Sex-related time-dependent variations in post-stroke survival--evidence of a female stroke survival advantage

Differences in stroke clinical presentation among sexes

INTRODUCTION

There are sex-based differences in stroke epidemiology, treatment, and outcomes. In this manuscript, we discuss the differences that exist in the clinical presentation of acute stroke among sexes.

DISCUSSION

We present the differences in stroke presentation among sexes including age at the time of presentation, severity of stroke on presentation, and stroke type and location. We discuss the atypical clinical presentations, explore the radiographic findings on presentation (including location, infarct core volume, the impact of collateral circulation, hematoma location in intracranial hemorrhage), and discuss differences in time elapsed between symptom onset and management amongst sexes.

CONCLUSION

Differences exist in stroke clinical presentation amongst sexes. These disparities have public health implications, and as they become better understood, impact awareness campaigns in both the public and healthcare communities.

Gender disparities in all-cause mortality among individuals with early-onset cardiovascular diseases

BACKGROUND AND OBJECTIVE

Gender disparities in mortality among individuals with early-onset cardiovascular disease (CVD) remain uncertain. This study aimed to investigate gender differences in all-cause mortality and identify influencing factors.

METHODS

Data extracted from the Kailuan Study, a prospective cohort study initiated in 2006, were analyzed. A total of 2,829 participants with early-onset CVD were included. Cox proportional hazard models were used to assess hazard ratios (HR) and 95% confidence intervals (CI) for gender disparities in all-cause mortality, adjusting for various factors.

RESULTS

Males experienced a median follow-up duration of 7.54 years with 276 recorded deaths, and females had a median follow-up of 6.45 years with 105 recorded deaths. Gender disparities in all-cause mortality were observed, with men experiencing a higher all-cause mortality risk compared to women (HR: 1.42, 95% CI: 1.04, 1.92) in the fully adjusted model. Both in men and women with early-onset CVD, elevated hs-CRP levels and an eGFR < 60 mL/min/1.73m2 notably escalated the risk of all-cause mortality. Furthermore, the utilization of antiplatelet agents and successful blood glucose control might mitigate the risk of all-cause mortality. Smoking and eGFR decline modified the association between gender and all-cause death, women were more vulnerable to tobacco consumption and kidney misfunctioning than men (P-interaction = 0.019).

CONCLUSION

The study highlights gender disparities in all-cause mortality among individuals with early-onset CVD, with men experiencing a higher risk of mortality compared to women. Addressing these disparities is important for improving outcomes in this population. Further research is needed to develop sex-specific interventions and strategies to reduce gender-related mortality disparities in early-onset CVD.

Astrocyte-like subpopulation of NG2 glia in the adult mouse cortex exhibits characteristics of neural progenitor cells

Glial cells expressing neuron-glial antigen 2 (NG2), also known as oligodendrocyte progenitor cells (OPCs), play a critical role in maintaining brain health. However, their ability to differentiate after ischemic injury is poorly understood. The aim of this study was to investigate the properties and functions of NG2 glia in the ischemic brain. Using transgenic mice, we selectively labeled NG2-expressing cells and their progeny in both healthy brain and after focal cerebral ischemia (FCI). Using single-cell RNA sequencing, we classified the labeled glial cells into five distinct subpopulations based on their gene expression patterns. Additionally, we examined the membrane properties of these cells using the patch-clamp technique. Of the identified subpopulations, three were identified as OPCs, whereas the fourth subpopulation had characteristics indicative of cells likely to develop into oligodendrocytes. The fifth subpopulation of NG2 glia showed astrocytic markers and had similarities to neural progenitor cells. Interestingly, this subpopulation was present in both healthy and post-ischemic tissue; however, its gene expression profile changed after ischemia, with increased numbers of genes related to neurogenesis. Immunohistochemical analysis confirmed the temporal expression of neurogenic genes and showed an increased presence of NG2 cells positive for Purkinje cell protein-4 at the periphery of the ischemic lesion 12 days after FCI, as well as NeuN-positive NG2 cells 28 and 60 days after injury. These results suggest the potential development of neuron-like cells arising from NG2 glia in the ischemic tissue. Our study provides insights into the plasticity of NG2 glia and their capacity for neurogenesis after stroke.

Sex Differences in Long-Term Functional Decline after Ischemic Stroke: A Longitudinal Observational Study from the Fukuoka Stroke Registry

INTRODUCTION

Data on sex differences in poststroke functional status for a period longer than 1 year based on large cohorts are sparse. This study aimed to determine whether there are sex differences in long-term functional decline after ischemic stroke.

METHODS

We tracked functional status for 5 years among 3-month survivors of acute ischemic stroke and compared outcomes between women and men using a large-scale hospital-based stroke registry in Fukuoka, Japan. Functional status was assessed using the modified Rankin Scale (mRS). Functional dependency was defined as an mRS score of 3, 4, or 5. Logistic regression analysis was used to estimate odds ratios (ORs) and 95% confidence intervals of outcomes after adjusting for possible confounders.

RESULTS

A total of 8,446 patients (71.9 ± 12.5 years, 3,377 (40.0%) female patients) were enrolled in this study. Female sex was associated with a higher risk of functional dependency at 5 years poststroke even when adjusting for age, 3-month mRS score, and other confounding factors (multivariable-adjusted OR vs. men, 1.56 [95% confidence interval, 1.26-1.93]). This significant association of female sex with higher dependency at 5 years was also found among patients who were independent at 3 months poststroke. Subgroup analysis showed that increased risk of functional dependency in female patients was more marked in patients aged ≥75 years than in those aged <75 years (p for heterogeneity = 0.02). Conversely, female sex was associated with a lower risk of death. No sex difference was observed in stroke recurrence during 5 years poststroke.

DISCUSSION/CONCLUSION

This longitudinal observational study suggests that female sex was independently associated with an increased risk of functional decline in the chronic phase of stroke, especially in older patients. There was no sex difference in 5-year stroke recurrence, and thus, other factors might be involved in more significant deterioration of functional status in female survivors of ischemic stroke. Further studies are needed to elucidate underlying causes of sex differences in long-term functional decline after stroke.

[Sex differences in stroke mortality in Thailand : A National cohort study]

BACKGROUND

Over half of the growing global stroke-mortality burden is accounted for by the East-Asian-subcontinent alone. Sex differences in stroke-mortality in the Asian population is yet to be assessed in the literature. We aimed to assess the sex-differences in mortality following stroke in a large cohort of Thai-patients.

METHOD

All stroke admissions between 2004-2015 were included from the Thailand public-health-insurance-database. The association between sex and mortality was assessed in-hospital, at 1 month, 1 year and 5 years, using multivariable Cox-regressions, separately for ischaemic-stroke (IS), haemorrhagic-stroke (HS) and stroke-of-undetermined-type(SUT), adjusting for confounders.

RESULTS

608,890 patients were included: 370,527 patients with IS(60.9%), 173,236 with HS(28.5%) and 65,127 with SUT(10.6%). Women were older than men in all three groups and had higher prevalence of comorbidities. Adjusted hazard-ratios(HRs) of mortality showed women had higher mortality post-IS compared to men (in-hospital: HR: 1.20; 95% CI: 1.17-1.23; 1 month: HR: 1.17; 95% CI: 1.15-1.20; 1 year: HR: 1.10; 95% CI: 1.09-1.12 and 5 years: HR: 1.02; 95% CI: 1.01-1.03). Women also had higher mortality after HS (in-hospital: HR: 1.02; 95% CI: 1.00-1.04; 1 month: HR: 1.08; 95% CI: 1.06-1.10; 1 year: HR: 1.04; 95% CI: 1.03-1.06 and 5 years: HR: 1.09; 95% CI: 1.08-1.11), and SUT (in-hospital: HR: 1.04; 95% CI: 1.03-1.06; 1 month: HR: 1.20; 95% CI: 1.14-1.27; 1 year: HR: 1.14; 95% CI: 1.09-1.18 and 5 years: HR: 1.06; 95% CI: 1.03-1.10).

CONCLUSIONS

Compared to men, women were older at time of stroke-diagnosis and had higher burden of stroke risk-factors. Women also had higher mortality after stroke regardless of stroke-type or duration since stroke-onset. Post-IS, excess stroke-mortality in women was greatest during the in-hospital period, whereas excess stroke-mortality increased with time in women who had HS. No clear relationship was found between duration since stroke-onset and mortality in patients who had SUT.

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.

Sex Differences in the Risk of 30-Day Death After Acute Ischemic Stroke

Objective

To examine sex differences in early stroke deaths according to cause of death.

Methods

We investigated 30-day deaths in patients with acute ischemic stroke enrolled in a multicenter stroke registry between 2007 and 2019 in Fukuoka, Japan. We estimated the multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of cause-specific deaths for women vs men using Cox proportional hazards models and competing risk models. The risk of acute infections during hospitalization and the associated case fatality rates were also compared between the sexes.

Results

Among 17,956 patients with acute ischemic stroke (women: 41.3%), the crude 30-day death rate after stroke was higher in women than men. However, adjusting for age and stroke severity resulted in a lower risk of death among women (HR [95% CI]: 0.76 [0.62-0.92]). Analyses using competing risk models revealed that women were less likely to die of acute infections (subdistribution HR [95% CI]: 0.33 [0.20-0.54]). Further analyses showed that women were associated with a lower risk of acute infections during hospitalization (OR [95% CI]: 0.62 [0.52-0.74]) and a lower risk of death due to these infections (subdistribution HR [95% CI]: 052 [0.33-0.83]).

Conclusions

When adjusting for confounders, the female sex was associated with a lower risk of 30-day death after stroke, which could be explained by a female survival advantage in poststroke infections. Sex-specific strategies are needed to reduce early stroke deaths.

Classification of Evidence

This is a Class I prognostic study because it is a prospective population-based cohort with objective outcomes. Female sex appears to be protective against early stroke deaths and post stroke infections.

Effect of Surgical Timing on the Refracture Rate after Percutaneous Vertebroplasty: A Retrospective Analysis of at Least 4-Year Follow-Up

Introduction

The effect of surgical timing on vertebral refracture rate and mortality remains elusive after percutaneous kyphoplasty (PKP) or percutaneous vertebroplasty (PVP), and we aim to assess the impact of surgical timing on vertebral refracture rate and mortality in patients undergoing percutaneous vertebroplasty.

Methods

We did a retrospective cohort study of patients who underwent PKP or PVP because of osteoporotic vertebral compression fracture (OVCF) between April 1, 2014 and March 31, 2016. The primary outcome measure was the incidence of vertebral refracture. Secondary outcomes included the mortality and chronic back pain.

Results

The rate of vertebral refracture was significantly lower in early surgical timing group than that in late surgical timing group (HR 2.415, 95% CI 1.318–4.427; P = 0.004). We found that the bone mineral density (BMD) was only the risk factor to increase the vertebral refracture rate after vertebroplasty (P = 0.001). In addition, there was similar mortality between the two groups (15.7% in early surgical timing group versus 10% in late surgical timing group). Male patients (27.3%, 12/44) had higher mortality compared to female patients (10.6%, 20/189), while the mortality was higher in patients with cerebral infarction (25%, 3/12) than those without cerebral infarction (12.1%, 17/140).

Conclusions

Surgical timing significantly affects the vertebral refracture rate after PKP or PVP, which is also influenced by BMD. The mortality after the surgery is not affected by the surgical timing, but gender and cerebral infarction may be the risk factors of mortality.

The Validity of Intracerebral Hemorrhage Diagnoses in the Danish Patient Registry and the Danish Stroke Registry

Purpose

To establish the validity of intracerebral hemorrhage (ICH) diagnoses in the Danish Stroke Registry (DSR) and the Danish National Patient Registry (DNPR).

Patients and Methods

Based on discharge summaries and brain imaging reports, we estimated the positive predictive value (PPV) of a first-ever diagnosis code for ICH (ICD-10, code I61) for all patients in the Region of Southern Denmark (1.2 million) during 2009-2017 according to either DNPR or DSR. We estimated PPVs for any non-traumatic ICH (a-ICH) and spontaneous ICH (s-ICH) alone (ie, without underlying structural cause). We also calculated the sensitivity of these diagnoses in each of the registers. Finally, we classified the location of verified s-ICH.

Results

A total of 3,956 patients with ICH diagnosis codes were studied (DSR only: 87; DNPR only: 1,513; both registries: 2,356). In the DSR, the PPVs were 86.5% (95% CI=85.1-87.8) for a-ICH and 81.8% (95% CI=80.2-83.3) for s-ICH. The PPVs in DNPR (discharge code, primary diagnostic position) were 76.2% (95% CI=74.7-77.6) for a-ICH and 70.2% (95% CI=68.6-71.8) for s-ICH. Sensitivity for a-ICH and s-ICH was 76.4% (95% CI=74.8-78.0) and 78.7% (95% CI=77.1-80.2) in DSR, and 87.3% (95% CI=86.0-88.5) and 87.7% (95% CI=86.3-88.9) in DNPR. The location of verified s-ICH was lobar (39%), deep (33.6%), infratentorial (13.2%), large unclassifiable (11%), isolated intraventricular (1.9%), or unclassifiable due to insufficient information (1.3%).

Conclusion

The validity of a-ICH diagnoses is high in both registries. For s-ICH, PPV was higher in DSR, while sensitivity was higher in DNPR. The location of s-ICH was similar to distributions seen in other populations.

Sex differences in stroke

Sex disparities within the field of stroke, including subarachnoid hemorrhages (SAHs), have been in focus during the last 2 decades. It is clear that stroke incidence is higher in men, and also that men have their first stroke earlier than women. On the other hand, women have more severe strokes, mainly because cardioembolic strokes are more common in women. This leads to higher case fatality and worse functional outcome in women. It has often been pointed out that women more often have nontraditional stroke symptoms, and therefore may seek medical help later. After discharge from the hospital, female stroke survivors live alone in many cases and are dependent on external care. Therefore, these women frequently rate their quality of life (QoL) lower than men do. Female spouses more often provide help to their male stroke survivors than the reverse, and they accept a heavier burden. These caregivers are at high risk for depression, low QoL, and low psychologic wellbeing. SAH is a special form of stroke, often caused by a ruptured aneurysm. It is about 20% more common in women. The case fatality is high, but does not differ between the sexes.

Determinants of Case Fatality After Hospitalization for Stroke in France 2010 to 2015

Background and Purpose- The aims of this study were to (1) describe early and late case fatality rates after stroke in France, (2) evaluate whether their determinants differed, and (3) analyze time trends between 2010 and 2015. Methods- Data were extracted from the Système National des données de santé database. Patients hospitalized for stroke each year from 2010 to 2015, aged ≥18 years, and affiliated to the general insurance scheme were selected. Cox regressions were used to separately analyze determinants of 30-day and 31- to 365-day case fatality rates for each stroke type (ischemic, intracerebral hemorrhage, and subarachnoid hemorrhage). Results- In 2015, of the 73 124 persons hospitalized for stroke, 26.8% died in the following year, with the majority of deaths occurring within the first 30 days (56.9%). Nonadmission to a stroke unit, older age, and having comorbidities were all associated with a poorer 30-day and 31- to 365-day prognosis. Female sex was associated with a lower 31- to 365-day case fatality rate for all patients with stroke. Living in an area with a high deprivation index was associated with both higher 30-day and 31- to 365-day case fatality rates for all stroke types. Between 2010 and 2015, significant decreases in both 30-day and 31- to 365-day case fatality rates for ischemic patients were observed. Conclusions- Case fatality rates after stroke remained high in 2015 in France, despite major improvements in stroke care and organization. Improvement in stroke awareness and preparedness, particularly in the most deprived areas, together with better follow-up after the acute phase are urgently needed.

Intracerebral hemorrhage: positive predictive value of diagnosis codes in two nationwide Danish registries

Purpose

The purpose of this study is to establish the validity of intracerebral hemorrhage (ICH) diagnoses in the Danish Stroke Registry (DSR) and the Danish National Patient Registry (DNPR).

Patients and methods

We estimated the positive predictive value (PPV) of ICH diagnoses for a sample of 500 patients from the DSR (patients recorded under ICH diagnosis) and DNPR (International Classification of Diseases, version 10, code I61) during 2010–2015, using discharge summaries and brain imaging reports (minimal data). We estimated PPVs for any ICH (a-ICH) and spontaneous ICH (s-ICH) alone. Furthermore, we assessed PPVs according to whether patients were recorded in both or only one of the registries. Finally, in a subsample with ICH diagnoses with access to full medical records and original imaging studies (extensive data, n=100), we compared s-ICH diagnosis and hemorrhage location after use of extensive vs minimal data.

Results

In the DSR, the PPVs were 94% (95% CI, 91%–96%) for a-ICH and 85% (95% CI, 81%–88%) for s-ICH. In the DNPR, the PPVs were 88% (95% CI, 84%–91%) for a-ICH and 75% (95% CI, 70%–79%) for s-ICH. PPVs for s-ICH for patients recorded in both registries, DSR only, and DNPR only were 86% (95% CI, 82–99), 80% (95%CI, 71–87), and 49% (95%CI, 39–59), respectively. Evaluation of extensive vs minimal data verified s-ICH diagnosis in 98% and hemorrhage location in 94%.

Conclusion

The validity of a-ICH diagnoses in DSR and DNPR is sufficiently high to support their use in epidemiologic studies. For s-ICH, validity was high in DSR. In DNPR, s-ICH validity was lower, markedly so for the small subgroup of patients only recorded in this registry. Minimal data including discharge summaries and brain imaging reports were feasible and valid for identifying ICH location.

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.

Stroke in-hospital survival and its predictors: the first results from Tabriz Stroke Registry of Iran

OBJECTIVE

The aim of this study was to determine the in-hospital survival of patients referred to the 2 stroke centers in North-West of Iran during a full seasonal year from April 2015.

METHODS

All the consecutive patients with stroke admitted to the 2 main stroke centers at Tabriz (Imam Reza University Hospital and Razi University Hospital) were recruited in this study. Stroke patients from both ischemic and hemorrhagic subtypes were selected based on the registry data and International Classification of Diseases, 10th edition. At admission, details of examination including vital signs, neurologic and systemic examination, Modified Rankin Scale, and Glasgow Coma Scale were recorded. Baseline hematological and biochemical parameter assessments as well as computerized tomographic scanning were conducted. Cox regression was used to investigate and detect potential predictors of in-hospital survival.

RESULTS

A total of 1,990 patients with stroke were studied. Males comprised 52.1% (1,036) of the subjects. The mean age of the patients was 65.8 years. Three hundred and fifty-seven (17.9%) patients had hemorrhagic stroke vs 1,633 (82.1%) with ischemic stroke. In-hospital case-fatality proportion was 12.5% (95% CI: 11.1-14). Based on modified Rankin Scale score at admission, 1,377 of 1,990 patients (69.2%) had a poor outcome (modified Rankin Scale score ≥3) at the admission time. The regression analysis showed that at least 7 variables could independently predict hospital survival of patients with stroke including age ≥65 years, higher admission modified Rankin Scale score, lower admission Glasgow Coma Scale score, hemorrhagic stroke nature, diabetes, having valvular heart disease, and having aspiration pneumonia.

CONCLUSION

The case-fatality of stroke in the present study setting is high and needs to be appropriately addressed through prevention or management of some of these factors such as diabetes, pneumonia, and valvular heart diseases.

Estrogen receptor-β of microglia underlies sexual differentiation of neuronal protection via ginsenosides in mice brain

AIMS

Streptococcus pneumoniae infection in acute bacterial meningitis can lead to widespread brain damage and mortality. Inflammatory responses by immune cells in the brain are thought to determine the degree of brain injury. Yet, the mechanisms underlying host responses to pneumococcal meningitis are largely unknown. To explore host responses as a potential therapeutic target for preventing brain injury after pneumococcal meningitis.

METHODS

We evaluated signaling mechanisms that minimize neuronal damage caused by pneumococcal infection; specifically, we assessed pathways related to neuronal survival after enhancing estrogen receptor-β (ER-β) expression using a natural therapeutic substance known as ginsenoside Rb1 and Rg3 enhanced ginseng.

RESULTS

Tissue damage caused by bacterial infection was reduced in Rb1/Rg3-treated mice as a result of microglial activation and the inhibition of apoptosis. Furthermore, Rb1 upregulated the expression of brain-derived neurotrophic factor (BDNF) as well as anti-apoptotic factors including Bcl-2 and Bcl-xL. Using BV2 microglial cells in vitro, Rb1 treatment inhibited microglial apoptosis in a manner associated with JAK2/STAT5 phosphorylation.

CONCLUSION

After S. pneumoniae infection in mice, particularly in female mice, Rb1-containing ginseng increased bacterial clearance and survival. These findings inform our understanding of the host immune response to pneumococcal meningitis.

Sex Differences in Epidemiology of Cardiac and Vascular Disease

In spite of a remarkable decline in death rates from cardiovascular disease (CVD) observed over the last decades, CVD still remains the leading cause of mortality in both men and women worldwide. Overall the age-adjusted CVD mortality and morbidity rates are highest in men than in women. However, the risk of CVD in women should not be underestimated given that approximately one of two women in developed countries will die of mostly preventable heart diseases or stroke. Although men and women share the same cardiovascular risk factors, there are substantial sex differences in the first manifestation and clinical presentation of CVD. In this part of the chapter, we will discuss the recent epidemiological data on sex discrepancies in the prevalence and burden of different CVDs.

Stroke Rehabilitation: Therapy Robots and Assistive Devices

Motor impairments after stroke are often persistent and disabling, and women are less likely to recover and show poorer functional outcomes. To regain motor function after stroke, rehabilitation robots are increasingly integrated into clinics. The devices fall into two main classes: robots developed to train lost motor function after stroke (therapy devices) and robots designed to compensate for lost skills (i.e., assistive devices). The article provides an overview of therapeutic options with robots for motor rehabilitation after stroke.

Risk of Stroke in Migraineurs Using Triptans. Associations with Age, Sex, Stroke Severity and Subtype

BACKGROUND

Identifying migraineurs by triptan utilization we studied risk for stroke in migraineurs compared to the general population.

METHODS

A cohort study including all citizens 25-80years of age in Denmark 2003-2011 was conducted. All persons prescribed triptans, and all those hospitalized for a first stroke were identified in the Danish Registries. Information on stroke severity/subtype and cardiovascular risk factors was available for stroke patients.

FINDINGS

Of the 49,711 patients hospitalized for a first stroke, 1084 were migraineurs using triptans. Adjusting for age, sex, income, and educational level, risk for stroke was higher among migraineurs in respect to all strokes (RR 1.07; CI 1.01-1.14) and ischemic strokes (RR 1.07; CI 1.00-1.14). Risk for hemorrhagic stroke was increased but only in women (RR 1.41; CI 1.11-1.79). Risk was for mild strokes (RR 1.31; CI 1.16-1.48) while risk for severe strokes was lower among migraineurs (RR 0.77; CI 0.65-0.91). Risk was age-related; highest among women 25-45years (RR≈1.7). Risk was unrelated to numbers of dispensations.

INTERPRETATION

Migraineurs identified by triptan utilization had higher risk for stroke. Strokes were minor and cardiovascular risk factors were less prevalent pointing to a migraine-specific etiology of stroke different from that of thromboembolism.

Greater Severity of Neurological Defects in Women Admitted With Atrial Fibrillation-Related Stroke

BACKGROUND

The magnitude of the CHA2DS2-VASc score is associated with not only stroke incidence but also long-term outcomes. The association between sex and initial stroke severity in AF-related cardioembolic stroke patients has not been clarified. The present study aimed to elucidate the risk factors for initial stroke severity among patients with cardioembolic stroke enrolled in a multicenter registry.

METHODS AND RESULTS

We selected 12,701 patients (age, 77±10 years; 5,653 women) with AF-related cardioembolic stroke from the Japan Standard Stroke Registry Study between January 2000 and July 2013. Indicators of National Institutes of Health Stroke Scale (NIHSS) scores at admission were identified using a multiple linear regression. Increased NIHSS scores positively correlated with CHA2DS2-VASc score (ρ=0.197; P<0.001). The initial neurological deficits were more severe in women than in men (NIHSS scores, median [interquartile range] 14 [5-22] vs. 8 [3-18]; P<0.001). Multiple regression analysis revealed that higher age (standardized partial regression coefficient [β] 0.162; P<0.001), female sex (β 0.120; P<0.001), diabetes mellitus (β 0.020; P=0.019), dyslipidemia (β -0.076; P<0.001), congestive heart failure (β 0.039; P<0.001), vascular disease (β 0.030; P=0.001), prior stroke/TIA (β 0.085; P<0.001) and prior anticoagulant use (β -0.020; P=0.028) were associated with the NIHSS score at admission.

CONCLUSIONS

Female sex was independently associated with the initial neurological severity among AF-related cardioembolic stroke patients.

Sex Differences in Stroke Subtypes, Severity, Risk Factors, and Outcomes among Elderly Patients with Acute Ischemic Stroke

Background

Although the age-specific incidence and mortality of stroke is higher among men, stroke has a greater clinical effect on women. However, the sex differences in stroke among elderly patients are unknown. Therefore, we aimed to assess the sex differences in stroke among elderly stroke patients.

Methods

Between 2005 and 2013, we recruited 1484 consecutive acute ischemic stroke (AIS) patients (≥75 years old) from a specialized neurology hospital in Tianjin, China. Information regarding their stroke subtypes, severity, risk factors, and outcomes at 3 and 12 months after stroke were recorded.

Results

Comparing with men, women had a significantly higher prevalence of severe stroke (17.20 vs. 12.54%), hypertension (76.42 vs. 66.39%), dyslipidemias (30.35 vs. 22.76%), and obesity (18.40 vs. 9.32%), P < 0.05. Comparing with women, men had a significantly higher prevalence of intracranial artery stenosis (23.11 vs. 17.45%), current smoking (29.60 vs. 13.05%), and alcohol consumption (12.15 vs. 0.47%), P < 0.05. Moreover, dependency was more common among women at 3 and 12 months after stroke, although the sex difference disappeared after adjusting for stroke subtypes, severity, and risk factors.

Conclusion

Elderly women with AIS had more severe stroke status and worse outcomes at 3 and 12 months after stroke. Thus, elderly female post-AIS patients are a crucial population that should be assisted with controlling their risk factors for stroke and changing their lifestyle.

One-year case fatality rate following stroke in the Mashhad Stroke Incidence Study: a population-based study of stroke in Iran

Background

In developing countries, there are few comprehensive studies of mortality following stroke.

Aims and/or hypothesis

We aimed to determine the one-year case fatality rate following stroke and to identify factors associated with death in a population-based stroke incidence study in Iran.

Methods

Six hundred eighty-four patients who had suffered a stroke between November 21, 2006, and November 20, 2007, and were recruited to the Mashhad Stroke Incidence Study were followed up at one-year. Most patients were seen in an outpatient visit. When patients had died, a verbal autopsy was conducted by telephone with the next of kin.

Results

A total of 226 (34.3%) patients died during the first year following stroke. The cumulative one-year case fatality rate was 30.6% following ischemic stroke and 53.0% following hemorrhagic stroke (55.8% after intracerebral hemorrhage and 35.7% after subarachnoid hemorrhage). The majority of these deaths occurred in the first 28 days after stroke (17.7% with ischemic and 43.0% with hemorrhagic stroke). Factors associated with greater mortality at one-year (excluding those who died during the first week) were hemorrhagic stroke [hazard ratio (HR) 3.99; 95% confidence interval 1.90-8.37], age (HR 1.05; 95% confidence interval 1.03-1.08), previous transient ischemic attack (HR 2.45; 95% confidence interval 1.00-5.99), and National Institutes of Health Stroke Scale on admission (HR 1.14; 95% confidence interval 1.10-1.17).

Conclusion

Despite the younger age of stroke occurrence in Iran, the one-year case fatality rate following stroke is similar to that reported in developed countries.

The obesity paradox in stroke: lower mortality and lower risk of readmission for recurrent stroke in obese stroke patients

BACKGROUND

Although associated with excess mortality and morbidity, obesity is associated with lower mortality after stroke. The association between obesity and risk of recurrent stroke is unclear.

AIMS

The study aims to investigate the association in stroke patients between body mass index and risk of death and readmission for recurrent stroke.

METHODS

An administrative Danish quality-control registry designed to collect a predefined dataset on all hospitalized stroke patients in Denmark 2000–2010 includes 45 615 acute first-ever stroke patients with information on body mass index in 29 326. Data include age, gender, civil status, stroke severity, computed tomography, and cardiovascular risk factors. Patients were followed up to 9·8 years (median 2·6 years). We used Cox regression models to compare risk of death and readmission for recurrent stroke in the four body mass index groups: underweight (body mass index < 18·5), normal weight (body mass index 18·5–24·9), overweight (body mass index 25·0–29·9), obese (body mass index ≥ 30·0).

RESULTS

Mean age 72·3 years, 48% women. Mean body mass index 23·0. Within follow-up, 7902 (26·9%) patients had died; 2437 (8·3%) were readmitted because of recurrent stroke. Mortality was significantly lower in overweight (hazard ratio 0·72; confidence interval 0·68–0·78) and obese (hazard ratio 0·80; confidence interval 0·73–0·88) patients while significantly higher in underweight patients (hazard ratio 1·66; confidence interval 1·49–1·84) compared with normal weight patients. Risk of readmission for recurrent stroke was significantly lower in obese than in normal weight patients (hazard ratio 0·84; confidence interval 0·72–0·92).

CONCLUSIONS

Obesity was not only associated with reduced mortality relative to normal weight patients. Compared with normal weight, risk of readmission for recurrent stroke was also lower in obese stroke patients.

Sex Differences in Outcomes and Associated Risk Factors After Acute Ischemic Stroke in Elderly Patients: A Prospective Follow-up Study

Stroke has a greater effect on women. However, sex differences in outcome and factors associated with outcome among elderly patients are unknown. From January 2009 to December 2011, 810 patients with acute ischemic stroke aged 75 years or older were recruited in China. Clinical profile and risk factors were recorded. Outcomes and associated risk factors at 12 and 36 months after stroke were assessed by sex. Hypertension, diabetes mellitus, dyslipidemias, and obesity prevalence rates were higher in women than in men; opposite trends were found for smoking and alcohol consumption. The mortality rate at 12 months after stroke was significantly greater in men than in women (23.3% versus 16.6%, P = .015). Large-artery atherothrombotic and cardioembolic stroke subtypes were risk factors for mortality, recurrence, and dependency in both sexes. In men, atrial fibrillation was a risk factor of mortality at 12 months after stroke (relative ratio [RR], 2.12; 95% confidence interval [CI], 1.38-3.27), but obesity was a protective factor of mortality at 36 months after stroke (RR, .30; 95% CI, .10-.94). However, in women, atrial fibrillation was a risk factor of recurrence at 12 months (RR, 2.32; 95% CI, 1.31-4.12) and dependency at 36 months after stroke (RR, 7.68; 95% CI, 1.60-36.82). We assessed sex differences in stroke outcomes and associated risk factors at 12 and 36 months after stroke in a large hospital-based stroke registry of elderly patients from Northern China. Thus, it is crucial to emphasize risk management to elderly patients to reduce mortality, recurrence, and dependency after stroke.

Sex Disparities in Stroke: Women Have More Severe Strokes but Better Survival Than Men

BACKGROUND

Uncertainty remains about whether stroke affects men and women similarly. We studied differences between men and women with regard to stroke severity and survival.

METHODS AND RESULTS

We used the Danish Stroke Registry, with information on all hospital admissions for stroke in Denmark between 2003 and 2012 (N=79 617), and the Danish Register of Causes of Death. Information was available on age, sex, marital status, stroke severity, stroke subtype, socioeconomic status, and cardiovascular risk profile. We studied only deaths due to the index stroke, with the assumption that death reported on death certificates as due to stroke was related to the index stroke if death occurred within the first week or month after stroke. Multivariate Cox regression analysis and multiple imputation were applied. Stroke was the cause of death for 4373 and 5512 of the 79 617 patients within 1 week (5.5%) or 1 month (6.9%), respectively. After the age of 60 years, women had more severe strokes than men. Up to ages in the mid-60s, no difference in the risk of death from stroke was seen between the 2 sexes. For people aged >65 years, however, the risk gradually became greater in men than in women and significantly so (>15%) from the mid-70s (adjusted for age, marital status, stroke severity, stroke subtype, socioeconomic status, and cardiovascular risk factors). Results were essentially the same when analyzing deaths within 1 week, 1 month and ischemic and hemorrhagic stroke separately.

CONCLUSIONS

Stroke affects women and men differently. Elderly women were affected more severely than elderly men but were more likely to survive.

Lower hazard ratio for death in women with cerebral hemorrhage

OBJECTIVES

The aim of the study was to clarify the hazard ratio for death within 30 days after stroke comparing women to men.

MATERIAL AND METHODS

We reviewed all stroke patients registered in the Kyoto Stroke Registry (from January 1999 to December 2009) in Japan. Hazard ratio (HR) for death and 95% confidence interval were calculated by the Cox regression in stroke and in each stroke subtype: cerebral infarction (CI), cerebral hemorrhage, (CH) and subarachnoid hemorrhage (SAH). We also evaluated HR for death in women in each consciousness level at the onset of stroke: the Japan Coma Scale (JCS) 0 (alert), JCS 1-digit code (disoriented but awake), JCS 2-digit code (arousable with stimulation), and JCS 3-digit code (unarousable).

RESULTS

A total of 13,788 patients were analyzed. HR for death comparing women to men were 1.04 (0.88-1.23, P = 0.66 in stroke as a whole), 0.91 (0.69-1.21, P = 0.51 in CI), 0.53 (0.41-0.71, P < 0.01 in CH), and 0.89 (0.60-1.30, P = 0.535 in SAH) after adjustment for age and histories of hypertension, arrhythmia, diabetes mellitus and hyperlipemia and uses of tobacco and alcohol. Stratified by JCS, HR for death in women with CH were 0.32 (0.11-0.94 in JCS0), 0.48 (0.28-0.82 in JCS1), 0.49 (0.28-0.83 in JCS2), and 0.79 (0.65-0.97 in JCS3), respectively. HR for death in women with CI in JCS3 was significantly lower than in men (0.71; 0.52-0.98).

CONCLUSION

We evaluated HR for death comparing men to women in stroke and in each stroke subtype. Women with CH had lower HR for death within 30 days after stroke than men.

Long-term survival of older Australian women with a history of stroke

BACKGROUND

Although many people survive an initial stroke, little is known about long-term impacts of stroke on survival.

METHODS

Data from the Australian Longitudinal Study on Women's Health were used to compare 12-year survival rates in older women with prevalent stroke, incident stroke, and no stroke. Cox regression models were fitted to assess the effect of lifestyle and demographic characteristics on the relationship between stroke and all-cause mortality. The "no stroke" group was used as the reference category in all statistical models.

RESULTS

At baseline, 4% of the women reported a previous stroke (prevalent stroke). At survey 2 in 1999, a further 3% reported having a stroke between 1996 and 1999 (incident stroke). Stroke was significantly associated with reduced long-term survival. Age-adjusted hazards ratios (HRs) were: 1.64 (1.43-1.89) for the "prevalent stroke" group and 2.29 (1.97-2.66) for the "incident stroke" group. Adjusting for comorbidities reduced the HRs, but the risk of death was still significantly higher in the 2 stroke groups. Adjusting for demographic and lifestyle factors did not make any further difference to the relationship between stroke and survival. However, obesity and past smoking were also risk factors for mortality.

CONCLUSIONS

This study highlights the long-term impacts of stroke on life expectancy and the importance of comorbidities and other lifestyle factors in affecting poststroke survival.

The impact of comorbidity on survival after hemorrhagic stroke among dialysis patients: a nationwide population-based study

BACKGROUND

This study was aimed at determining the outcome and examining the association between comorbidities and mortality after intracerebral hemorrhage in chronic dialysis patients.

METHODS

We used the Taiwan National Health Insurance Research Database and enrolled patients who underwent maintenance dialysis between 2000 and 2007. Annual incidence of intracerebral hemorrhage in patients receiving dialysis from 2000 to 2007 was determined. To identify predictors of hemorrhagic stroke, we used logistic regression model to estimate the relative ratio of factors for intracerebral hemorrhage in the most recent cohort (2007). The cumulative survival rate and comorbid conditions associated with mortality after intracerebral hemorrhage among all dialysis patients between 2000 and 2007 was calculated using the Kaplan-Meier method and Cox regression analysis.

RESULTS

We identified 57,261 patients on maintenance dialysis in the cohort of 2007, and 340 patients had history of intracerebral hemorrhage among them. Hypertension was the most common comorbidity of dialysis patients. The incidence rate of intracerebral hemorrhage among dialysis patients was about 0.6%. Adjusted logistic regression model showed that male gender, middle age (45-64 years), hypertension, and previous history of stroke were the independent predictors for the occurrence of intracerebral hemorrhage among chronic dialysis patients. 1,939 dialysis patients with development of intracerebral hemorrhage in the analysis period from 2000 to 2007 were identified. In-hospital mortality was high (36.15%) following intracerebral hemorrhage. They were followed up after intracerebral hemorrhage for a mean time of 41.56 months. Adjusted Cox regression analyses demonstrated that the factors independently associated with mortality after intracerebral hemorrhage among dialysis patients included diabetes mellitus, malignancy and a history of prior stroke.

CONCLUSIONS

Dialysis patients who have history of prior stroke, diabetes and malignancy have worse survival than patients without these comorbidities. Attention must focus on providing optimal medical care after hemorrhagic stroke for these target groups to reduce mortality.

Socioeconomic position and incidence of ischemic stroke in Denmark 2003-2012. A nationwide hospital-based study

BACKGROUND

A greater burden of stroke risk factors in general is associated with a higher risk for stroke among people of lower than those of higher socioeconomic position. The relative impact of individual stroke risk factors is still unclear.

METHODS AND RESULTS

We studied the relations between socioeconomic position, measured as household income and length of education, and all hospital admissions for a first ischemic stroke among 54 048 people over the age of 40 years in Denmark in 2003-2012 in comparison with the general Danish population (23.5 million person-years). We also studied the cardiovascular risk factor profile associated with socioeconomic position in stroke patients. Relative risks for stroke were estimated in log-linear Poisson regression models. The risk for hospitalization for a first ischemic stroke was almost doubled for people in the lowest income group, and the risk of those of working age (<65 years) was increased by 36% among people with the shortest education. Diabetes, obesity, smoking, and high alcohol consumption in particular and, to a lesser extent, previous myocardial infarction or intermittent arterial claudication were significantly overrepresented among stroke patients with lower socioeconomic position. Atrial fibrillation and hypertension were not.

CONCLUSIONS

In Denmark, there is a strong relation between low socioeconomic position and risk for hospitalization for stroke. Lifestyle, as indicated by smoking, obesity, and alcohol consumption, and diabetes appears to increase the risk for stroke in people with lower socioeconomic position.

Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura.

CONCLUSIONS

To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted.

[Gender and stroke in Brazzaville]

BACKGROUND

The relationship between gender and cerebrovascular disease is controversial. The aim of our study was to evaluate the relationship between gender and vascular risk factors, biological variables and the severity of the neurological deficit in stroke.

METHODS

This cross-sectional study, conducted from March to August 2011 in the department of neurology of the university hospital of Brazzaville which included all patients hospitalized for confirmed stroke. The study variables were: age, sex, vascular risk factors, NIHSS scores and Glasgow, blood pressure, and the biological exams and complications. Statistical analysis was performed on SPSS12.

RESULTS

Eighty patients were included. The mean age was 62.7 ± 11.2 years, with 58.8% of men. Alcohol intake and smoking were more frequent in men than women respectively P=0.005 and P=0.032. Psychosocial stress was more often declared by women than men (P=0.042). However there was no significant difference in biological variables, the severity of stroke and the occurrence of complications

CONCLUSION

Our study suggests that in the Congolese context, gender does not influence significantly most parameters during stroke, but men consume more alcohol and women are exposed to psychosocial stress.

Impact of gender-age interaction on the outcome of ischemic stroke in an Italian cohort of patients treated according to a standardized clinical pathway

BACKGROUND

Stroke outcome has been reported as worse in women, especially in terms of disability. As for mortality, the data are conflicting, with some reports suggesting a female advantage. Our objective was to explore such issues in an Italian cohort of patients managed by a standardized clinical pathway (CPW) and, as such, homogeneous in terms of clinical management.

METHODS

Data from a cohort of 1993 patients (987 women and 1006 men) with first-ever ischemic stroke, consecutively referred to an in-hospital Clinical Pathway Program from January 1, 2001 to December 31, 2009, were retrospectively analyzed. The relationship between female gender and one-month outcome was assessed with adjustment for age, stroke severity and premorbid disability.

RESULTS

The outcome was worse in women in terms of disability (age-adjusted odds ratio 2.03, 95% CI 1.69-2.46), while no difference was found for mortality. In multivariate models, female gender turned out to be associated with a lower case-fatality rate (adjusted hazard ratio 0.65, 95% CI 0.48-0.89, P=0.007), whereas the odds ratio for disability decreased but remained significant (OR 1.30; 95% CI 1.01-1.69). We found a significant interaction between gender and age in the case-fatality rate, and a female survival advantage was apparent only below 50 years.

CONCLUSIONS

Our study confirms the excess risk of disability after stroke in women, although it is mostly explained by the occurrence of the most severe clinical syndromes. As for mortality, female gender seems to play a protective role, at least in the short-term and in younger patients.

Early case-fatality rates in elderly stroke patients do not increase when age increases

AIM

We studied the association between age and survival after stroke. We particularly focused on deaths that could be attributed to the stroke lesion itself; that is, early death in severe stroke.

METHODS

A registry of all hospitalized stroke patients in Denmark included 93897 patients with information on stroke severity (Scandinavian Stroke Scale [SSS] 0-58), computed tomography, cardiovascular risk, age, sex and fatality within 1 month. Using regression models, we constructed age trajectories of 3-days, 1-week, and 1-month case-fatality rates unadjusted and adjusted for stroke severity, sex, and cardiovascular risk factors for patients with SSS <25 and SSS ≥ 25.

RESULTS

The 3-days, 1-week, and 1-month case-fatality were 3.6%, 5.8% and 10.3%, respectively. Age-trajectories (SSS <25): 3-days case-fatality rates increased to the age of 75 years. Case-fatality rates then declined (unadjusted model) or leveled off (adjusted model) as age increased. One-week case-fatality increased to the age of 85 years. Case-fatality then leveled off (unadjusted model) or continued to rise (adjusted model) as age increased. One-month case-fatality rates increased throughout the entire lifespan. Age-trajectories (SSS ≥ 25): the leveling off phenomenon was still present for 3-days case-fatality; however, it was less pronounced.

CONCLUSIONS

Very early stroke case-fatality rates increasing to the age of 75-85 years subsequently leveled off or even declined with increasing age. Advanced age per se should not be seen as a disadvantage in terms of surviving stroke in the very acute phase.

5-year survival and rehospitalization due to stroke recurrence among patients with hemorrhagic or ischemic strokes in Singapore

Background

Stroke is the 4th leading cause of death and 1st leading cause of disability in Singapore. However the information on long-term post stroke outcomes for Singaporean patients was limited. This study aimed to investigate the post stroke outcomes of 5-year survival and rehospitalization due to stroke recurrence for hemorrhagic and ischemic stroke patients in Singapore. The outcomes were stratified by age, ethnic group, gender and stroke types. The causes of death and stroke recurrence were also explored in the study.

Methods

A multi-site retrospective cohort study. Patients admitted for stroke at any of the three hospitals in the National Healthcare Group of Singapore were included in the study. All study patients were followed up to 5 years. Kaplan-Meier was applied to study the time to first event, death or rehospitalization due to stroke recurrence. Cox proportional hazard model was applied to study the time to death with adjustment for stroke type, age, sex, ethnic group, and admission year. Cumulative incidence model with competing risk was applied for comparing the risks of rehospitalization due to stroke recurrence with death as the competing risk.

Results

Totally 12,559 stroke patients were included in the study. Among them, 59.3% survived for 5 years; 18.4% were rehospitalized due to stroke recurrence in 5 years. The risk of stroke recurrence and mortality increased with age in all stroke types. Gender, ethnic group and admitting year were not significantly associated with the risk of mortality or stroke recurrence in hemorrhagic stroke. Male or Malay patient had higher risk of stroke recurrence and mortality in ischemic stroke. Hemorrhagic stroke had higher early mortality while ischemic stroke had higher recurrence and late mortality. The top cause of death among died stroke patients was cerebrovascular diseases, followed by pneumonia and ischemic heart diseases. The recurrent stroke was most likely to be the same type as the initial stroke among rehospitalized stroke patients.

Conclusions

Five year post-stroke survival and rehospitalization due to stroke recurrence as well as their associations with patient demographics were studied for different stroke types in Singapore. Specific preventive strategies are needed to target the high risk groups to improve their long-term outcomes after acute stroke.

Body mass index and stroke: overweight and obesity less often associated with stroke recurrence

BACKGROUND

Although obesity is associated with excess mortality and morbidity, mortality is lower in obese than in normal weight stroke patients (the obesity paradox). Studies now indicate that obesity is not associated with increased risk of recurrent stroke in the years after first stroke. We studied the association between body mass index (BMI) and stroke patient's risk of having a history of previous stroke (recurrent stroke).

METHODS

A registry designed to collect data on all hospitalized stroke patients in Denmark 2000-2010 includes 61,872 acute stroke patients with information on BMI in 38,506. Data include age, sex, civil status, stroke severity (Scandinavian Stroke Scale), computed tomography, and cardiovascular risk factors. There were 28,382 patients with complete covariate information. We used multiple logistic regression models on this data set to compare the risk of stroke being recurrent in the 4 BMI groups: underweight (BMI<18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), and obese (BMI≥30.0).

RESULTS

Of the patients with complete covariate information, 22,811 (80.1%) had first-ever stroke; in 5571 patients (19.6%), stroke was recurrent. Multiple logistic regression analysis adjusting for age, stroke severity, sex, BMI, civil status, and cardiovascular risk factors showed that being obese and overweight in comparison with normal weight was associated with a significantly lower risk of stroke being recurrent (obese: odds ratio [OR]=.90, confidence interval [CI] .82-.98; overweight: OR=.89, CI .83-.96). Being underweight was associated with a significantly higher risk of stroke being recurrent (OR=1.23; CI 1.06-1.43).

CONCLUSIONS

The obesity paradox in stroke can be extended to include also stroke recurrence. Obese and overweight stroke patients had experienced less previous strokes than normal weight stroke patients.

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

BACKGROUND AND PURPOSE

Sex related differences in cardiovascular disease and stroke are issues of increasing interest. The aim of this study was to evaluate for sex differences in clinical presentation, severity of stroke and outcome in a population of patients admitted to 4 public and 1 private hospitals in three different regions of Italy.

METHODS

All hospital admissions for ischemic and haemorrhagic stroke (ICD-IX code 434 and 431 respectively) between January 1st and December 31st, 2011 at five different hospitals located in three different regions of Italy: Milan (North), Rome and Perugia (Center), and Palermo (South) have been recorded and sex-differences have been evaluated.

RESULTS

A total of 1272 stroke patients were included in the analysis: 1152 ischemic and 120 haemorrhagic strokes, 567 women and 705 men. Compared to men, women were significantly older (mean age 75.2 SD 13.7 vs 71.5 SD 12.5 years, P<0.001) and their stroke severities at onset, measured by NIHSS, were also compared to men (10 SD 8 vs 8 SD 7, P<0.001). Female sex was associated with a worse functional prognosis measured by modified Rankin Scale score (mRS≥3), as well as in-hospital mortality, without reaching statistical significance. There were no observed significant differences between sexes regarding the number of patients treated with thrombolytic therapy. Analysis of the distribution of risk factors between sexes showed a prevalence of atrial fibrillation in women (29% vs 21%, P=0.003).

CONCLUSIONS

Both stroke severity and functional outcome were worse in women.

Cause-specific mortality after stroke: relation to age, sex, stroke severity, and risk factors in a 10-year follow-up study

We investigated cause-specific mortality in relation to age, sex, stroke severity, and cardiovascular risk factor profile in the Copenhagen Stroke Study cohort with 10 years of follow-up. In a Copenhagen community, all patients admitted to the hospital with stroke during 1992-1993 (n = 988) were registered on admission. Evaluation included stroke severity, computed tomography scan, and a cardiovascular risk profile. Cause of death within 10 years according to death certificate information was classified as stroke, heart/arterial disease, or nonvascular disease. Competing-risks analyses were performed by cause-specific Cox regression after multiple imputation of missing data, assuming that values were missing at random. Death was due to stroke in 310 patients (31%), to heart/arterial disease in 209 patients (21%), and to nonvascular diseases in 289 patients (29%); 180 patients were still alive after 10 years (18%). Stroke was the dominant cause of death during first year, with an absolute risk of 20.2% versus 5.2% for heart/arterial disease and 6.5% for nonvascular disease. The subsequent absolute risk of death per year was 2.8% for stroke, 4.5% for heart/arterial disease, and 5.2% for nonvascular disease. Death after stroke was associated with older age, male sex, greater stroke severity, and diabetes regardless of the cause of death. Previous stroke and hemorrhagic stroke were associated with death by stroke, ischemic heart disease was associated with death by heart/arterial disease and atrial fibrillation was associated with death by cardiovascular disease (stroke or heart/arterial disease). Hypertension, smoking, and alcohol consumption were not associated with cause-specific death.

Explaining poorer stroke outcomes in women: women surviving 3 months have more severe strokes than men despite a lower 3-month case fatality

BACKGROUND

Women who survive stroke are more disabled and more often institutionalized than men.

OBJECTIVE

We explore this phenomenon by studying case fatality and stroke severity in stroke survivors separately for men and women.

METHODS

A Danish stroke registry (2000-2007) contains information about 26,818 patients with first-ever ischemic stroke, including stroke severity (Scandinavian Stroke Scale, 0 worst to 58 best), computed tomography scan, cardiovascular risk factors, and death 3 months after stroke. We modeled stroke severity by generalized additive linear model and 3-month case fatality with logistic model adjusting for age and cardiovascular risk factors.

RESULTS

Male to female ratio was 51.5% to 48.5%. Mean age was 68.8 (SD 12.6) years in men; 73.7 (13.8) years in women. Stroke was more severe in women (mean [SD] Scandinavian Stroke Scale, 42.2 [16.0]) than in men (mean [SD] Scandinavian Stroke Scale, 45.6 [14.2]) also after adjustment for age and cardiovascular risk factors; significant in patients older than 75 years. In survivors at 3 months, stroke was more severe in women than men, given same age and cardiovascular risk factor profile; significant in patients older than 75 years. More women (11.9%) had died within 3 months than men (8.6%). However, adjusting for age, stroke severity, and risk factor profile, 3-month case fatality was lower in women than men; significant in patients older than 78 years.

CONCLUSIONS

Although 3-month case fatality was lower in women than men, strokes were more severe among survivors at 3 months in women than in men. In addition, strokes were more severe in women. Our data help elucidate why women survive stroke better but have poorer functional outcomes that require more care than men.

Gender difference in stroke case fatality: an integrated study of hospitalization and mortality

BACKGROUND

Providing regional and state-specific prognosis factors for stroke patients has both clinical and public health importance. Results from previous studies of sex difference in stroke case fatality have been mixed. The current study links stroke hospitalizations to community-based mortality records to examine sex difference in stroke case fatality and associated prognosis factors.

METHODS

Hospital discharge data and death certificate data from January 2005 to December 2009 in Nebraska were linked. Multivariable logistic regression was used to estimate sex differences in 30-day mortality, and the Cox proportional hazard model was used to predict overall survival.

RESULTS

A total of 15,806 patients were included. Females were more likely to die during the 30 days after stroke hospitalization. However, there was no significant difference in overall survival in the multivariate analysis that controlled for age, comorbidity, and rehabilitation factors. Females were more likely to have comorbidities, such as atrial fibrillation, anemia, and heart failure, while males were more likely to have chronic kidney disease. In addition, males were more likely to receive rehabilitation services after stroke.

CONCLUSIONS

Among persons hospitalized with a stroke in Nebraska between 2005 and 2009, the crude case fatality rate was 50% higher in women. However, after accounting for age and other variables, adjusted mortality rates were essentially the same for men and women.

Socioeconomic disparities in stroke rates and outcome: pooled analysis of stroke incidence studies in Australia and New Zealand

OBJECTIVE

To assess the influence of area-level socioeconomic status (SES) on incidence and case-fatality rates for stroke.

DESIGN, SETTING AND PARTICIPANTS

Analysis of pooled data for 3077 patients with incident stroke from three population-based studies in Perth, Melbourne, and Auckland between 1995 and 2003.

MAIN OUTCOME MEASURES

Incidence and 12-month case-fatality rates for stroke.

RESULTS

Annual age-standardised stroke incidence rates ranged from 77 per 100,000 person-years (95% CI, 72-83) in the least deprived areas to 131 per 100,000 person-years (95% CI, 120-141) in the most deprived areas (rate ratio, 1.70; 95% CI, 1.47-1.95; P < 0.001). The population attributable risk of stroke was 19% (95% CI, 12%-27%) for those living in the most deprived areas compared with the least deprived areas. Compared with people in the least deprived areas, those in the most deprived areas tended to be younger (mean age, 68 v 77 years; P < 0.001), had more comorbidities such as hypertension (58% v 51%; P < 0.001) and diabetes (22% v 12%; P < 0.001), and were more likely to smoke (23% v 8%; P < 0.001). After adjustment for age, area-level SES was not associated with 12-month case-fatality rate.

CONCLUSIONS

Our analysis provides evidence that people living in areas that are relatively more deprived in socioeconomic terms experience higher rates of stroke. This may be explained by a higher prevalence of risk factors among these populations, such as hypertension, diabetes and cigarette smoking. Effective preventive measures in the more deprived areas of the community could substantially reduce rates of stroke.

Age trajectories of stroke case fatality: leveling off at the highest ages

BACKGROUND

Mortality rates level off at older ages. Age trajectories of stroke case-fatality rates were studied with the aim of investigating prevalence of this phenomenon, specifically in case-fatality rates at older ages.

METHODS

A registry of all hospitalized stroke patients in Denmark included 40,155 patients with evaluations of stroke severity, computed tomography, and cardiovascular risk factors. Data on mortality were used to construct age trajectories of 3-day, 1-week, 1-month, and 1-year case-fatality rates in men and women.

RESULTS

Of the 40,155 patients, 19,301 (48%) were women (mean age, 74.5 years) and 20,854 (52%) were men (mean age, 69.7 years). In both women and men, 3-day case-fatality rates leveled off, beginning in the patients' mid-70s. In women, 1-week case-fatality rates leveled off further in their early 80s, whereas in men, 1-week case-fatality rates accelerated with age. One-month and 1-year case-fatality rates accelerated with age for both sexes.

CONCLUSIONS

It is an apparent paradox that case-fatality rates in the acute state of stroke level off at the highest ages. Heterogeneity, innate or acquired, in regard to survival capacity may explain the phenomenon.

Predictors of early and late case-fatality in a nationwide Danish study of 26,818 patients with first-ever ischemic stroke

BACKGROUND AND PURPOSE

Predictors of early case-fatality (3-day, 7-day, and 30-day) in first-ever ischemic stroke were identified and compared with predictors of late case-fatality (90-day and 1-year).

METHODS

A registry designed to register hospitalized patients with stroke in Denmark 2000 to 2007 holds 26,818 patients with first-ever ischemic stroke with information on stroke severity (Scandinavian Stroke Scale), CT scan, cardiovascular risk factors, marital status, and fatality within 1 year. Multiple logistic regression was used in identifying predictors.

RESULTS

Mean age was 71.2 years; 48.5% were women; mean Scandinavian Stroke Scale score was 43.9. Early case-fatality showed stroke severity and age were significant predictors of 3-day, 7-day, and 30-day case-fatality (nonlinear effect). In addition, atrial fibrillation (OR, 1.56) predicted 30-day case-fatality. For late case-fatality, significant predictors of 90-day and 1-year case-fatality were age, stroke severity (nonlinear effect), atrial fibrillation (OR, 1.37 and 1.57), and diabetes (OR, 1.35 and 1.33), respectively. Male gender (OR, 1.28), previous myocardial infarction (OR, 1.40), and smoking (OR, 1.21) were also associated with 1-year case-fatality. Alcohol consumption, hypertension, intermittent arterial claudication, and marital state had no influence. All case-fatality rates accelerated with increasing age, but 3-day and 7-day case-fatality rates tended to level off or decline at the highest ages.

CONCLUSIONS

Age and stroke severity were the only significant predictors of fatality within the first poststroke week; they were associated with late case-fatality as well. Cardiovascular risk factors were associated with late case-fatality; with the exception of atrial fibrillation, they were not significantly associated with early case-fatality rates.