehabilitation from January 2013 to May 2014 were reviewed. Patient who had diabetes, quadriplegia, bilateral lesion, brainstem lesion, severe musculoskeletal problem, and old age over 80 years were excluded. MEPs in lower limbs were measured when they were transferred to the Department of Rehabilitation Medicine. Subjects were categorized into three groups (normal, abnormal, and absent response) according to MEPs findings. Berg Balance Scale (BBS) and Functional Ambulation Category (FAC) at initial and discharge were compared among the three groups by one-way analysis of variance (ANOVA). Correlation was determined using a linear regression model.

RESULTS

Fifty-eight hemiplegic patients were included. BBS and FAC at discharge were significantly (ANOVA, p<0.001) different according to MEPs findings. In linear regression model of BBS and FAC using stepwise selection, patients' age (p<0.01), BBS at admission (p<0.01), and MEPs (p<0.01) remained significant covariates. In regression assumption model of BBS and FAC at admission, MEPs and gender were significant covariates.

CONCLUSION

Initial MEPs of lower limbs can prognosticate the ambulatory outcomes of hemiplegic patients.

Case-fatality and functional status three months after first-ever stroke in Vietnam

BACKGROUND

To provide novel information on outcomes after first-ever stroke in Vietnam, case-fatality and functional status were assessed 3months after stroke onset.

METHODS

First-ever stroke patients admitted to the stroke unit of a tertiary teaching hospital in Ho Chi Minh City, Vietnam were recruited, examined and interviewed. Functional status was assessed on the modified Rankin Scale (mRS) at admission and again at 3months.

RESULT

We recruited 450 consecutive first-ever stroke patients (99.6% participation, 47.9% female, mean age 62.5 [SD 14.0] years, 76.2% ischaemic stroke). Three-month observed case-fatality was 10.4%. Under plausible assumptions about deaths among non-recruited participants, the estimated case-fatality would be higher (16.4%) Those who had died were mostly older patients compromised by comorbidities and pre-existing disability, and who had severe impairment or severe disability due to stroke at the time of admission. At 3-month follow-up of 376 patients, 34% had least severe disability (mRS=0/1), 39% had intermediate disability and 28% had most severe disability (mRS=4/5). Those with least severe disability were mostly men younger than 65years of age and principally with ischemic stroke. Those with most severe disability were predominantly women aged ≥65years and those with severe disability, mainly attributable to intracerebral haemorrhage. At 3months, 50% had better functional status than at stroke onset, and 27% had poorer function.

CONCLUSION

Case-fatality was relatively low in this study, possibly because of cultural preferences for end-of-life care at home. The dependency burden was relatively high, placing pressure on the healthcare system and society.

Women-specific factors to consider in risk, diagnosis and treatment of cardiovascular disease

In the era of individualized medicine, gaps in knowledge remain about sex-specific risk factors, diagnostic and treatment options that might reduce mortality from cardiovascular disease (CVD) and improve outcomes for both women and men. In this review, contributions of biological mechanisms involving the sex chromosomes and the sex hormones on the cardiovascular system will be discussed in relationship to the female-specific risk factors for CVD: hypertensive disorders of pregnancy, menopause and use of hormonal therapies for contraception and menopausal symptoms. Additionally, sex-specific factors to consider in the differential diagnosis and treatment of four prevalent CVDs (hypertension, stroke, coronary artery disease and congestive heart failure) will be reviewed with emphasis on areas where additional research is needed.

Pre-admission CHADS2, CHA2DS2-VASc, and R2CHADS2 Scores on Severity and Functional Outcome in Acute Ischemic Stroke with Atrial Fibrillation

BACKGROUND

We examined the association between pre-admission risk scores and severity on admission and functional outcome in acute ischemic stroke with atrial fibrillation (AF).

METHODS

Between September 2011 and April 2014, we retrospectively extracted consecutive ischemic stroke patients with AF whose pre-admission modified Rankin Scale (mRS) score was 2 or less from our prospective database. Pre-admission CHADS2, CHA2DS2-VASc, and R2CHADS2 scores were calculated in each patient, and their association with the National Institutes of Health Stroke Scale (NIHSS) score on admission or unfavorable outcome (mRS ≥ 3 at 3 months from the onset) was assessed.

RESULTS

A total of 344 patients (189 were men; age, 77.7 ± 10.0 years) were included in the analysis. The median pre-admission CHADS2, CHA2DS2-VASc, and R2CHADS2 scores were 2, 4, and 4, respectively. NIHSS score on admission was positively correlated with pre-admission CHADS2 (ρ = .116, P = .031), CHA2DS2-VASc (ρ = .166, P = .020), and R2CHADS2 scores (ρ = .106, P = .049). Receiver operating characteristic (ROC) curve analysis revealed that pre-admission CHADS2 score of 2 or more (sensitivity, 80%; specificity, 45%; area under the ROC curve [AUC], .654), CHA2DS2-VASc score of 3 or more (sensitivity, 86%; specificity, 44%; AUC, .683), and R2CHADS2 score of 4 or more (sensitivity, 61%; specificity, 62%; AUC, .657) were associated with unfavorable outcome. The pre-admission CHA2DS2-VASc score was better than the pre-admission CHADS2 score in estimating unfavorable outcome (P = .017). In multivariate analysis, cutoffs of these scores, female sex, higher NIHSS score, and internal carotid artery occlusion were associated with unfavorable outcome.

CONCLUSIONS

Pre-admission CHADS2, CHA2DS2-VASc, and R2CHADS2 scores were associated with onset severity and functional outcome in acute ischemic stroke with AF.

Acute stroke symptoms: do differences exist between sexes?

BACKGROUND

Previous studies have reported that women with stroke often present different stroke symptoms than men. The aim of our study was to assess for the relevance of these differences from a large case series.

METHODS

Consecutive patients admitted to the Stroke Unit at the University of Perugia, with acute stroke or transient ischemic attack between 1 June, 2005, and May 2012, and recorded in Perugia Stroke Registry were prospectively included. Associations between the recorded symptoms and sex were assessed by preliminary cross-tabulations with the Chi-square test or Fisher exact test with Yate correction when appropriate. Multivariable regression analysis was used to identify independent predictors of a single symptom including sex as an independent variable.

RESULTS

Overall, 1072 men and 811 women were included in this study. Women had a higher average age at onset (75.40 ± 12.90 years in women and 70.14 ± 12.61 years in men) and presented more severe strokes with higher National Institute of Health Stroke Scale scores than men, whereas men were more likely to have a posterior stroke.Regarding symptoms, multivariate analysis revealed correlations between postural instability and male sex and between dysphagia and female sex.

CONCLUSIONS

We found no differences in the clinical presentation of stroke between the sexes, except that men were more likely to have postural instability and females were more likely to have dysphagia. These findings suggest that stroke locations and stroke severity were associated with sex.

Gender differences and woman-specific trends in acute stroke: results from a hospital-based registry (1986-2009)

OBJECTIVE

We assessed gender differences and women-specific secular trends in stroke.

METHODS

Data from 2318 women and 2274 men with first-ever stroke collected from the Sagrat Cor Hospital Stroke Registry of Barcelona between 1986 and 2009 were analyzed.

RESULTS

Patient's age increased significantly from a mean of 74.5 years in 1986-1992 to 81.2 years in 2004-2009 (P < 0.001). Patients aged ≥ 85 years increased from 18.5% to 38.5% (P = 0.0001) as were patients with hypertension, atrial fibrillation, and cardioembolic stroke. The in-hospital death decreased from 17.6% to 11% (P = 0.02), median length of hospital from 14 to 9 days (P = 0.0001) and prolonged hospital stay (> 12 days) from 59.7% to 33.7% (P = 0.0001). Lacunar infarction was more frequent in men (21.5% vs. 16.2%, P = 0.0003) and cardioembolic infarction in women (26% vs. 15.6%, P = 0.0001). Acute stroke in women continues to be a severe disease with high risk of death in the immediate post-stroke phase (13.5%) and low probability of early full neurological recovery (13.9% vs. 11.8%, P = 0.029).

CONCLUSION

Women differ from men in the distribution of risk factors and stroke subtype, stroke severity, and outcome. An increase in the patient's age, hypertension, atrial fibrillation and cardioembolic infarction, as well as a decrease mortality and length of hospitalization over a 24-year period was recorded.