Sex differences in US mortality rates for stroke and stroke subtypes by race/ethnicity and age, 1995-1998

Sex-specific mechanisms in vascular aging: exploring cellular and molecular pathways in the pathogenesis of age-related cardiovascular and cerebrovascular diseases

Aging remains the foremost risk factor for cardiovascular and cerebrovascular diseases, surpassing traditional factors in epidemiological significance. This review elucidates the cellular and molecular mechanisms underlying vascular aging, with an emphasis on sex differences that influence disease progression and clinical outcomes in older adults. We discuss the convergence of aging processes at the macro- and microvascular levels and their contributions to the pathogenesis of vascular diseases. Critical analysis of both preclinical and clinical studies reveals significant sex-specific variations in these mechanisms, which could be pivotal in understanding the disparity in disease morbidity and mortality between sexes. The review highlights key molecular pathways, including oxidative stress, inflammation, and autophagy, and their differential roles in the vascular aging of males and females. We argue that recognizing these sex-specific differences is crucial for developing targeted therapeutic strategies aimed at preventing and managing age-related vascular pathologies. The implications for personalized medicine and potential areas for future research are also explored, emphasizing the need for a nuanced approach to the study and treatment of vascular aging.

Intracerebral hemorrhage mortality in individuals with atrial fibrillation: a nationwide analysis of mortality trends in the United States

BACKGROUND

Atrial fibrillation (AF) is a risk factor for intracerebral hemorrhage (ICH), both with and without use of anticoagulation. Limited data exists on mortality trends and disparities related to this phenomenon. We aimed to assess ICH mortality trends and disparities based on demographic factors in individuals with atrial fibrillation in the United States (US).

METHODS

Our cross-sectional analysis utilized mortality data from the CDC database through death certificate queries from the years 1999 to 2020 in the US. We queried for all deaths with ICH as the underlying cause of death and atrial fibrillation as the multiple causes of death. Mortality data was obtained for overall population and demographic subpopulations based on sex, race and ethnicity, and geographic region. Trend analysis and average annual-mortality percentage change (AAPC) were completed using log-linear regression models.

RESULTS

ICH age-adjusted mortality rate (AAMR) in patients with AF increased from 0.27 (95% CI 0.25-0.29) in 1999 to 0.30 (95% CI 0.29-0.32) in 2020. A higher mortality rate was observed in males (AAMR 0.33) than in females (AAMR 0.26). The highest mortality was found in Asian/Pacific Islander (AAMR: 0.32) populations, followed by White (AAMR: 0.30), Black (AAMR: 0.15), and American Indian/Alaska Native (AAMR: 0.11) populations. Southern (AAPC: 1.3%) and non-metropolitan US regions (AAPC: + 1.9%) had the highest increase in annual mortality change.

CONCLUSION

Our findings highlight the disparities in ICH mortality in patients with AF. Further investigation is warranted to confirm these findings and evaluate for contributors to the observed disparities.

Do stroke services still show sex differences? A multicenter study

BACKGROUND

The issue of sex differences in stroke has gained concern in the past few years. However, multicenter studies are still required in this field. This study explores sex variation in a large number of patients and compares stroke characteristics among women in different age groups and across different countries.

METHODS

This multicenter retrospective cross-sectional study aimed to compare sexes regarding risk factors, stroke severity, quality of services, and stroke outcome. Moreover, conventional risk factors in women according to age groups and among different countries were studied.

RESULTS

Eighteen thousand six hundred fifty-nine patients from 9 countries spanning 4 continents were studied. The number of women was significantly lower than men, with older age, more prevalence of AF, hypertension, and dyslipidemia. Ischemic stroke was more severe in women, with worse outcomes among women (p: < 0.0001), although the time to treatment was shorter. Bridging that was more frequent in women (p:0.002). Analyzing only women: ischemic stroke was more frequent among the older, while hemorrhage and TIA prevailed in the younger and stroke of undetermined etiology. Comparison between countries showed differences in age, risk factors, type of stroke, and management.

CONCLUSION

We observed sex differences in risk factors, stroke severity, and outcome in our population. However, access to revascularization was in favor of women.

Predictive Clinical Factors of In-Hospital Mortality in Women Aged 85 Years or More with Acute Ischemic Stroke

INTRODUCTION

There are limited data on the outcome of acute ischemic stroke in oldest old women. We assessed clinical risk factors for in-hospital mortality in women aged 85 years or more with acute ischemic stroke.

METHODS

This single-center retrospective cohort study included 506 women aged ≥85 years collected from a total of 4,600 patients with acute cerebral infarction registered in an ongoing 24-year hospital stroke database. The identification of clinical risk factors for in-hospital mortality was the primary endpoint of the study.

RESULTS

The mean (± standard deviation) age of the patients was 88.6 ± 3.2 years. Stroke subtypes were cardioembolic infarcts in 37.7% of patients, atherothrombotic infarcts in 30.8%, infarcts of unknown cause and lacunar infarcts in 26.1% each, and infarcts of unusual cause in 11.5%. The in-hospital mortality rate was 20.4% (n = 103). Cardioembolic infarct accounted for 67% of all deaths (n = 69). Sudden stroke onset (OR 1.87, 95% CI 1.14-3.06), altered consciousness (OR 7.05, 95% CI 4.36-11.38), and neurological, cardiac, respiratory, and hemorrhagic events during hospitalization were independent risk factors for death, whereas lacunar infarction was a protective factor (OR 0.10, 95% CI 0.01-0.82).

CONCLUSION

The oldest old age segment of women with acute ischemic infarction is a subgroup of stroke patients with unfavorable prognosis and high in-hospital mortality associated with sudden stroke onset, altered consciousness, and medical complications developed during hospitalization. Lacunar infarction as stroke subtype showed a favorable prognosis.

Gender Predicts Differences in Acute Ischemic Cardioembolic Stroke Profile: Emphasis on Woman-Specific Clinical Data and Early Outcome-The Experience of Sagrat Cor Hospital of Barcelona Stroke Registry

Background and Objectives: Acute ischemic cardioembolic stroke (CS) is a clinical condition with a high risk of death, and can lead to dependence, recurrence, and dementia. Materials and Methods: In this study, we evaluated gender differences and female-specific clinical data and early outcomes in 602 women diagnosed with CS from a total of 4600 consecutive acute stroke patients in a single-center hospital stroke registry over 24 years. A comparative analysis was performed in women and men in terms of demographics, cerebrovascular risk factors, clinical data, and early outcomes. Results: In a multivariate analysis, age, hypertension, valvular heart disease, obesity, and internal capsule location were independent variables associated with CS in women. The overall in-hospital mortality rate was similar, but the group of women had a greater presence of neurological deficits and a higher percentage of severe limitation at hospital discharge. After the multivariate analysis, age, altered consciousness, limb weakness, and neurological, respiratory, gastrointestinal, renal, cardiac and peripheral vascular complications were independent predictors related to early mortality in women. Conclusions: Women with CS showed a differential demographic and clinical profile and worse early outcomes than men. Advanced age, impaired consciousness, and medical complications were predictors of stroke severity in women with CS.

Stroke in women: experience in a developing country

BACKGROUND

Several studies have addressed gender differences in stroke. Yet, results are diverse, and research is still required in different populations. So, this study investigates variation in stroke according to gender in a developing country.

METHODS

This is a registry-based, retrospective observational cross-sectional study comparing men and women as regards age, risk factors, stroke severity, quality of services, and stroke outcome.

RESULTS

Data analyzed comprised 4620 patients. It was found that men outnumbered women, while women had an older age, more prevalence of hypertension and atrial fibrillation, with severer strokes and worse outcomes. However, there was no gender difference in promptness nor frequency of administration of revascularization therapies.

CONCLUSION

Despite the gender difference in risk factors and stroke severity, we could not detect any significant disparity in acute stroke services provided to either gender. Among age categories in women, we identified differences in acute ischemic stroke subtypes, and acute management in favor of older age.

Sex-related differences in symptom presentation of patients with aneurysmal subarachnoid hemorrhage

Background: In patients with myocardial infarction, atypical symptoms at onset have been demonstrated in women. We aimed to investigate the presence of sex-related differences in symptom presentation in patients with aneurysmal subarachnoid hemorrhage (aSAH) to enable earlier diagnosis and treatment. Methods: We assessed symptoms on admission to hospital in 343 patients with aSAH in this retrospective single-center cohort-study. Univariate statistical analysis was performed by comparing sexes including the whole study population and subgroups (dichotomized using Fisher scale 1-2 vs. 3-4, WFNS grade 1-3 vs. 4-5, and anterior vs. posterior circulation aneurysms, respectively). Results: The majority of patients was female (63.6%, n=218, vs. 36.4%, n=125), the mean age 57.4 years (standard deviation (SD) 13.3) with older women compared to men (59.2, SD 13.8, vs. 54.4, SD 11.6; p=0.003). Anterior communicating artery (AcomA) aneurysms were most common (30.9%, n=106), predominantly in men (43.2%, n=54, vs. 23.9%, n=52; p=0.0002), whereas posterior communicating artery (PcomA) aneurysms were more frequent in women (19.3%, n=42, vs. 8.8%, n=11; p=0.005). Exercise-induced headache was more often reported by men (10.4%, n=13, vs. 5%, n=11; p=0.04) in all patients as well as in the subgroup of WFNS 1-3. Anisocoria was more frequent in women within the subgroup of severely impaired consciousness (WFNS 4-5; 25.3%, n=22, vs. 10.7%, n=6; p=0.032). For all other symptoms, there was no evidence for sex-specific differences in the whole study group as well as in subgroups. Conclusion: Our results show no evidence for relevant sex-related differences in symptom presentation at onset in aSAH patients. Women presenting with an acute onset anisocoria should be screened even more carefully for an underlying ruptured Pcom aneurysm.

Prediction and Implications of Edoxaban-Associated Bleeding in Patients after Critical Illness

In this retrospective study, we aimed to identify the risk factors for bleeding in patients after critical illness during edoxaban treatment. Data from patients who received edoxaban after critical illness at the Emergency Department at a tertiary care hospital were obtained from the hospital medical records. Multivariate analysis revealed the risk factors for edoxaban-associated bleeding. Additionally, we developed an edoxaban-associated bleeding score (EAB score) based on these results. The derived EAB score was compared with the HAS-BLED score using receiver operating characteristic (ROC) curve analysis. Bleeding was observed in 42 of 114 patients (36.8%). We identified the following bleeding predictors (odds ratios, 95% confidence interval, score points) using multivariate analysis: concomitant use of antiplatelet agents (6.759, 2.047-22.32, 2 points), concomitant use of P-glycoprotein inhibitors (3.825, 1.484-9.856, 1 point), prothrombin time (PT)% following edoxaban administration of <75% and ≥60% (2.507, 0.788-7.970, 1 point), and PT% following edoxaban administration of <60% (11.23, 3.560-35.42, 3 points). The ROC curve analysis revealed an area under the curve of 0.826 for the EAB score and 0.625 for the HAS-BLED score. Under appropriate edoxaban dosing regimens in patients after critical illness, a combination of antiplatelet agents, P-gp inhibitors, and a low PT% following edoxaban administration were identified as strong risk factors for bleeding.

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.

Association of sex and age with in-hospital mortality and complications of patients with intracerebral hemorrhage: A study from the Chinese Stroke Center Alliance

BACKGROUND AND PURPOSE

The impact of sex and age on prognosis in patients with intracerebral hemorrhage (ICH) in the Chinese population remains unclear. Our study aimed to investigate the relationship between sex and age of Chinese ICH patients and adverse prognosis.

METHODS

We used the Chinese Stroke Center Alliance database with in-hospital mortality as the primary outcome and hospital complications as the secondary outcome. Patients were divided into four groups by sex and age. Logistic regression analyses were performed to assess the association between sex and age and the prognosis of ICH patients.

RESULTS

We enrolled 60,911 ICH patients, including 22,284 young and middle-aged males, 15,651 older males, 11,948 young and middle-aged females, and 11,028 older females. After adjusting for variables, older male patients had a higher mortality rate (OR = 1.21, 95% CI 1.01-1.45), combined with more frequent hematoma expansion (OR = 1.14, 95% CI 1.03-1.26), pneumonia (OR = 1.91, 95% CI 1.81-2.03), and hydrocephalus (OR = 1.28, 95% CI 1.04-1.59). Young and middle-aged female patients had a lower mortality rate (OR = 0.74, 95% CI 0.58-0.95) and less frequent combined pneumonia (OR = 0.81, 95% CI 0.75-0.87). In-hospital mortality was not significantly different in older females compared with young and middle-aged males, but the odds of deep vein thrombosis, swallowing disorders, urinary tract infections, and gastrointestinal bleeding were significantly higher.

CONCLUSION

Among young and middle-aged patients, females are related to a lower in-hospital mortality rate from ICH. Older patients are at an increased risk of ICH complications, with higher in-hospital mortality in older men.

Epidemiology of intracerebral hemorrhage: A systematic review and meta-analysis

Background

Intracerebral hemorrhage (ICH) is associated with high mortality and disability rates. This study aimed to investigate the relationship between sex, age, study year, risk factors, bleeding site, median year of study, and the incidence of ICH.

Method

Literature on the incidence of ICH published on 1 January 1980 and 1 January 2020, was systematically retrieved from PubMed and Embase databases. The random-effects model and subgroup analysis were used to explore the relationship between the incidence of ICH and different ages, sex, bleeding sites, and risk factors.

Results

We summarized the epidemiological changes in ICH in the past 40 years according to 52 studies and found that the total incidence of ICH is 29.9 per 100,000 person-years (95% CI: 26.5–33.3), which has not decreased worldwide. The incidence of ICH in the Asian population is much higher than in other continents. In addition, the incidence of ICH increases with age and differs at the 85-year-old boundary. Men are more likely to develop ICH than women, and the basal ganglia region is the most common area for ICH. Of the 10 risk factors examined in this study, those with hypertension had the highest incidence of ICH, followed by those with excessive alcohol consumption and heart disease.

Conclusion

The prevention and treatment of ICH still need to be improved continuously according to age, sex, risk factors, and other factors, and targeted and normative strategies should be gradually developed in the future.

Determinants of metabolic syndrome and its prognostic implications among stroke patients in Africa: Findings from the Stroke Investigative Research and Educational Network (SIREN) study

BACKGROUND

The prognostic implications of metabolic syndrome (METS) among African stroke patients are poorly understood. This study aimed to investigate the determinants of METS and its prognostic implications among Africans with newly diagnosed stroke in the SIREN study.

METHODS

We included stroke cases (adults aged >18 years with CT/MRI confirmed stroke). The validated tools comprehensively evaluated vascular, lifestyle, and psychosocial factors. We used logistic regression to estimate adjusted odds ratios (OR) with 95% CIs for the association between METS and risk factors. We also computed the prediction power of the domain of covariates in a sequential manner using the area under the receiver operating curve (ROC) curve.

RESULTS

Among 3998 stroke subjects enrolled in the study, 76.8% had METS by at least one of the clinical definitions. Factors associated with METS were age > 50 years (OR- 1.46, CI-1.19-1.80), male gender (OR 4.06, CI- 3.28-5.03), income >100USD (OR1.42, CI-1.17-1.71), stress (OR1.46, CI-1.14-1.87), family history of diabetes mellitus (OR1.38, CI-1.06-1.78), and cardiac disease (OR1.42, CI-1.18-1.65). Stroke severity was higher among those with METS (SLS = 5.8 ± 4.3) compared with those without METS (6.2 ± 4.5) at p = 0.037. METS was associated with higher odds (aOR 1.31, CI-1.08-1.58) of one-month fatality after adjusting for stroke severity, age > 50 years, and average monthly income >100USD.

CONCLUSION

METS is very common among African stroke patients and is associated with stroke severity and worse one-month fatality. Lifestyle interventions may prevent METS and attenuate its impact on stroke occurrence and outcomes.

Sex differences in global disability-adjusted life years due to ischemic stroke: findings from global burden of diseases study 2019

To investigate the sex differences in disability-adjusted life years (DALYs) due to ischemic stroke (IS) by year, location and age. We extracted sex-specific data on DALYs number, age-standardized DALYs rate (ASDR) and all-age DALYs rate of IS by year, location and age from the Global Burden of Diseases study 2019. The estimated annual percentage changes (EAPC) were calculated to evaluate the temporal trend of ASDR. For both sexes, although the ASDR of IS slightly decreased from 1990 to 2019, there has been an 60.3% increase in DALYs number worldwide. Sex difference in DALYs number (men minus women) decreased from − 2.83 million in 1990 to 0.14 million in 2019, while the men to women’s ASDR ratio slightly increased from 1.10 in 1990 to 1.21 in 2019. The sex differences in IS DALYs showed remarkable regional variation. The largest sex differences in DALYs number and ASDR were in China and Vietnam. Middle-aged men had a higher IS DALYs than their age-matched counterparts. High systolic blood pressure accounted for the highest DALYs number in 2019, but the top three attributable risk factors that had the greatest sex differences were tobacco, dietary risk, and alcohol use. Sex differences in IS DALYs varied by year, location and age, mostly attributed to the disproportion of cardiovascular risk factors between sexes. Considering the population growth and aging, it is necessary to monitor the sex difference in IS DALYs in different populations and thus provide evidence for local administration to improve current preventive and management strategies of IS.

Senkyunolide H protects PC12 cells from OGD/R-induced injury via cAMP-PI3K/AKT signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Senkyunolide H (SNH) is a bioactive phthalide isolated from Ligusticum chuanxiong Hort rhizome and was reported to have multiple pharmacological effects.

AIM OF THE STUDY

The study was performed to verify the potency of SNH protecting PC12 cells from oxygen glucose deprivation/reperfusion (OGD/R)-induced injury and to elucidate the underlying mechanisms.

MATERIALS AND METHODS

OGD/R model was established in PC12 cells and the cell viability was measured by MTT assay. The cell morphology was observed using scanning electron microscope (SEM). The potential targets of SNH and related targets of OGD/R were screened, and a merged protein-protein interaction (PPI) network of SNH and OGD/R was constructed based on the network pharmacology analysis. Kyoto Encyclopedia of Genes and Genomes (KEGG) database was used for pathway analysis. Intracellular cAMP level and the protein expression levels were measured to elucidate the underlying mechanisms.

RESULTS

SNH pretreatment protected PC12 cells against OGD/R-induced cell death. SNH also significantly protected the cell protrusion. A merged PPI network was constructed and the shared candidate targets significantly enriched in cAMP signaling pathway. The level of intracellular cAMP and the protein level of p-CREB, p-AKT, p-PDK1 and PKA protein were up-regulated after the treatment of SNH compared with OGD/R modeling.

CONCLUSIONS

The present study indicated that SNH protected PC12 cells from OGD/R-induced injury via cAMP-PI3K/AKT signaling pathway.

Sex Differences in Cerebral Aneurysms and Subarachnoid Hemorrhage

Sex differences in cerebral aneurysm occurrence and characteristics have been well described. Although sex differences in outcomes following ischemic stroke have been identified, the effect of sex on outcomes following hemorrhagic stroke, and in particular, aneurysm treatment has been less studied. We describe the current state of knowledge regarding the impact of sex on treatment and outcomes of cerebral aneurysms. Although prior studies suggest that aneurysm prevalence and progression may be related to sex, we did not find clear evidence that outcomes following subarachnoid hemorrhage vary based on sex. Last, we identify areas for future research that could enhance understanding of the role sex plays in this context.

Sex-related differences of invasive therapy in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Sex-related differences in patients with aneurysmal subarachnoid hemorrhage (aSAH) exist. More females than males are affected. Aneurysm location is associated to sex. The relationship between sex and outcome, however, is unclear. Possible differences in management might influence the occurrence of primary and secondary brain injury and thus outcome. The study compares demographics, intensity of treatment, complications, and outcome among females and males with aSAH.

METHODS

All consecutive patients with aSAH admitted to the neurocritical care unit, University Hospital Zurich over a 5-year period were eligible in this retrospective study. Patients' characteristics, comorbidities, aSAH severity, frequency of vasospasm/delayed cerebral ischemia, frequency of invasive interventions, and 3-month outcome were compared by sex. Univariate analysis was performed with the data dichotomized by sex, and outcome. Multivariate analysis for prediction of outcomes was performed.

RESULTS

Three hundred forty-eight patients were enrolled (64% females). Women were older than men. Comorbidities, scores at admission, and treatment modality were comparable among males and females. Vasospasm and DCI occurred similarly among females and males. Interventions and frequency of intraarterial spasmolysis were comparable between sexes. In the multivariate analysis, increasing age, female sex, increasing comorbidities, WFNS and Fisher grade, and presence of delayed cerebral ischemia were predictors of unfavorable outcome when considering all patients. However, after excluding death as a possible outcome, sex did not remain a predictor of unfavorable outcome.

CONCLUSIONS

In the study population, women with aSAH might have present a worse outcome at 3 months. However, no differences by sex that might explain this difference were found in intensity of treatment and management.

Delays in presentation and mortality among Black patients with mechanical thrombectomy after large-vessel stroke at a US hospital

OBJECTIVE

The incidence and severity of stroke are disproportionately greater among Black patients. In this study, the authors sought to examine clinical outcomes among Black versus White patients after mechanical thrombectomy for stroke at a single US institution.

METHODS

All patients who underwent mechanical thrombectomy at a single center from January 1, 2014, through March 31, 2020, were retrospectively analyzed. Patients were grouped based on race, and demographic characteristics, preexisting conditions, clinical presentation, treatment, and stroke outcomes were compared. The association of race with mortality was analyzed in multivariable logistic regression analysis adjusted for potential confounders.

RESULTS

In total, 401 patients (233 males) with a reported race of Black (n = 28) or White (n = 373) underwent mechanical thrombectomy during the study period. Tobacco use was more prevalent among Black patients (43% vs 24%, p = 0.04), but there were no significant differences between the groups with respect to insurance, coronary artery disease, diabetes, illicit drug use, hypertension, or hyperlipidemia. The mean time from stroke onset to hospital presentation was significantly greater among Black patients (604.6 vs 333.4 minutes) (p = 0.007). There were no differences in fluoroscopy time, procedural success (Thrombolysis in Cerebral Infarction grade 2b or 3), hospital length of stay, or prevalence of hemicraniectomy. In multivariable analysis, Black race was strongly associated with higher mortality (32.1% vs 14.5%, p = 0.01). The disparity in mortality rates resolved after adjusting for the average time from stroke onset to presentation (p = 0.14).

CONCLUSIONS

Black race was associated with an increased risk of death after mechanical thrombectomy for stroke. The increased risk may be associated with access-related factors, including delayed presentation to stroke centers.

Cerebrovascular disease in women

Cerebrovascular disease is a major cause of morbidity, mortality, and disability in women. The spectrum of disease differs between men and women, with women being particularly vulnerable to certain conditions, especially during specific periods of life such as pregnancy. There are several unique risk factors for cerebrovascular disease in women, and the influence of some traditional risk factors for stroke is stronger in women. Moreover, disparities persist in representation of women in clinical trials, acute intervention, and stroke outcomes. In this review, we aimed to explore the epidemiology, etiologies, and management of cerebrovascular disease in women, highlighting some of these differences and the growing need for sex-specific management guidelines and health policies.

Why Are Women Less Represented in Intracerebral Hemorrhage Trials?

BACKGROUND AND PURPOSE

Fewer women than men tend to be enrolled in clinical trials of intracerebral hemorrhage. It is unclear whether this reflects lower prevalence of intracerebral hemorrhage in women, selection bias, or poor recruitment efforts. We undertook this study to examine differences between men and women in the reasons for exclusion from the iDEF trial (Intracerebral Hemorrhage Deferoxamine).

METHODS

The screen failure log included 29 different reasons for exclusion. Chi-square statistics were used to evaluate the differences in reasons for exclusion between men and women.

RESULTS

A total of 38.2% of participants in iDEF were women. Three thousand nine hundred eighty-two women (45.7%) and 4736 men (54.3%) were screen failures (P<0.0001). Similar proportions of women (1.28%) and men (1.73%) were excluded due to inability to obtain consent (P=0.1). Patients or families declined participation in 1.26% of women versus 1.31% of men (P=0.9). More women than men failed screening because of age>80 (22.40% versus 12.61%; adjusted P=0.0007) and preexisting do-not-resuscitate/do-not-intubate (3.69% versus 2.83%; adjusted P=0.067).

CONCLUSIONS

Lower rates of women enrollment in the iDEF trial may be attributed to older age. Inability to obtain consent or declining participation was similar between women and men, arguing against selection bias. Our findings should be confirmed in other intracerebral hemorrhage trials to determine best strategies to improve women's representation in future trials.

Posttraumatic Stress Disorder, Antidepressant Use, and Hemorrhagic Stroke in Young Men and Women: A 13-Year Cohort Study

BACKGROUND AND PURPOSE

Antidepressants are commonly prescribed for posttraumatic stress disorder (PTSD) and may increase the risk of bleeding, including hemorrhagic stroke.

METHODS

We prospectively examined independent effects of PTSD, selective serotonin and norepinephrine reuptake inhibitors (SSRI and SNRI) on the risk of incident hemorrhagic stroke in a nationwide sample of 1.1 million young and middle-aged veterans. Time-varying multivariate Cox models were used to examine hemorrhagic stroke risk by PTSD status and use of SSRI or SNRI while adjusting for demographics, lifestyle factors, stroke, and psychiatric comorbidities. Sensitivity analyses controlled for health care utilization.

RESULTS

During 13 years of follow-up (2.14 years on average), 507 patients (12% women) suffered a hemorrhagic stroke. The overall incidence rate was 1.70 events per 10 000-person years. In unadjusted models, PTSD was associated with an 82% greater risk of new-onset hemorrhagic stroke (hazard ratio [HR], 1.82 [95% CI, 1.48-2.24]), SSRI use was associated with a >2-fold risk (HR, 2.02 [95% CI, 1.66-2.57]), and SNRI use was associated with a 52% greater risk (HR, 1.52 [95% CI, 1.08-2.16]). In fully adjusted models, effects of PTSD and SNRI were attenuated (adjusted HR, 1.03 [95% CI, 0.81-1.34]; adjusted HR, 1.19 [95% CI, 0.83-1.71]), but SSRI use remained associated with a 45% greater risk of hemorrhagic stroke (adjusted HR, 1.45 [95% CI, 1.13-1.85]). Hypertension, drug abuse, and alcohol abuse were also associated with increased stroke risk. Nonobesity and being non-Hispanic were protective factors. In sensitivity analyses, health care utilization was a small but significant predictor of stroke.

CONCLUSIONS

In the largest known investigation of PTSD and antidepressant-associated risk for hemorrhagic stroke in young adults, use of SSRIs, but neither PTSD nor SNRIs were independently associated with incident stroke. SNRIs may be preferable for treating PTSD and comorbid conditions, although pursuing other modifiable risk factors and non-pharmacological treatments for PTSD also remains essential.

Association of risk factors and bleeding complications in Asian patients taking edoxaban

AIMS

Asian patients are known to be more prone to bleeding complications than patients of other ethnicities. Therefore, there are possibilities of other risk factors that should be given special consideration for dosage adjustment in this specific ethnic group. This study aimed to investigate the risk factors for bleeding complications in Asian patients under appropriate edoxaban dosage regimens.

METHODS

Data on patients taking proper dosages, based on the Lixiana package insert, were analysed. Univariate and multivariable analyses were conducted to evaluate associations between risk factors and bleeding outcomes. Subgroup analysis was performed on high-risk patients for bleeding complications whose edoxaban dose was reduced according to the package insert.

RESULTS

In total, 346 patients were included. Among them, 32 patients experienced bleeding complications. Patients with weight ≤60 kg and with cancer showed around 3.3- and 3.4-fold increased risk of bleeding complications compared to heavier patients (>60 kg) and those without cancer, respectively. In subgroup analysis with high-risk patients who took low-dose edoxaban (15 and 30 mg), weight ≤60 kg remained a significant factor for bleeding outcomes.

CONCLUSION

This study showed that weight ≤60 kg and the presence of cancers could affect bleeding complications, which occurred despite proper edoxaban treatment in Asian patients. Therefore, more strict dosage guideline could be considered in populations with high proportions of Asian ethnicities.

Associations Between Physician Supply Levels and Amenable Mortality Rates: An Analysis of Taiwan Over Nearly 4 Decades

Access to health care is an important determinant of health, but it remains unclear whether having more physicians reduces mortality. In this study, we used Taiwan’s population-level National Death Certification Registry data to investigate whether a greater supply of physicians is associated with lower rates of amenable mortality, defined as deaths that can be delayed with appropriate and timely medical treatment. Our baseline regression analysis adjusting only for age and sex shows that an increase in the number of physicians per 1000 is associated with a reduction of 1.7 (P < .01) and 0.97 (P < .01) age-standardized deaths per 100 000 for men and women, respectively. However, in our full analyses that control for socioeconomic factors and Taiwan’s health insurance expansion, we find that physician supply is no longer statistically associated with amenable mortality rates. Nevertheless, we found that greater physician supply levels are associated with a reduction in deaths from ischemic heart disease (−0.13 (P < .05) for men, and −0.066 (P < .05) for women). These findings suggest that overall, physician supply is not associated with amenable mortality rates after controlling for socioeconomic factors but may help reduce amenable mortality rates in specific causes of death.

Impact of Gender Inequalities in the Causes of Mortality on the Competitiveness of OECD Countries

The aim of the present study is to quantify the relations between gender inequalities in mortality by selected causes of mortality and between competitiveness of Organisation for Economic Co-operation and Development (OECD) countries. Data for the analyses were obtained from OECD databases and the World Economic Forum (Global Competitiveness Index), for the years 2011–2016, for all 36 countries. The methods of descriptive analysis, analysis of differences in causes of mortality by gender characteristics, regression analysis, relationship analysis of gender inequalities in causes of mortality and competitiveness, and cluster analysis were used for the statistical data processing. Based on the research findings, it can be concluded that gender inequality occurs in most of the examined mortality groups of diagnoses, while it was most significant in the case of mortality due to neoplasms. The impacts of mortality on competitiveness are significant. In assessing gender inequalities in causes of mortality, significant impacts were seen in most mortality causes, but the most significant impact was identified within mortality due to neoplasms. Emphasis should be placed on men when reducing inequalities. Health and health equity should be supported by national governments, and health equity should be one of the key performance indicators of the country.

Gender Inequalities in Health and Their Effect on the Economic Prosperity Represented by the GDP of Selected Developed Countries-Empirical Study

The objective is to evaluate the relations between gender health inequalities and economic prosperity in the Organisation for Economic Co-operation and Development (OECD) countries. The groups included health indicators in the specification of men, women and gender inequalities: life expectancy, causes of mortality and avoidable mortality. The variable determining the economic prosperity was represented by the Gross Domestic Product (GDP). The analytical processing included descriptive analysis, analysis of differences and analysis of relationships. The regression analysis was presented as the main output of the research. Most of the significant gender differences in health showed a more positive outcome for women. It is possible to identify a certain relation between gender health inequalities and economic prosperity. If there is some reduction in gender inequalities in health, the economic prosperity will increase. The reduction seems to be more effective on the part of men than women. The output of the cluster analysis showed the relations of indicators evaluating the inequalities and the prosperity. The countries such as Luxembourg, Norway or Switzerland showed very positive outputs, on the other hand, the countries with a potential for the improvement are Lithuania, Latvia or Estonia. Overall, the policies should focus on reducing the inequalities in avoidable mortality as well as reducing the frequent diseases in younger people.

Differential Impact of Risk Factors on Stroke Occurrence Among Men Versus Women in West Africa

Background and Purpose- The interplay between sex and the dominant risk factors for stroke occurrence in sub-Saharan Africa has not been clearly delineated. We compared the effect sizes of risk factors of stroke by sex among West Africans. Methods- SIREN study (Stroke Investigative Research and Educational Networks) is a case-control study conducted at 15 sites in Ghana and Nigeria. Cases were adults aged >18 years with computerized tomography/magnetic resonance imaging confirmed stroke, and controls were age- and sex-matched stroke-free adults. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed using validated tools. We used conditional logistic regression to estimate odds ratios and reported risk factor specific and composite population attributable risks with 95% CIs. Results- Of the 2118 stroke cases, 1193 (56.3%) were males. The mean±SD age of males was 58.1±13.2 versus 60.15±14.53 years among females. Shared modifiable risk factors for stroke with adjusted odds ratios (95% CI) among females versus males, respectively, were hypertension [29.95 (12.49-71.77) versus 16.1 0(9.19-28.19)], dyslipidemia [2.08 (1.42-3.06) versus 1.83 (1.29-2.59)], diabetes mellitus [3.18 (2.11-4.78) versus 2.19 (1.53-3.15)], stress [2.34 (1.48-3.67) versus 1.61 (1.07-2.43)], and low consumption of green leafy vegetables [2.92 (1.89-4.50) versus 2.00 (1.33-3.00)]. However, salt intake and income were significantly different between males and females. Six modifiable factors had a combined population attributable risk of 99.1% (98.3%-99.6%) among females with 9 factors accounting for 97.2% (94.9%-98.7%) among males. Hemorrhagic stroke was more common among males (36.0%) than among females (27.6%), but stroke was less severe among males than females. Conclusions- Overall, risk factors for stroke occurrence are commonly shared by both sexes in West Africa favoring concerted interventions for stroke prevention in the region.

Gender Differences in Outcomes after Non-traumatic Intracerebral Hemorrhage

Background

Nontraumatic intracranial hemorrhages (ICH) are serious cerebrovascular events with high morbidity and mortality. They occur in about two million people a year worldwide. While ICH continues to be a focus of research in the medical community, there is little data on the differences in outcomes by gender. We aimed to further investigate these differences in our study.

Methods

This analysis involves a de-identified dataset of all adult patients who presented to one of our hospital system's emergency departments with ICHs as one of the top three discharge diagnoses. This study was considered exempt by our medical school's Institutional Review Board (IRB). Our hospital system comprises over 176 hospitals in the United States with over 8.6 million emergency department visits annually. Logistic regression analyses were performed using JMP 14.1. Outcome variables included the length of stay, mortality, and disposition.

Results

The cohort (n = 8069) comprised 68% Caucasians, 17% Blacks, 5% Asians, and 1% Hispanic. Forty-eight percent of patients were females with a median age of 71 years. Fifty-two percent of patients were males with a median age of 65 years. One-fifth of the cohort (20%) died while another fifth (21%) were discharged home. Thirteen percent joined hospice. Women were significantly more likely to die or join hospice (p <0.0001, OR 1.304, 95% CI: 1.183-1.440) even after controlling for age. Women also had a significantly shorter length of stay even when controlled for age (P = 0.0002, 95% CI: -1.58 to -0.489, R² = 1.5%) with a median of four days for men and three days for women.

Conclusion

The median age for women with nontraumatic ICH is older than men, which could explain their increased rates of mortality and discharge to hospice. However, even after controlling for age, women were significantly more likely to die or be discharged to hospice. Conversely, men and younger patients had a longer hospital stay and a higher likelihood of being discharged home.

Men Experience Higher Risk of Pneumonia and Death After Intracerebral Hemorrhage

BACKGROUND

Infectious complications worsen outcome after intracerebral hemorrhage (ICH). We investigated the impact of sex on post-ICH infections and mortality.

METHODS

Consecutive ICH patients (admitted to a single hospital between 1994 and 2015) were retrospectively assessed via chart review to ascertain the following in-hospital infections: urinary tract infection (UTI), pneumonia, and sepsis. Adjusted logistic regression was performed to identify associations between sex, infection, and mortality at 90 days.

RESULTS

Two thousand and four patients were investigated, 1071 (53.7%) males. Men were more likely to develop pneumonia (21.9 vs 15.5% p < 0.001) and sepsis (3.4 vs 1.6%, p = 0.009), whereas women had higher risk of UTI (19.9 vs 11.7% p < 0.001). Multivariate analyses confirmed association between male sex and pneumonia (Odds Ratio (OR) 1.37, 95% confidence interval (CI) 1.08-1.74, p = 0.011). Male sex (OR 1.40; CI 1.07-1.85; p = 0.015) and infection (OR 1.56; CI 1.11-1.85; p = 0.011) were independently associated with higher 90-day mortality.

CONCLUSIONS

Types and rates of infection following ICH differ by sex. Male sex independently increases pneumonia risk, which subsequently increases 90-day mortality. Sex-specific preventive strategies to reduce the risk of these complications may be one strategy to improve ICH outcomes.

Analysis on geographic variations in hospital deaths and endovascular therapy in ischaemic stroke patients: an observational cross-sectional study in China

OBJECTIVES

Stroke is the leading cause of death and adult disability in China, following a rise in incidence over the last few decades. We aimed to explore the geographic variations in hospital mortality and endovascular therapy (EVT) use among ischaemic stroke (IS) patients in China, and investigate the associated potential risk factors.

DESIGN

Observational cross-sectional study of patients hospitalised for stroke.

SETTING

Hospital discharge data for 1267 tertiary hospitals between 1 January 2015 and 31 December 2015 were derived from the Nationwide Hospital Discharge Database operated by the National Health Commission of China.

PARTICIPANTS

1 826 332 patients aged ≥18 years, hospitalised following stroke.

OUTCOME MEASURES

In-hospital mortality and EVT use.

RESULTS

The nationwide hospital mortality rate of IS patients was 0.88% (95% CI 0.86% to 0.90%); there was a significantly greater risk of mortality in the Northeast (OR 2.37; 95% CI 2.23 to 2.52), West (1.65; 1.54 to 1.78), South (1.25; 1.17 to 1.33) and North (1.29; 1.20 to 1.39) than in the East. Tertiary B hospitals (OR 1.05; 95% CI 1.00 to 1.09), patients admitted from emergency departments and older patients were associated with higher hospital mortality. The national EVT use rate was 0.45% (95% CI 0.44% to 0.46%). Compared with in East China, EVT use was significantly lower in the Northeast (OR 0.22; 95% CI 0.20 to 0.24) and West (0.64; 0.58 to 0.71), though not the North (1.23; 1.14 to 1.33). Tertiary A hospitals (OR 2.62; 95% CI 2.43 to 2.83), male patients and patients admitted from emergency departments were also associated with higher EVT use rates.

CONCLUSIONS

There were substantial disparities in mortality and EVT use for hospitalised patients with IS among China's tertiary hospitals, linked with both geographic and hospital characteristics. More targeted intervention at regional and hospital levels is needed for providing effective health technologies and eventually improving post-stroke outcomes.

Sex difference in the incidence of stroke and its corresponding influence factors: results from a follow-up 8.4 years of rural China hypertensive prospective cohort study

Background

Few studies investigate sex difference in stroke incidence in rural China hypertensive population.

Methods

A total of 5097 hypertensive patients aged ≥35 years (mean age, 56.3 ± 11.2 years; 43.8% men) were included in our analysis with a median follow-up 8.4 years in Fuxin county of Liaoning province in China. Cox proportional hazard models were used to analyze the association between the potential factors and incident stroke.

Results

We observed 501 new strokes (310 ischemic, 186 hemorrhagic, and 5 unclassified stroke) during the follow-up. The overall incidence of stroke was 1235.21 per 100,000 person-years; for men, the rates were 1652.51 and 920.80 for women. This sex difference in all stroke can be explained by approximately 25% through age, systolic blood pressure, body mass index, low-density lipoprotein-cholesterol, current smoking, current drinking, antihypertensive drugs, education and physical activity. Subgroup analysis indicated that in hemorrhagic stroke this sex difference was more remarkable (63.89% can be explained).

Conclusions

The incidence of stroke was higher in men than that in women and this difference was partly explained by several traditional cardiovascular risk factors.

Evaluation of adult stroke presentations at an Emergency Department in Queensland Australia

BACKGROUND

Stroke is a leading cause of mortality and morbidity which places high demands on emergency departments (EDs). Currently there is limited data on stroke presentations to Australian EDs and the time performance management of these presentations. Therefore, the aim of this study was to evaluate stroke presentations at an ED in Queensland, Australia in terms of demographics and time performance measures over a five year period.

METHODS

Retrospective analysis of ED presentations by patients ≥18 years with a final diagnosis of stroke between 1 July 2010 and 30 June 2015.

RESULTS

Over the five years there was a 51.4% increase in presentations diagnosed with stroke. The majority of these patients arrived by ambulance (71.0%) and were admitted (94.9%) with death in ED for 1.4% of presentations. From 2010 to 2015 for both haemorrhagic and ischaemic stroke there was a significant decrease in median LOS in ED (435 to 215 min, p < 0.05 and 451 to 238 min, p < 0.001 respectively) and in the proportion of patients in ED greater than four hours (82.4% to 44%, p < 0.05 and 92.4% to 45.8%,p < 0.0001 respectively).

CONCLUSION

Despite increased presentations of stroke, the ED improved in multiple time performance measures. Improving time-based targets in ED is particularly important for stroke presentations given the time critical nature of stroke management.

Decline in Stroke Mortality Between 1997 and 2012 by Sex: Ecological Study in Brazilians Aged 15 to 49 Years

This study aimed to analyse the time trends of stroke mortality between 1997 and 2012 according to sex in Brazilians aged 15 to 49 years. This ecological study used data obtained from the Mortality Information System, which is available from the National Health System Department of Informatics - DATASUS and maintained by the Brazilian Ministry of Health. Stroke definition included International Classification of Disease version 10 (ICD-10) codes I60, I61, I63, and I64. Crude and age-standardized mortality rates and respective 95% confidence intervals were estimated per 100,000 inhabitants and stratified by age, region, year, and sex. Linear regression models were used to analyse the time trends with a confidence level of 95%. The statistical program used was Stata 11.0. Between 1997 and 2012, there were 124,866 deaths due to stroke in Brazilians aged 15 to 49 years. There was a decreasing linear trend in stroke mortality among men (β = −0.46, p < 0.001, R² = 0.95) and women (β = −0.40, p < 0.001, R² = 0.98) during this period. Overall there was no significant difference in stroke mortality trends by sex, except with respect to the age group of 40 to 49 years where there was a difference in the decrease of stroke mortality between men and women (interaction sex * year: β = 0.238, p = 0.012, R² = 0.96). Mortality rates decrease significantly over time in men and women in the age group 15 to 49 years old, but there is only significant difference in the decrease of rates by sex only in the age group from 40 to 49 years old.

The role of inflammation and potential use of sex steroids in intracranial aneurysms and subarachnoid hemorrhage

Background

Aneurysmal subarachnoid hemorrhage (aSAH) continues to be a devastating neurological condition with a high risk of associated morbidity and mortality. Inflammation has been shown to increase the risk of complications associated with aSAH such as vasospasm and brain injury in animal models and humans. The goal of this review is to discuss the inflammatory mechanisms of aneurysm formation, rupture and vasospasm and explore the role of sex hormones in the inflammatory response to aSAH.

Methods

A literature review was performed using PubMed using the following search terms: "intracranial aneurysm," "cerebral aneurysm," "dihydroepiandrosterone sulfate" "estrogen," "hormone replacement therapy," "inflammation," "oral contraceptive," "progesterone," "sex steroids," "sex hormones" "subarachnoid hemorrhage," "testosterone." Only studies published in English language were included in the review.

Results

Studies have shown that administration of sex hormones such as progesterone and estrogen at early stages in the inflammatory cascade can lower the risk and magnitude of subsequent complications. The exact mechanism by which these hormones act on the brain, as well as their role in the inflammatory cascade is not fully understood. Moreover, conflicting results have been published on the effect of hormone replacement therapy in humans. This review will scrutinize the variations in these studies to provide a more detailed understanding of sex hormones as potential therapeutic agents for intracranial aneurysms and aSAH.

Conclusion

Inflammation may play a role in the pathogenesis of intracranial aneurysm formation and subarachnoid hemorrhage, and administration of sex hormones as anti-inflammatory agents has been associated with improved functional outcome in experimental models. Further studies are needed to determine the therapeutic role of these hormones in the intracranial aneurysms and aSAH.

Regional differences in the temporal evolution of stroke: a population-based study of Brazil according to sex in individuals aged 15-49 years between 1997 and 2012

Objective

The present study analyzed the temporal trend of stroke mortality according to sex in individuals aged 15–49 years in the different regions of Brazil between 1997 and 2012.

Results

There was progressive reduction in mortality rate due to stroke in Brazil. The reduction trend was the same for both sexes, although mortality remained slightly higher among men. There was a difference in mortality rates according to the administrative region of the country.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3439-x) contains supplementary material, which is available to authorized users.

A Community-Partnered Approach to Inform a Culturally Relevant Health Promotion Intervention for Stroke

Background. The purpose of this study was to generate information from multiethnic, high-risk communities to inform the creation of culturally relevant health promotion intervention for increasing early hospital arrival after stroke. Methods. The study employed a qualitative design, using focus groups with African American, Caucasian, and Hispanic adults in two Chicago community areas. The study relied heavily on stakeholder input in creating the focus group guide, recruiting participants, and interpreting the analysis. Results. Six focus groups gained information from 51 participants, including insights and perspective on participants’ stroke experience and knowledge as well as on facilitators and barriers to calling 9-1-1. Qualitative analysis uncovered themes relating to risk factors, symptoms, knowledge of stroke mechanisms, experience of acute stroke, help seeking, stroke education, recovery, treatment, and emotions. Communities were closely aligned in their knowledge of stroke, but had differing ideas around stroke education and dissemination of education. Discussion. This study identified nuances in real-world barriers to receiving acute stroke services in minority and disadvantaged communities in Chicago neighborhoods. Our findings indicated significant amount of variation by race/ethnicity and, in particular, a lack of similarities based on race/ethnic groups in different communities. These findings underscore the importance of working with communities to fully understand the community-level dynamics that occur.

Gender related issues in thrombosis and hemostasis

INTRODUCTION

Many aspects of hemostasis, both primary and secondary, as well as fibrinolysis display sex differences. From a clinical viewpoint, certain differential phenotypic presentations clearly arise within various disorders of thrombosis and hemostasis. Areas covered: The present mini-review summarizes selected clinical entities where sex differences are reflected in both frequency and clinical presentation of hemostasis disorders. Sex differences are discussed within the settings of cardiovascular disease, including coronary artery disease and ischemic stroke, venous thromboembolism and inherited bleeding disorders. Moreover, pregnancy and labor present particular challenges in terms of increased thromboembolic and bleeding risk, and this is also summarized. Expert commentary: Available knowledge on sex differences in risk factors and clinical presentation of disorders within thrombosis and hemostasis is increasing. However, more evidence is needed to further clarify different risk factors and treatment effect in men and women, both as regards to cardiovascular disease and venous thromboembolism. This should facilitate improved gender guided risk stratification, and prevention and treatment of these diseases. Finally, risk assessment during pregnancy remains a challenge; this applies both to thromboembolic risk assessment during normal pregnancy and special care of women with inherited bleeding disorders during labor.

Sex differences in intracerebral hemorrhage expansion and mortality

BACKGROUND AND OBJECTIVE

Due to conflicting results in multiple studies, uncertainty remains regarding sex differences in severity and mortality after intracerebral hemorrhage (ICH). We investigated the impact of sex on ICH severity, expansion, and mortality.

METHODS

We analyzed prospectively collected ICH patients and assessed clinical variables and mortality rate. Mediation analyses were used to examine associations between sex and mortality and sex and hematoma expansion.

RESULTS

2212 patients were investigated, 53.5% male. Men with ICH were younger (72 vs. 77years), had greater smoking and alcohol use, and were more likely to have hypertension, diabetes, hypercholesterolemia and coronary artery disease (all p<0.05). Lobar hemorrhages were more frequent in women (47.6% vs 38.4%, p<0.001). Male sex was a risk factor for hematoma expansion (Odd Ratio (OR) 1.7, 95% confidence interval (CI) 1.15-2.50, p=0.007). Multivariable analysis found that male sex was independently associated with 90-day mortality (OR 2.15 (95% CI 1.46-3.19), p<0.001), and one-year mortality (Hazard Ratio 1.28 (95% CI: 1.09-1.50), p=0.003). Early hematoma expansion mediated a portion of the association between sex and mortality (mediation p=0.02).

CONCLUSIONS

Men with ICH experience a higher risk of both expansion and early and late mortality, even after controlling for known risk factors. Further research is needed to explore the biological mechanisms underlying these observed differences.

Assessment of the interaction of age and sex on 90-day outcome after intracerebral hemorrhage

OBJECTIVE

Because age affects hormonal production differently in women compared with men, we sought to define sex and age interactions across a multiracial/ethnic population after intracerebral hemorrhage (ICH) to uncover evidence that loss of gonadal hormone production would result in loss of the known neuroprotective effects of gonadal hormones.

METHODS

Clinical and radiographic data from participants in the Ethnic/Racial Variations of Intracerebral Hemorrhage study and the Genetic and Environmental Risk Factors for Hemorrhagic Stroke study prior to December 2013 were used. Relationships among sex, age, and outcome after ICH in 616 non-Hispanic black, 590 Hispanic, and 868 non-Hispanic white participants were evaluated using multivariable logistic regression analysis. Poor outcome was defined as modified Rankin Scale score ≥3 at 90 days after ICH.

RESULTS

Sex differences were found in multiple variables among the racial/ethnic groups, including age at onset, premorbid neurologic status, and neurologic outcome after ICH. Overall, no sex-age interaction effect was found for mortality (p = 0.183) or modified Rankin Scale score (p = 0.378) at 90 days after ICH. In racial/ethnic subgroups, only the non-Hispanic black cohort provided possible evidence of a sex-age interaction on 90-day modified Rankin Scale score (p = 0.003).

CONCLUSION

Unlike in ischemic stroke, there was no evidence that patient sex modified the effect of age on 90-day outcomes after ICH in a large multiracial/ethnic population. Future studies should evaluate biological reasons for these differences between stroke subtypes.

CLINICALTRIALSGOV IDENTIFIER

NCT01202864.

The influence of dehydration on the prognosis of acute ischemic stroke for patients treated with tissue plasminogen activator

Background

Many studies have determined that dehydration is an independent predictor of outcome after ischemic stroke (IS); however, none have determined if the use of thrombolytic therapy modifies the negative impact of poor hydration. To inform the stroke registry established at our institution, we conducted a retrospective study to determine if dehydration remains a negative prognostic factor after IS patients treated with tissue plasminogen activator (tPA).

Methods

Between 2007 and 2012, we recruited 382 subjects; 346 had data available and were divided into 2 groups on the basis of their blood urea nitrogen/creatinine (BUN/Cr) ratio. Dehydrated subjects had a BUN/Cr ratio ≥ 15; hydrated subjects had a BUN/Cr < 15. The primary outcome was impairment at discharge as graded by the Barthel Index (BI) and the modified Rankin Scale (mRS).

Results

The dehydration group had a greater mean age; more women; lower mean levels of hemoglobin, triglycerides, and sodium; and higher mean potassium and glucose levels. A favorable outcome as assessed by the mRS (≤2) was significantly less frequent among dehydrated subjects, but a favorable outcome by the BI (≥60) was not. Logistic regression and multivariate models confirmed that dehydration is an independent predictor of poor outcome by both the mRS and the BI; however, it was not predictive when patients were stratified by Trial of Org 10,172 in Acute Stroke Treatment subtype.

Conclusions

Our findings indicate that use of thrombolytic therapy does not eliminate the need to closely monitor hydration status in patients with IS.

Sex Differences in the Clinical Features, Risk Factors, and Outcomes of Intracerebral Hemorrhage: a Large Hospital-based Stroke Registry in China

Intracerebral hemorrhage (ICH) is common in China. However, the sex differences in clinical features, risk factors, and outcomes of ICH remain controversial. Between 2005 and 2014, we recruited patients with primary ICH in Tianjin, China, and evaluated sex differences in clinical features, risk factors, and outcomes at 3, 12, and 36 months after ICH. The 1,325 patients included 897 men (67.7%) and 428 women (32.3%). The mean age at ICH onset was younger among men (59.14 years) than among women (63.12 years, P < 0.001). Men were more likely to have a hematoma in the basal ganglia, while women were more likely to have one in the thalamus. Women had higher frequencies of urinary tract infections, diabetes mellitus, cardiovascular diseases, and obesity. Men had a greater risk of death at 3 months after ICH. However, no sex differences were observed for mortality at 12 and 36 months after ICH or for recurrence and dependency at 3, 12, and 36 months after ICH. These findings suggested that it crucial to strengthen management of AF and complications in patients with ICH, especially management of blood pressure in men for reducing the mortality rates and the burden of ICH in China.

No sex differences in long-term functional outcome after intracerebral hemorrhage

Background There is conflicting evidence about the influence of sex on outcome after spontaneous intracerebral hemorrhage (sICH) and the majority of the research focused on mortality and short-term outcome only. We investigated sex differences in long-term functional outcome after sICH. Methods We used data from a prospective hospital registry and included all consecutive patients with ICH admitted to our institution between January 2006 and July 2014. Functional outcome was assessed by modified Rankin Scale evaluated 3 and 12 months after ICH. We explored the influence of sex on long-term functional outcome using multivariable regression models and additionally by means of propensity score matching. Results We analyzed 823 patients, of whom 380 (46%) women. Women were on average three years older (p < 0.001), men had more often deep hematomas (p = 0.01). Unadjusted mortality rates were significantly increased in women at three months (42% vs. 35%; odds ratio (OR): 1.35; 95% confidence interval (CI): 1.02-1.80). After adjusting for baseline prognostic factors there were no differences between men and women in short- and long-term mortality (OR = 1.01; 95% CI = 0.66-1.54 and OR = 1.04; 95%CI = 0.69-1.57, respectively) and short- and long-term unfavorable outcome (OR = 1.02; 95%CI = 0.67-1.55 and OR = 0.96; 95% CI = 0.62-1.48, respectively). Conclusion We found no sex-related differences in long-term functional outcome in patients with sICH. The apparently worse functional outcome in women can be explained by differences in age.

Sex and Age Interactions and Differences in Outcomes After Intracerebral Hemorrhage

BACKGROUND

Compared to ischemic stroke, sex differences in response to intracerebral hemorrhage (ICH) are largely unexplored, and their potential interactions with patient age have not been examined. This study hypothesized that risk for poor outcome is greater in women with increasing age.

METHODS AND RESULTS

The Get With The Guidelines^®-Stroke database was used to assess differences between men and women with ICH. Data from 192,826 ICH patients admitted from January 1, 2009 through March 31, 2014 to 1,728 fully participating sites were analyzed using logistic regression to test interactions between age/sex and outcome.

RESULTS

In the total study population, 48.9% were women (median age 75; male median age 67). On admission, women over 65 years were less likely to have atrial fibrillation or dyslipidemia, or use antiplatelet therapy or cholesterol reducers, but more likely to suffer worse neurological deficit than men over 65. As age increased, odds of in-hospital mortality increased in both men and women, although the relationship was stronger in men. Odds of combined mortality and discharge to hospice were similar in men and women with increasing age, but odds for discharge to home and independent ambulation at discharge decreased more in women with increasing age.

CONCLUSIONS

After adjusting for covariates, modest sex differences in early outcomes after ICH were linked to age. While statistically significant, detected interactions should be considered in context. Future study may examine whether sex-based interactions represent biologic or treatment differences, unmeasured covariates, or some combination thereof.

Retrospective Study on National Institutes of Health Stroke Scale as a Predictor of Patient Recovery After Stroke

BACKGROUND

The National Institutes of Health Stroke Scale (NIHSS) was designed primarily as a research instrument and is used in clinical settings. Its use has not yet been examined as a predictor of patient functional outcomes and prognosis in a community hospital setting.

OBJECTIVES

The aim of this study was to determine the effectiveness of baseline NIHSS score in predicting patient functionality and disposition at discharge in a designated stroke center at a community hospital.

METHODS

The study population included every transient ischemic attack and stroke encounter seen at our community hospital over the past 6 years (n = 2909). Neurological impairment at baseline was quantified using the NIHSS score on the patient's arrival. Outcomes included the patient's discharge disposition (expired or alive) and ambulatory status at discharge. Results were adjusted for age, gender, race, and stroke, myocardial infarction, diabetes, and hypertension history. Analysis was done using R-based statistical tools.

RESULTS

Baseline NIHSS score was a strong predictor of both patient discharge disposition and ambulatory status. After adjusting for confounding factors, with every 1 point increase in the stroke scale at baseline, there was a 2.3 times increased likelihood of mortality and 3 times increased likelihood in worsening of ambulatory function.

CONCLUSIONS

In our community hospital setting, the NIHSS score was found to be a strong predictor of patient recovery after stroke. The NIHSS score at baseline may be important for clinicians to consider before patient management decisions and counseling.

Ethnic variation in acute cerebrovascular disease: Analysis from the Qatar stroke registry

Objective

We analysed the Qatar stroke registry for ethnic variations in patients admitted with cerebrovascular disease at Hamad General Hospital, Qatar.

Methods

Patients admitted with acute stroke from January 2014 to December 2015, enrolled in the registry were included in the study. We evaluated the clinical presentation, risk factors, and outcome at discharge and 90 days post-discharge in relation to the patient's ethnic background.

Results

A total of 1727 patients were enrolled in the Hamad General Hospital stroke registry (Middle Eastern 594 (34.4%), South East Asian 924 (53.5%) and Far Eastern 209 (12.1%)). There were significant differences in risk factors, clinical presentation and prognosis. Compared to Middle Eastern patients, Far Eastern patients were younger (62.8 ± 13.7 vs. 48.9 ± 9.1 years; p < 0.001). Diabetes and hypertension were significantly more common in Middle Eastern patients (358 (60.3%), 458 (77.1%)) compared to South East Asian patients (420 (45.5%), 596 (64.5%)) and Far Eastern patients (57 (27.3%), 154 (73.7%)), respectively (p < 0.001). Stroke was more severe in the Far Eastern group (median (interquartile range) - 5.0 (2-11.5)) compared to the Middle Eastern group (median (interquartile range) - 4.0 (1-8)) and South East Asian (median (interquartile range) - 4.0 (2-9)), p = 0.011. Mortality at 90 days was highest in patients from the Far East (15/209 (8.2%)) compared to the Middle East (35/594 (6.5%)) and South East Asia (33/924 (4.0)), p = 0.028. Patients from the Far East had significantly higher rates of intracranial hemorrhage compared to the Middle East and South East Asia (70/209 (33.5%), 77/594 (13.0%), and 169/924 (18.3%)), respectively (p < 0.001).

Conclusion

The early age at presentation and the poor control of risk factors, especially in patients from South East Asia and the Far East requires attention.

Neurologic Diseases in Special Care Patients

Neurologic diseases can have a major impact on functional capacity. Patients with neurologic disease require individualized management considerations depending on the extent of impairment and impact on functional capacity. This article reviews 4 of the more common and significant neurologic diseases (Alzheimer disease, cerebrovascular accident/stroke, multiple sclerosis, and Parkinson disease) that are likely to present to a dental office and provides suggestions on the dental management of patients with these conditions.

Sex Differences in the Formation of Intracranial Aneurysms and Incidence and Outcome of Subarachnoid Hemorrhage: Review of Experimental and Human Studies

Intracranial aneurysms are defined as pathological dilatations of cerebral arteries and rupture of intracranial aneurysms leads to subarachnoid hemorrhage (SAH). The goal of this review was to outline the sex differences in the formation and progression of intracranial aneurysms as well as sex-related differences in incidence and outcome of SAH. The literature review was performed using PubMed with a combination of these search terms: "subarachnoid hemorrhage," "incidence," "outcome," "sex," "gender," "male," "female," "experimental," "mice," and "rats." Studies written in English were used. Female sex is thought to be a risk factor for aneurysm formation, especially in postmenopausal age populations, suggesting the potential protective involvement of sex steroids. Female sex is also considered a risk factor for SAH occurrence. Although incidence and mortality are confirmed to be higher in females in most studies, they elucidated no clear differences in the functional outcome among SAH survivors. The effect of gender on the pathophysiology of SAH is not very well understood; nevertheless, the majority of pre-clinical studies suggest a beneficial effect of sex steroids in experimental SAH. Moreover, conflicting results exist on the role and effect of hormone replacement therapies and oral contraceptive pills on the incidence and outcome of human SAH. Sex differences exist in the formation of aneurysms as well as the incidence and mortality of SAH. Potential therapeutic effects of sex steroids have been replicated in many animal studies, but their potential use in the treatment of acute SAH in human populations needs more future study.