Gender comparisons of diagnostic evaluation for ischemic stroke patients

Possible sex and racial disparities in myasthenia gravis care

INTRODUCTION/AIMS

Given the importance of early diagnosis and treatment of myasthenia gravis (MG), it is critical to understand disparities in MG care. We aimed to determine if there are any differences in testing, treatment, and/or access to neurologists for patients of varying sex and race/ethnicity with MG.

METHODS

We used a nationally representative healthcare claims database of privately insured individuals (2001-2018) to identify incident cases of MG using a validated definition. Diagnostic testing, steroid-sparing agents, intravenous immunoglobulin (IVIG), plasma exchange (PLEX), and thymectomy were defined using drug names or CPT codes. Steroid use was defined using AHFS class codes. We also determined whether an individual had a visit to a neurologist and the time between primary care and neurologist visits. Logistic regression determined associations between sex and race/ethnicity and testing, treatments, and access to neurologists.

RESULTS

Female patients were less likely to get a computed tomography (CT) chest (odds ratio (OR) 0.73, 95% confidence interval (CI): 0.64-0.83), receive steroids (OR: 0.85, 95% CI: 0.75-0.97), steroid-sparing agents (OR: 0.84, 95% CI: 0.72-0.97), and IVIG or PLEX (OR: 0.80, 95% CI: 0.67-0.95). Black patients were less likely to receive steroids (OR: 0.78, 95% CI: 0.63-0.96). No significant disparities were seen in access to neurologists.

DISCUSSION

We found healthcare disparities in MG treatment with female and Black patients receiving less treatment than men and those of other races/ethnicities. Further research and detailed assessments accounting for individual patient factors are needed to confirm these apparent disparities.

Service delivery in acute ischemic stroke patients: Does sex matter?

BACKGROUND AND PURPOSE

Women with acute ischemic stroke (AIS) are older and have greater preexisting handicap than men. Given that these factors do not fully explain their poorer long-term outcomes, we sought to investigate potential sex differences in the delivery of acute stroke care in a large cohort of consecutive AIS patients.

METHODS

We analyzed all patients from ASTRAL (Acute Stroke Registry and Analysis of Lausanne) from March 2003 to December 2019. Multivariable analyses were performed on acute time metrics, revascularization therapies, ancillary examinations for stroke workup, subacute symptomatic carotid artery revascularization, frequency of change in goals of care (palliative care), and length of hospital stay.

RESULTS

Of the 5347 analyzed patients, 45% were biologically female and the median age was 74.6 years. After multiple adjustments, female sex was significantly associated with higher onset-to-door (adjusted hazard ratio [aHR] = 1.09, 95% confidence interval [CI] = 1.04-1.14) and door-to-endovascular-puncture intervals (aHR = 1.15, 95% CI = 1.05-1.25). Women underwent numerically fewer diagnostic examinations (adjusted odds ratio [aOR] = 0.94, 95% CI = 0.85-1.04) and fewer subacute carotid revascularizations (aOR = 0.69, 95% CI = 0.33-1.18), and had longer hospital stays (aHR = 1.03, 95% CI = 0.99-1.07), but these differences were not statistically significant. We found no differences in the rates of acute revascularization treatments, or in the frequency of change of goals of treatments.

CONCLUSIONS

This retrospective analysis of a large, consecutive AIS cohort suggests that female sex is associated with unfavorable pre- and in-hospital time metrics, such as a longer onset-to-door and door-to-endovascular-puncture intervals. Such indicators of less effective stroke care delivery may contribute to the poorer long-term functional outcomes in female patients and require further attention.

Gender-Based Disparity in Acute Stroke Imaging Utilization and the Impact on Treatment and Outcomes: 2012 to 2021

INTRODUCTION

Prior studies have revealed significant socio-economic disparities in neuro-imaging and treatment utilization for patients with acute ischemic stroke (AIS). In this study, we sought to evaluate whether a sex-based disparity exists in neuro-imaging and to determine its etiology and association with acute treatment and outcomes.

MATERIALS AND METHODS

This was a retrospective study of consecutive patients with AIS admitted to a comprehensive stroke center between 2012 and 2021. Patient demographic and clinical characteristics, neuro-imaging, acute treatment, and early clinical outcomes were extracted from the electronic medical records. Trend analysis, bivariate analysis of patient characteristics by sex, and multivariable logistic regression analyses were conducted.

RESULTS

Of the 7,540 AIS episodes registered from 2012 to 2021, 47.9% were female patients. After adjusting for demographic, clinical, and temporal factors, significantly higher utilization of CTA was found for male patients (odds ratio = 1.20 [95% confidence interval 1.07-1.34]), particularly from socio-economically advantaged groups, and in years 2015 and 2019, representing the years endovascular thrombectomy recommendations changed. Despite this, male patients had significantly lower intravenous thrombolysis utilization (odds ratio = 0.83 [95% confidence interval 0.71-0.96]) and similar endovascular thrombectomy rates as female patients. There were no significant sex differences in early clinical outcomes, and no relevant clinical or demographic factors explained the CT angiography utilization disparity.

CONCLUSION

Despite higher CT angiography utilization in socio-economically advantaged male patients with AIS, likely overutilization due to implicit biases following guideline updates, the rates of acute treatment, and early clinical outcomes were unaffected.

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.

The Effect of Easily Implementable Changes to the "D's of Stroke Care" in Reducing Sex Disparity in Door-to-Needle Time

BACKGROUND

Door-to-needle (DTN) is the duration between patient's arrival at the hospital and receiving intravenous thrombolysis in ischemic stroke settings, for which studies have reported delays in women. The "D's of stroke care" describes 8 steps (D1 to D8) in patients' time tracker. We implemented simple modifications to the "D's of stroke care" by splitting D4 and D6 steps into these substeps: patients' arrival to the emergency room (D4-A), early assessment by a neurologist (D4-B), neurologist decision on patient's eligibility to receive recombinant tissue plasminogen activator (D6-A), and patient's transfer to the stroke unit (D6-B). We evaluated the effect of these changes on reducing DTN time disparity between men and women.

METHODS

This study was conducted from September 2019 to August 2021, at a comprehensive stroke center. Patients were analyzed in 2 groups: group 1, before, and group 2, after using the modifications. Sex as the main variable of interest along with other covariates was regressed toward the DTN time.

RESULTS

In groups 1 and 2, 47 and 56 patients received intravenous thrombolysis, respectively. Although there was a significant difference in DTN≤1 hour between women and men in group 1 (36% vs. 52%, P =0.019), it was not significantly different in group 2 ( P =0.97). Regression analysis showed being female was a significant predictor of DTN>1 hour in group 1 (adjusted odds ratio=6.65, P =0.02), whereas after using the modifications, sex was not a significant predictor for delayed DTN.

CONCLUSIONS

Implementing these substeps reduced sex disparity in DTN time in our center.

Ischemic stroke demographics, clinical features and scales and their correlations: an exploratory study from Jordan

Aims:

The authors aimed to assess the ischemic stroke risk factors and scales.

Materials & methods:

A retrospective cohort study was conducted on patients with acute ischemic stroke (from January 2017 to December 2018). The scores of the National Institutes of Health Stroke Scale (NIHSS) at admission and discharge and of the modified Rankin Scale (mRS) and Barthel Index (BI) scale post-month of the stroke were collected.

Results:

Out of 376 patients, 359 were included, with a mean (standard deviation) age of 67.8 (12.2) years and male predominance (56.2%). Hyperlipidemia and hypertension were the most prevalent comorbidities (91.1% and 80.5%, respectively). The NIHSS, BI and mRS scores were worse among women, with no significant effects for comorbidities. The NIHSS scores at admission and discharge were significantly correlated with the post-month BI and mRS scores.

Conclusion:

The study findings suggest a complex interplay of gender, strict control and prevention of the modifiable stroke risk factors, as well as the association of neurological deficits' intensity with the functional outcomes.

This study aimed to explore the demographics, the clinical risk factors and the scores of the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index (BI) scale at different points of time among the survivors of acute ischemic stroke at a tertiary hospital in Jordan. Also, the study aimed to investigate the differences in the scales' scores by the patients' characteristics and the correlations between these scales. Out of 376 screened patients, 359 were included. Their mean (standard deviation) age was 67.8 (12.2) years, and 56.2% were men. Compared with male participants, women scored significantly worse on the NIHSS at admission (7.61 [5.51] vs 9.47 [6.64]; p = 0.048), NIHSS at discharge (5.57 [4.72] vs 7.40 [5.88]; p = 0.028) and BI scale 1 month post-event (78.68 [28.33] vs 66.03 [35.86]; p = 0.011). The mean (standard deviation) mRS score post-month of stroke was lower in men (2.4 [1.7]) than in women (2.9 [1.9]), with a lack of statistical significance (p = 0.097). Thus, despite the male predominance in the cohort, women tended to have a more severe stroke, worse neurological impairment and poorer functional outcomes. Hyperlipidemia had the highest prevalence, sensitivity, positive predictive value and negative predictive value rates, followed by hypertension. No statistically significant differences existed in the comorbidities' NIHSS, BI scale and mRS scores. Strong and significant correlations were observed between the scores of NIHSS at admission and discharge and the BI scale and mRS scores at 1 month post-event. Thus, the authors concluded that neurological deficit severity has a potential role in predicting functioning outcomes and vice versa.

The Impact of Sex and Gender on Stroke

Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.

Long-Term Trends in Stroke Management and Burden Among Low-Income Women in a Rural Area From China (1992-2019): A Prospective Population-Based Study

Although an increasing number of studies are considering sex-related differences in stroke burden, the trends in stroke burden and management among women in China, especially among low-income women, remain unclear. This study evaluated the long-term trends in stroke management and burden among low-income Chinese women during the period between 1992 and 2019. Stroke burden was assessed using the age-adjusted incidence of first-ever stroke, whereas stroke management was assessed using the rates of neuroimaging diagnoses, hospitalizations, case fatalities, and stroke recurrence. Stroke burden and management were analyzed during four study periods: 1992–1998, 1999–2004, 2005–2012, and 2013–2019. During the 193,385 person-years of surveillance in this study, 597 female stroke patients were identified. The stroke incidences per 100,000 person-years were 88.1 cases during 1992–1998, 145.4 cases during 1999–2004, 264.3 cases during 2005–2012, and 309.8 cases during 2013–2019 (P < 0.001). Between 1992 and 2019, the incidence of stroke significantly increased (6.4% annually) as did the incidence of ischemic stroke (7.8% annually; both, P < 0.001). The rates of neuroimaging diagnoses and hospitalizations significantly increased during the four periods, while the case fatality rates and 1-year recurrence rates decreased significantly for both overall strokes and ischemic strokes, especially among patients ≥45 years old (all, P < 0.001). Among low-income women in China, stroke management is gradually improving, despite the increasing stroke burden. Thus, improved healthcare coverage is needed to further reduce the stroke burden among low-income Chinese women.

Performance of Carotid Revascularization Procedures as Modified by Sex

BACKGROUND

Current recommendations on carotid revascularization postulate that women have both increased perioperative risks, such as stroke and death, as well as reduced benefit from intervention. These recommendations do not include data on transcarotid artery revascularization (TCAR). This study strives to compare safety and benefits of TCAR, TFCAS (Transfemoral Carotid Artery Stenting), and CEA (Carotid Endarterectomy) with regard to patient sex.

METHODS

We performed retrospective analysis of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and stenting registries, as well as TCAR Surveillance Project data. We compared outcomes after TCAR, TFCAS, and CEA based on sex. The primary outcome was the rate of in-hospital stroke or death. Secondary outcomes included in-hospital stroke, death, transient ischemic attack (TIA), myocardial infarction (MI), stroke/death/MI, stroke/TIA, and recurrent ipsilateral stroke and/or death at 1-year of follow-up.

RESULTS

 A total of 75,538 patients were included, of which 28,960 (38.3%) were female and 46,578 (61.7%) were male. TFCAS females had more than 2 times higher odds of stroke/death (OR:2.85, 95%CI: 2.21-3.67, P < 0.001) and stroke/death/MI (OR:2.23, 95%CI:1.75-2.83, P < 0.001) when compared to CEA females. Odds of TIA were also higher in both TFCAS females (OR:2.01, 95%CI:1.19-3.42, P = 0.010) and TCAR females (OR:1.91, 95%CI:1.09-3.35, P = .023) when compared to CEA females. However, only TFCAS females experienced increased odds of stroke/TIA (OR:1.96, 95%CI:1.45-2.65, P < 0.001) when compared to CEA females. TFCAS males had almost twice the odds of stroke/death (OR:1.74, 95%CI:1.39-2.16, P < 0.001) and 44% higher odds of stroke/death/MI (OR:1.44, 95%CI:1.19-1.75, P < 0.001), and more than 3-times increased odds of death (OR:3.45, 95%CI:2.53-4.71, P < 0.001) when compared to CEA males. Odds of in-hospital stroke were comparable between TFCAS and CEA after adjusting for covariates. TCAR males have half the odds of MI when compared to CEA males (OR:0.52, 95%CI:0.34-0.80, P = 0.003). At 1-year TCAR had comparable risk of stroke/death while TFCAS had increased risk of stroke/death when compared to CEA among both males and females.

CONCLUSION

TCAR performed similarly to CEA in both sexes regardless of symptomatic status. Stroke/death and stroke/death/MI rates were similar in symptomatic and asymptomatic males and females treated by CEA or TCAR. The 1-year outcomes of TCAR were also comparable to CEA in both sexes. It seems that TCAR may be a safe alternative to CEA particularly in women when surgical risk prohibits CEA and while TFCAS is associated with substantial adverse outcomes.

Sex Differences in Diagnosis and Diagnostic Revision of Suspected Minor Cerebral Ischemic Events

OBJECTIVE

To describe sex differences in the presentation, diagnosis, and revision of diagnosis after early brain MRI in patients who present with acute transient or minor neurologic events.

METHODS

We performed a secondary analysis of a prospective multicenter cohort study of patients referred to neurology between 2010 and 2016 with a possible cerebrovascular event and evaluated with brain MRI within 8 days of symptom onset. Investigators documented the characteristics of the event, initial diagnosis, and final diagnosis. We used multivariable logistic regression analyses to evaluate the association between sex and outcomes.

RESULTS

Among 1,028 patients (51% women, median age 63 years), more women than men reported headaches and fewer reported chest pain, but there were no sex differences in other accompanying symptoms. Women were more likely than men to be initially diagnosed with stroke mimic (54% of women vs 42% of men, adjusted odds ratio (OR) 1.60, 95% confidence interval [CI] 1.24-2.07), and women were overall less likely to have ischemia on MRI (10% vs 17%, OR 0.52, 95% CI 0.36-0.76). Among 496 patients initially diagnosed with mimic, women were less likely than men to have their diagnosis revised to minor stroke or TIA (13% vs 20%, OR 0.53, 95% CI 0.32-0.88) but were equally likely to have acute ischemia on MRI (5% vs 8%, OR 0.56, 95% CI 0.26-1.21).

CONCLUSIONS

Stroke mimic was more frequently diagnosed in women than men, but diagnostic revisions were common in both. Early brain MRI is a useful addition to clinical evaluation in diagnosing transient or minor neurologic events.

Time trends in incidence, comorbidity, and mortality of ischemic stroke in Denmark (1996–2016)

Objective

To examine whether the incidence, comorbidity, and mortality of first-time ischemic stroke changed in Denmark between 1996 and 2016 overall and according to age and sex using a nationwide cohort design.

Methods

In this cohort study, 224,617 individuals ≥18 years of age admitted with first-time ischemic stroke between 1996 and 2016 were identified through Danish nationwide registries. We calculated annual age-standardized incidence rates and absolute 30-day and 1-year mortality risks. Furthermore, we calculated annual incidence rate ratios using Poisson regression, odds ratios for 30-day mortality using logistic regression, and hazard ratios for 1-year mortality using Cox regression.

Results

The overall age-standardized incidence rates of ischemic stroke per 1,000 person-years increased from 1996 (2.70 [95% confidence interval [CI] 2.65–2.76]) to 2002 (3.25 [95% CI 3.20–3.31]) and then gradually decreased to below the initial level until 2016 (1.99 [95% CI 1.95–2.02]). Men had higher incidence rates than women in all age groups except 18 to 34 and ≥85 years. Absolute mortality risk decreased between 1996 and 2016 (30-day mortality from 17.1% to 7.6% and 1-year mortality from 30.9% to 17.3%). Women between 55 and 64 and ≥85 years of age had higher mortality than men. Similar trends were observed for all analyses after multivariable adjustment. The prevalence of atrial fibrillation, hypertension, diabetes mellitus, and use of lipid-lowering medication increased during the study period.

Conclusions

The age-standardized incidence of first-time hospitalization for ischemic stroke increased from 1996 to 2002 and then gradually decreased to below the initial level until 2016. Absolute 30-day and 1-year mortality risks decreased between 1996 and 2016. These findings correspond to increased stroke prevention awareness and introduction of new treatments during the study period.

Differences in Diagnostic Evaluation in Women and Men After Acute Ischemic Stroke

Background

Sex differences have been found in stroke risk factors, incidence, treatment, and outcomes. There are conflicting data on whether diagnostic evaluation for stroke may differ between men and women.

Methods and Results

We performed a retrospective cohort study using inpatient and outpatient claims between 2008 and 2016 from a nationally representative 5% sample of Medicare beneficiaries. We included patients ≥65 years old and hospitalized with ischemic stroke, defined by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) and ICD‐10‐CM diagnosis codes. Logistic regression was used to determine the association between female sex and the odds of diagnostic testing and specialist evaluation, adjusted for age, race, and number of Charlson comorbidities. Among 78 822 patients with acute ischemic stroke, 58.3% (95% CI, 57.9–58.6%) were women. Female sex was associated with decreased odds of intracranial vessel imaging (odds ratio [OR]: 0.94; 95% CI, 0.91–0.97), extracranial vessel imaging (OR: 0.89; 95% CI, 0.86–0.92), heart‐rhythm monitoring (OR: 0.92; 95% CI, 0.87–0.98), echocardiography (OR: 0.92; 95% CI, 0.89–0.95), evaluation by a neurologist (OR: 0.94; 95% CI, 0.91–0.97), and evaluation by a vascular neurologist (OR: 0.94; 95% CI, 0.90–0.97), after adjustment for age, race, and comorbidities. These findings were unchanged in separate sensitivity analyses excluding patients who died during the index hospitalization or were discharged to hospice and excluding patients with atrial fibrillation diagnosed before their index stroke.

Conclusions

In a nationally representative cohort of Medicare beneficiaries, we found that women with acute ischemic stroke were less likely to be evaluated by stroke specialists and less likely to undergo standard diagnostic testing compared with men.

Sex differences in the evaluation and treatment of acute ischaemic stroke

With the greater availability of treatments for acute ischaemic stroke, including advances in endovascular therapy, personalised assessment of patients before treatment is more important than ever. Women have a higher lifetime risk of stroke; therefore, reducing potential sex differences in the acute stroke setting is crucial for the provision of equitable and fast treatment. Evidence indicates sex differences in prevalence and types of non-traditional stroke symptoms or signs, prevalence of stroke mimics, and door-to-imaging times, but no substantial differences in use of emergency medical services, stroke knowledge, eligibility for or access to thrombolysis or thrombectomy, or outcomes after either therapy. Women presenting with stroke mimics or non-traditional stroke symptoms can be misdiagnosed, which can lead to inappropriate triage, and acute treatment delays. It is essential for health-care providers to recognise possible sex differences in stroke symptoms, signs, and mimics. Future studies focused on confounders that affect treatment and outcomes, such as age and pre-stroke function, are also needed.

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.

Ischemic stroke across sexes: What is the status quo?

Stroke prevalence is expected to increase in the next decades due to the aging of the Western population. Ischemic stroke (IS) shows an age- and sex-dependent distribution in which men represent the most affected population within 65 years of age, being passed by post-menopausal women in older age groups. Furthermore, a sexual dimorphism concerning risk factors, presentation and treatment of IS has been widely recognized. In order to address these phenomena, a number of issue have been raised involving both socio-economical and biological factors. The latter can be either dependent on sex hormones or due to intrinsic factors. Although women have poorer outcomes and are more likely to die after a cerebrovascular event, they are still underrepresented in clinical trials and this is mirrored by the lack of sex-tailored therapies. A greater effort is needed in the future to ensure improved treatment and quality of life to both sexes.

Ischemic stroke across sexes: what is the status quo?

Stroke prevalence is expected to increase in the next decades due to the aging of the Western population. Ischemic stroke (IS) shows an age- and sex-dependent distribution in which men represent the most affected population within 65 years of age, being passed by post-menopausal women in older age groups. Furthermore, a sexual dimorphism concerning risk factors, presentation and treatment of IS has been widely recognized. In order to address these phenomena, a number of issue have been raised involving both socio-economical and biological factors. The latter can be either dependent on sex hormones or due to intrinsic factors. Although women have poorer outcomes and are more likely to die after a cerebrovascular event, they are still underrepresented in clinical trials and this is mirrored by the lack of sex-tailored therapies. A greater effort is needed in the future to ensure improved treatment and quality of life to both sexes.

Acute Stroke Care in Dementia: A Cohort Study from the Swedish Dementia and Stroke Registries

BACKGROUND

Previous studies have shown that patients with dementia receive less testing and treatment for stroke.

OBJECTIVES

Our aim was to investigate hospital management of acute ischemic stroke in patients with and without dementia.

METHODS

Retrospective analysis of prospectively collected data 2010-2014 from the Swedish national dementia registry (SveDem) and the Swedish national stroke registry (Riksstroke). Patients with dementia who suffered an acute ischemic stroke (AIS) (n = 1,356) were compared with matched non-dementia AIS patients (n = 6,755). Outcomes included length of stay in a stroke unit, total length of hospitalization, and utilization of diagnostic tests and assessments.

RESULTS

The median age at stroke onset was 83 years. While patients with dementia were equally likely to be directly admitted to a stroke unit as their non-dementia counterparts, their stroke unit and total hospitalization length were shorter (10.5 versus 11.2 days and 11.6 versus 13.5, respectively, p < 0.001). Dementia patients were less likely to receive carotid ultrasound (OR 0.36, 95% CI [0.30-0.42]) or undergo assessments by the interdisciplinary team members (physiotherapists, speech therapists, occupational therapists; p < 0.05 for all adjusted models). However, a similar proportion of patients received CT imaging (97.4% versus 98.6%, p = 0.001) and a swallowing assessment (90.7% versus 91.8%, p = 0.218).

CONCLUSIONS

Patients with dementia who suffer an ischemic stroke have equal access to direct stroke unit care compared to non-dementia patients; however, on average, their stay in a stroke unit and total hospitalization are shorter. Dementia patients are also less likely to receive specific diagnostic tests and assessments by the interdisciplinary stroke team.

Sex Differences in rt-PA Utilization at Hospitals Treating Stroke: The National Inpatient Sample

Background and purpose

Sex and race disparities in recombinant tissue plasminogen activator (rt-PA) use have been reported. We sought to explore sex and race differences in the utilization of rt-PA at primary stroke centers (PSCs) compared to non-PSCs across the US.

Methods

Data from the National (Nationwide) Inpatient Sample (NIS) 2004–2010 was utilized to assess sex differences in treatment for ischemic stroke in PSCs compared to non-PSCs.

Results

There were 304,152 hospitalizations with a primary diagnosis of ischemic stroke between 2004 and 2010 in the analysis: 75,160 (24.7%) patients were evaluated at a PSC. A little over half of the patients evaluated at PSCs were female (53.8%). A lower proportion of women than men received rt-PA at both PSCs (6.8 vs. 7.5%, p < 0.001) and non-PSCs (2.3 vs. 2.8%, p < 0.001). After adjustment for potential confounders the odds of being treated with rt-PA remained lower for women regardless of presentation to a PSC (OR 0.87, 95% CI 0.81–0.94) or non-PSC (OR 0.88, 95% CI 0.82–0.94). After stratifying by sex and race, the lowest absolute treatment rates were observed in black women (4.4% at PSC, 1.9% at non-PSC). The odds of treatment, relative to white men, was however lowest for white women (PSC OR = 0.85, 95% CI 0.78–0.93; non-PSC OR = 0.80, 95% CI 0.75–0.85). In the multivariable model, sex did not modify the effect of PSC certification on rt-PA utilization (p-value for interaction = 0.58).

Conclusion

Women are less likely to receive rt-PA than men at both PSCs and non-PSCs. Absolute treatment rates are lowest in black women, although the relative difference in men and women was greatest for white women.

Aggressiveness of care following intracerebral hemorrhage in women and men

OBJECTIVE

To compare comorbidities and use of surgery and palliative care between men and women with intracerebral hemorrhage (ICH).

METHODS

The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a prospective, multicenter, case-control study of ICH risk factors and outcomes. We compared comorbidities, treatments, and use of do-not-resuscitate (DNR) orders in men vs women. Multivariate analysis was used to assess the likelihood of ICH surgery and palliative care after adjustment for variables that were p < 0.1 in univariate analyses and backward elimination to retain those that were significant (p < 0.05).

RESULTS

Women were older on average (65.0 vs 59.9, p < 0.0001), and higher proportions of women had previous stroke (24.1% vs 19.3%, p = 0.002), had dementia (6.1% vs 3.4%, p = 0.0007), lived alone (23.1% vs 18.0%, p = 0.0005), and took anticoagulants (12.8% vs 10.1% p = 0.02), compared with men. Men had higher rates of alcohol and cocaine use. After adjusting for age, hematoma volume, and ICH location, there was no difference in rates of surgical treatment by sex (odds ratio [OR] 0.93 for men vs women, 95% confidence interval [CI] 0.68-1.28, p = 0.67), and there was no difference in DNR/comfort care decisions after adjustment for ICH score, prior stroke, and dementia (OR 0.96, CI 0.77-1.22, p = 0.76).

CONCLUSIONS

After ICH, women do not receive less aggressive care than men after controlling for the substantial comorbidity differences. Future studies on sex bias should include the presence of comorbidities, prestroke disability, and other factors that may influence management.

Sex Disparity in Stroke Quality of Care in a Community-Based Study

BACKGROUND

Studies have suggested that women may receive lower stroke quality of care (QOC) than men, although population-based studies at nonacademic centers are limited. We investigated sex disparities in stroke QOC in the Brain Attack Surveillance in Corpus Christi Project.

METHODS

All ischemic stroke patients admitted to 1 of 6 Nueces County nonacademic hospitals between February 2009 and June 2012 were prospectively identified. Data regarding compliance with 7 performance measures (PMs) were extracted from the medical records. Two overall quality metrics were calculated: a composite score of QOC representing the number of achieved PMs over all patient-appropriate PMs, and a binary measure of defect-free care. Multivariable models with generalized estimating equations assessed the association between sex and individual PMs and between sex and overall quality metrics.

RESULTS

A total of 757 patients (51.6% female) were included in our analysis. After adjustment, women were less likely to receive deep vein thrombosis prophylaxis at 48 hours (relative risk [RR] = .945; 95% CI, .896-.996), an antithrombotic by 48 hours (RR = .952; 95% CI, .939-.965), and to be discharged on an antithrombotic (RR = .953; 95% CI, .925-.982). Women had a lower composite score (mean difference -.030, 95% CI -.057 to -.003) and were less likely to receive defect-free care than men (RR = .914; 95% CI, .843-.991).

CONCLUSIONS

Women had lower overall stroke QOC than men, although absolute differences in most individual PMs were small. Further investigation into the factors contributing to the sex disparity in guideline-concordant stroke care should be pursued.

Sex Disparities in Ischemic Stroke Care: FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities)

BACKGROUND AND PURPOSE

Sex-specific disparities in stroke care including thrombolytic therapy and early hospital admission are reported. In a large registry of Florida and Puerto Rico hospitals participating in the Get With The Guidelines-Stroke program, we sought to determine sex-specific differences in ischemic stroke performance metrics and overall thrombolytic treatment.

METHODS

Around 51 317 (49% women) patients were included from 73 sites from 2010 to 2014. Multivariable logistic regression with generalized estimating equations evaluated sex-specific differences in the prespecified Get With The Guidelines-Stroke metrics for defect-free care in ischemic stroke, adjusting for age, race-ethnicity, insurance status, hospital characteristics, individual risk factors, and the presenting stroke severity.

RESULTS

As compared with men, women were older (73±15 versus 69±14 years; P<0.0001), more hypertensive (67% versus 63%, P<0.0001), and had more atrial fibrillation (19% versus 16%; P<0.0001). Defect-free care was slightly lower in women than in men (odds ratio, 0.96; 95% confidence interval, 0.93-1.00). Temporal trends in defect-free care improved substantially and similarly for men and women, with a 29% absolute improvement in women (P<0.0001) and 28% in men (P<0.0001), with P value of 0.13 for time-by-sex interaction. Women were less likely to receive thrombolysis (odds ratio, 0.92; 95% confidence interval, 0.86-0.99; P=0.02) and less likely to have a door-to-needle time <1 hour (odds ratio, 0.83; 95% confidence interval, 0.71-0.97; P=0.02) as compared with men.

CONCLUSIONS

Women received comparable stroke care to men in this registry as measured by prespecified Get With The Guidelines metrics. However, women less likely received thrombolysis and had door-to-needle time <1 hour, an observation that calls for the implementation of interventions to reduce sex disparity in these measures.

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.

Variations in acute hospital stroke care and factors influencing adherence to quality indicators in 6 European audits

BACKGROUND AND PURPOSE

We compared compliance with standards of acute stroke care between 6 European audits and identified factors associated with delivery of appropriate care.

METHODS

Data were derived from stroke audits in Germany, Poland, Scotland, Catalonia, Sweden, and England/Wales/Northern-Ireland participating within the European Implementation Score (EIS) collaboration. Associations between demographic and clinical characteristics with adherence to predefined quality indicators were investigated by hierarchical logistic regression analyses.

RESULTS

In 2007/2008 data from 329 122 patients with stroke were documented. Substantial variations in adherence to quality indicators were found; older age was associated with a lower probability of receiving thrombolytic therapy, anticoagulant therapy, or stroke unit treatment and a higher probability of being tested for dysphagia. Women were less likely to receive anticoagulant or antiplatelet therapy or stroke unit treatment. No major weekend effect was found.

CONCLUSIONS

Detected variations in performance of acute stroke services were found. Differences in adherence to quality indicators might indicate population subgroups with specific needs for improving care delivery.

Women Stroke Association Statement on Stroke

We describe the current and future objectives of the Women Stroke Association, a nonprofit multidisciplinary organization promoting research awareness on medical, psychological, and social issues concerning women affected by cerebrocardiovascular disease. In this paper, we deal with only cerebrovascular disease, whereas cardiovascular disorders will be addressed in a future paper. Gender differences in the clinical presentation of cerebrovascular diseases have been repeatedly suggested, and some treatment options may not be as effective and safe in men and women. For many years, women have either been underrepresented or excluded from randomized clinical trials, and the majority of therapeutic research has been carried on predominantly male populations. Furthermore, gender differences have been shown to contribute to different responses to cerebrovascular drugs in women when compared with men, regarding pharmacokinetics, pharmacodynamics, and physiology. In this statement, we discuss main research fields relevant to Women Stroke Association's mission and commitment, highlighting opportunities and critical from the women's health perspective. Future directions and goals of the Women Stroke Association arise from these considerations and represent the association's commitment to combating stroke.

Sex-related differences of acute stroke unit care: results from the Austrian stroke unit registry

BACKGROUND AND PURPOSE

Sex-related differences in quality of acute stroke care are an important concern with limited data available, specifically regarding stroke unit (SU) setting. We used the prospective nationwide Austrian SU registry to address this issue.

METHODS

Our analysis covered an 8-year time period (January 2005 to December 2012) during which all patients with transient ischemic attack or ischemic stroke admitted to 1 of 35 Austrian SU had been captured in the registry. These data were analyzed for age-adjusted preclinical and clinical characteristics and quality of acute stroke care in men and women. In addition, we assessed the outcome at 3 months in multivariate analysis.

RESULTS

A total of 47 209 individuals (47% women) had received SU care. Women were significantly older (median age: 77.9 versus 70.3 years), had higher pre-existing disability and more severe strokes. Correcting for age, no significant sex-related differences in quality of care were identified with comparable onset-to-door times, times to and rates of neuroimaging, as well as door-to-needle times and rates of intravenous thrombolysis (14.5% for both sexes). Despite equal acute stroke care and a comparable rate of neurorehabilitation, women had a worse functional outcome at 3-month follow-up (modified Rankin scale 3-5: odds ratio, 1.26; 95% confidence interval [1.17-1.36]), but a lower mortality (odds ratio, 0.70; 95% confidence interval [0.78-0.88]) after correcting for confounders.

CONCLUSIONS

We identified no disproportions in quality of care in the acute SU setting between men and women, but the outcome was significantly different. Further studies on the poststroke period including socioeconomic aspects are needed to clarify this finding.

Stroke experiences in weblogs: a feasibility study of sex differences

Background

Research on cerebral stroke symptoms using hospital records has reported that women experience more nontraditional symptoms of stroke (eg, mental status change, pain) than men do. This is an important issue because nontraditional symptoms may delay the decision to get medical assistance and increase the difficulty of correct diagnosis. In the present study, we investigate sex differences in the stroke experience as described in stories on weblogs.

Objective

The goal of this study was to investigate the feasibility of using the Internet as a source of data for basic research on stroke experiences.

Methods

Stroke experiences described in blogs were identified by using StoryUpgrade, a program that searches blog posts using a fictional prototype story. In this study, the prototype story was a description of a stroke experience. Retrieved stories coded by the researchers as relevant were used to update the search query and retrieve more stories using relevance feedback. Stories were coded for first- or third-person narrator, traditional and nontraditional patient symptoms, type of stroke, patient sex and age, delay before seeking medical assistance, and delay at hospital and in treatment.

Results

There were 191 relevant stroke stories of which 174 stories reported symptoms (52.3% female and 47.7% male patients). There were no sex differences for each traditional or nontraditional stroke symptom by chi-square analysis (all Ps>.05). Type of narrator, however, affected report of traditional and nontraditional symptoms. Female first-person narrators (ie, the patient) were more likely to report mental status change (56.3%, 27/48) than male first-person narrators (36.4%, 16/44), a marginally significant effect by logistic regression (P=.056), whereas reports of third-person narrators did not differ for women (27.9%, 12/43) and men (28.2%, 11/39) patients. There were more reports of at least 1 nontraditional symptom in the 92 first-person reports (44.6%, 41/92) than in the 82 third-person reports (25.6%, 21/82, P=.006). Ischemic or hemorrhagic stroke was reported in 67 and 29 stories, respectively. Nontraditional symptoms varied with stroke type with 1 or more nontraditional symptoms reported for 79.3% (23/29) of hemorrhagic stroke patients and 53.7% (36/67) of ischemic stroke patients (P=.001).

Conclusions

The results replicate previous findings based on hospital interview data supporting the reliability of findings from weblogs. New findings include the effect of first- versus third-person narrator on sex differences in the report of nontraditional symptoms. This result suggests that narrator is an important variable to be examined in future studies. A fragmentary data problem limits some conclusions because important information, such as age, was not consistently reported. Age trends strengthen the feasibility of using the Internet for stroke research because older adults have significantly increased their Internet use in recent years.

Cerebral ischemic stroke: is gender important?

Cerebral stroke continues to be a major cause of death and the leading cause of long-term disability in developed countries. Evidence reviewed here suggests that gender influences various aspects of the clinical spectrum of ischemic stroke, in terms of influencing how a patients present with ischemic stroke through to how they respond to treatment. In addition, this review focuses on discussing the various pathologic mechanisms of ischemic stroke that may differ according to gender and compares how intrinsic and hormonal mechanisms may account for such gender differences. All clinical trials to date investigating putative neuroprotective treatments for ischemic stroke have failed, and it may be that our understanding of the injury cascade initiated after ischemic injury is incomplete. Revealing aspects of the pathophysiological consequences of ischemic stroke that are gender specific may enable gender relevant and effective neuroprotective strategies to be identified. Thus, it is possible to conclude that gender does, in fact, have an important role in ischemic stroke and must be factored into experimental and clinical investigations of ischemic stroke.

Gender differences in the clinical characteristics of Saudi heart failure patients with subsequent stroke

BACKGROUND AND OBJECTIVES

Studies about stroke in Saudi Arabia are limited. This retrospective study aims to determine the clinical characteristics of Saudi patients with heart failure (HF) with and without subsequent stroke, and also to find out whether gender differences exist in the presentation of HF patients who had stroke.

DESIGN AND SETTINGS

Retrospective study done at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia, from 2002-2008.

PATIENTS AND METHODS

A total of 293 patient (151 males, 142 females) charts from 2002-2008 were re.viewed at KAMC. These charts were from Saudi patients who were diagnosed with HF, with and without subsequent stroke. Demographics, HF characteristics, stroke risk factors, and metabolic characteristics were noted and analyzed.

RESULTS

No difference was observed in HF characteristics and stroke risk factors among HF patients with and without subsequent stroke. In terms of metabolic profile, those who had stroke had significantly higher low-density lipoprotein (LDL)--cholesterol levels as compared to those without (P=.03). Stratification to gender and adjusting for age and risk factors revealed that significantly higher LDL-cholesterol and total cholesterol levels were observed in female stroke patients (P values .02, .028, respectively) and significantly higher blood urea nitrogen levels were observed in male stroke patients (P=.04) as compared to their counterparts who never had a stroke.

CONCLUSION

The gender differences in the metabolic presentation of Saudi HF patients with stroke warrant further clinical investigation. Atherogenic dyslipidemia and renal insufficiency are suggested to be early predic.tors for stroke and should be closely monitored in Saudi HF patients.

Sex differences in stroke case fatality: a meta-analysis

BACKGROUND

In recent years, there were great controversies about gender disparities in stroke outcome. The study was aimed to investigate sex differences in stroke case fatality on all published studies based in a comprehensive meta-analysis.

METHODS

A systematic search of Pubmed, EMBASE, SCOPUS, ISI Web of Science, and Cochrane Library was conducted for the included papers between 1992 and 2009. For the pooled group and subgroup analysis, fixed effects or random effects model were used to find sex differences in case fatality of stroke with a Mantel-Haenszel method. Meta-regression analysis was performed to study methodological heterogeneity.

RESULTS

Thirty-six population-based studies, together with three randomized clinical trials (RCTs), were included in the present study. For the pooled group, there was an overall hazard risk of 1.13 for women compared with men. A hazard risk of 1.27 was observed for women in RCTs subgroup and 1.12 for women in population-based subgroup. The regression analysis found no significant correlation between methodological variables and heterogeneity.

CONCLUSIONS

Due to the limited data about sex differences in stroke case fatality, the findings should be treated cautiously as preliminary. More large multicenter clinical trials should be performed to verify the reliability of the results.

Sex differences in revascularization interventions after acute ischemic stroke

BACKGROUND

Studies suggest that women are less likely than men to receive intravenous (IV) tissue plasminogen activator (tPA) for acute ischemic stroke (AIS). Relatively little is known about whether this sex disparity in AIS management extends beyond IV tPA use, reflects national practice patterns, or is changing.

METHODS

Data from the Nationwide Inpatient Sample from 1997 to 2006 were used to identify adults (≥18 years of age) who were discharged with a primary diagnosis of AIS (n = 4,453,207) in the United States. Of 605,960 individuals admitted to 1056 hospitals that performed reperfusion/revascularization procedures, sex-specific rates of cerebrovascular reperfusion (e.g., IV tPA, intra-arterial therapy, angioplasty, stent, or carotid endarterectomy [CEA]), and cardiac reperfusion (e.g., catheterization, angioplasty, stent, or bypass graft) were determined before and after adjustment for sociodemographic, clinical, and hospital factors.

RESULTS

Men were more likely than women to receive IV tPA (prevalence ratio [PR] 1.37, 95% confidence interval [CI] 1.32-1.42), catheter angiography (PR 1.36, 95% CI 1.33-1.38), intracranial or extracranial angioplasty/stent (PR 1.73, 95% CI 1.49-2.01), CEA (PR 1.79, 95% CI 1.72-1.86), or any cardiac reperfusion therapy (PR 1.62, 95% CI 1.53-1.71). Multivariable adjustment slightly attenuated the sex disparity. Use of all procedures except CEA rose from 1997 to 2006 in both sexes, but IV tPA use increased at a higher rate for women (compared to men); by 2006, there was no sex difference.

CONCLUSIONS

Over the last decade, women hospitalized for AIS in the United States were less likely than men to receive cerebrovascular and cardiac reperfusion therapies. However, the IV tPA treatment sex disparity may have been eliminated.

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.

Sex differences and hemoglobin levels in relation to stroke outcomes

OBJECTIVE

Women have worse outcomes after stroke compared to men. Since women have lower hemoglobin values, we examined whether hemoglobin levels may associate with worse stroke outcomes in women.

METHODS

We retrospectively studied 274 patients enrolled in a prospective multicenter study. We explored the relationship of hemoglobin with clinical outcome at 6 months, as measured by the modified Rankin Scale (mRS). Ordinal logistic regression was used to evaluate the independent effect of hemoglobin on clinical outcome, and to explore the influence of sex on that association.

RESULTS

Women had a lower mean hemoglobin level (11.7 ± 1.8 g/dL) compared to men (13.3 ± 1.7 g/dL). Low hemoglobin was associated with worse 6-month mRS outcomes in univariate analysis (p < 0.001). Lower hemoglobin remained independently associated with poor outcome after adjustment for comorbid disease, stroke severity, age, and sex. The inclusion of hemoglobin in the model attenuated the independent effect of sex on outcome.

CONCLUSIONS

Sex differences in stroke outcome are linked to lower hemoglobin level, which is more prevalent in women. Further examination of this potentially modifiable predictor is warranted.

Carotid artery stenosis as a cause of stroke

BACKGROUND

Population-based studies have estimated that about 15% of ischemic strokes are caused by large-vessel cerebrovascular disease. We determined the types of large-vessel atherosclerosis responsible for ischemic strokes in a population-based stroke study.

METHODS

Patients with first-ever or recurrent ischemic stroke in the Greater Cincinnati area were identified during 2005 at all local hospitals. Study physicians assigned ischemic stroke subtypes. Overall event rates and incidence rates for first-ever events were calculated, and age-, race- and sex-adjusted to the 2000 US population.

RESULTS

There were 2,204 ischemic strokes, including 365 strokes of large-vessel subtype (16.6% of all ischemic strokes). Extracranial internal carotid artery (ICA) stenosis was associated with 8.0% of all ischemic strokes, while extracranial ICA occlusion and intracranial atherosclerosis were each associated with 3.5% of strokes. The annual rate of first-ever and recurrent stroke attributed to extracranial ICA was 13.4 (11.4-15.4) per 100,000 persons. We conservatively estimate that about 41,000 strokes may be attributed to extracranial ICA stenosis annually in the United States.

CONCLUSIONS

Large-vessel atherosclerosis is an important cause of stroke, with extracranial ICA stenosis being significantly more common than extracranial ICA occlusion or intracranial atherosclerotic disease.

Lower use of carotid artery imaging at minority-serving hospitals

OBJECTIVE

We determined whether site of care explains a previously identified racial disparity in carotid artery imaging.

METHODS

In this retrospective cohort study, data were obtained from a chart review of veterans hospitalized with ischemic stroke at 127 Veterans Administration hospitals in 2007. Extensive exclusion criteria were applied to obtain a sample who should have received carotid artery imaging. Minority-serving hospitals were defined as the top 10% of hospitals ranked by the proportion of stroke patients who were black. Population level multivariate logistic regression models with adjustment for correlation of patients in hospitals were used to calculate predictive probabilities of carotid artery imaging by race and minority-service hospital status. Bootstrapping was used to obtain 95% confidence intervals (CIs).

RESULTS

The sample consisted of 1,534 white patients and 628 black patients. Nearly 40% of all black patients were admitted to 1 of 13 minority-serving hospitals. No racial disparity in receipt of carotid artery imaging was detected within nonminority serving hospitals. However, the predicted probability of receiving carotid artery imaging for white patients at nonminority-serving hospitals (89.7%, 95% CI [87.3%, 92.1%]) was significantly higher than both white patients (78.0% [68.3%, 87.8%] and black patients (70.5% [59.3%, 81.6%]) at minority-serving hospitals.

CONCLUSIONS

Underuse of carotid artery imaging occurred most often among patients hospitalized at minority-serving hospitals. Further work is required to explore why site of care is a mechanism for racial disparities in this clinically important diagnostic test.

Sexual dimorphism in ischemic stroke: lessons from the laboratory

Ischemic stroke is emerging as a major health problem for elderly women. Women have lower stroke incidence than men until an advanced age, when the epidemiology of ischemic stroke shifts and incidence rises dramatically in women. Experimental models of rodent stroke have replicated this clinical epidemiology, with exacerbated injury in older compared with young female rodents. Many of the detrimental effects of aging on ischemic stroke outcome in females can be replicated by ovariectomy, suggesting that hormones such as estrogen play a neuroprotective role. However, emerging data suggest that the molecular mechanisms leading to ischemic cell death differ in the two sexes, and these effects may be independent of circulating hormone levels. This article highlights recent clinical and experimental literature on sex differences in stroke outcomes and mechanisms.

Gender differences in presenting signs and symptoms of acute ischemic stroke: a population-based study

BACKGROUND

There are few population-based data regarding gender differences in signs and symptoms of acute ischemic stroke, and previously reported data have been inconsistent and conflicting.

OBJECTIVE

The goal of this study was to address the gender differences of the presenting signs and symptoms of acute ischemic stroke in a population-based study.

METHODS

All patients with first ischemic stroke occurring between 1985 and 1989 were identified; subjects were residents of Rochester, Minnesota. Signs and symptoms were collected via review of comprehensive medical records. Differences were identified using the Pearson χ(2) test.

RESULTS

A total of 449 cases of first ischemic stroke were identified; 268 (60%) were women. Symptoms at ischemic stroke presentation differed between men and women. Women more commonly presented with generalized weakness (P = 0.005) and mental status change (P = 0.0001). Men more commonly presented with paresthesia (P = 0.003), ataxia (P = 0.006), and double vision (P = 0.005). Signs at ischemic stroke presentation differed between men and women. Men more commonly presented with nystagmus (P = 0.002) on examination. Significant trends were that women more commonly presented with fatigue (P = 0.02), disorientation (P = 0.04), and fever (P = 0.02), whereas men more commonly presented with sensory abnormalities (P = 0.02).

CONCLUSIONS

There were gender differences in signs and symptoms at presentation of ischemic stroke in these study patients. In addition to selected focal symptoms, women more commonly presented with diffuse symptoms of generalized weakness, fatigue, disorientation, and mental status change.

Demographic and stroke-related factors as predictors of quality of acute stroke care provided by allied health professionals

Background:

We recently indicated that patient age on its own is not a determinant of quality of allied health care received after an acute stroke. It has not been tested whether other non-age variables influence care decisions made by allied health professionals. This paper explores demographic and stroke-related variables that are putatively associated with the quality of care provided to acute stroke patients by allied health professionals.

Methods:

Data were retrospectively audited from 300 acute stroke patient records regarding allied health care. Compliance with each of 20 indicators of allied health care quality was established. The influence of various demographic and stroke-related variables on each performance indicator was examined. We undertook a series of analyses using univariate logistic regression models to establish the influence of these variables on care quality.

Results:

Patient age had a significant correlation with only one process indicator (early mobilization). Seven variables, including stroke severity and level of dependence, were associated with patient age. The majority of these age proxies had significant associations with process indicator compliance. Correlations between non-age variables, in particular stroke severity and comorbidity, suggest the potential for complex confounding relationships between non-age variables and quality of allied health care.

Conclusion:

Compliance with individual indicators of allied health care was significantly associated with variables other than patient age, and included stroke severity, previous independence, comorbidities, day of admission, stroke unit admission, and length of stay. The inter-relationships between these non-age variables suggest that their influence on quality of care is complex.

Age and gender as predictors of allied health quality stroke care

Background:

Improvement in acute stroke care requires the identification of variables which may influence care quality. The nature and impact of demographic and stroke-related variables on care quality provided by allied health (AH) professionals is unknown.

Aims:

Our research explores the association of age and gender on an index of acute stroke care quality provided by AH professionals.

Methods:

A retrospective clinical audit of 300 acute stroke patients extracted data on AH care, patients’ age and gender. AH care quality was determined by the summed compliance with 20 predetermined process indicators. Our analysis explored relationships between this index of quality, age, and gender. Age was considered in different ways (as a continuous variable, and in different categories). It was correlated with care quality, using gender-specific linear and logistic regression models. Gender was then considered as a confounder in an overall model.

Results:

No significant association was found for any treatment of age and the index of AH care quality. There were no differences in gender-specific models, and gender did not significantly adjust the age association with care quality.

Conclusion:

Age and gender were not predictors of the quality of care provided to acute stroke patients by AH professionals.

Sex differences in risk factors, etiology, and short-term outcome of cerebral infarction in young patients

Investigations to date have demonstrated that the underlying etiology, causes and burden of stroke may be different for women and men. However, data regarding sex differences among young cerebral ischemic stroke patients remains scarce. We conducted this study in 669 young Chinese adults with acute ischemic stroke as determined by the modified Rankin Scale at discharge. Stepwise multiple logistic regression analysis confirmed that NIHSS score (OR 1.277; 95% CI 1.179-1.383, p=0.000), diabetes mellitus (OR 0.121; 95% CI 0.0209-0.718, p=0.020) and serum glucose levels on admission (OR 1.135; 95% CI 0.997-1.293, p=0.046) independently predict short-term outcomes at discharge in young female patients with acute stroke, but the significant variables related to male patients appeared to be Apo A1 (OR 0.165; 95% CI 0.035-0.776, p=0.023) and NIHSS score on admission (OR 1.458; 95% CI 1.325-1.605, p=0.000). In our series, our data suggest that there are several sex differences for risk of cerebral infarction in young patients, which have important implications for the diagnosis, management and prognosis of stroke in young adults.

Gender differences in stroke care and outcomes in Ontario

BACKGROUND

Studies of potential gender differences in stroke care and outcomes have yielded inconsistent findings. The Project for an Ontario Women's Health Evidence-based Report study measured established stroke care indicators in a large, representative sample of women and men with stroke or transient ischemic attack (TIA) admitted to acute care institutions in the province of Ontario, Canada.

METHODS

The Registry of the Canadian Stroke Network performs a biennial audit on a random sample of 20% of patients with stroke or TIA seen at more than 150 acute care institutions across Ontario. We used data from the 2004/05 audit to compare stroke care by gender, with stratification by age and neighborhood income.

RESULTS

The sample consisted of 4,046 patients (51% women). There were no significant gender differences in the use of thrombolysis, neuroimaging, carotid imaging, dysphagia screening, antithrombotic therapy, or neurology and other consultations. Women with ischemic stroke or TIA were less likely than men to be prescribed statins or undergo carotid imaging and endarterectomy within 6 months of stroke; women were more likely than men to receive antihypertensives. There were no significant gender differences in readmission or mortality rates after stroke.

INTERPRETATION

In this population-based study, we found little evidence of gender differences in stroke care or outcomes other than lipid-lowering therapy, carotid imaging, and endarterectomy. Further study is needed to assess the contribution of the provincial stroke strategy in eliminating gender differences in management of acute stroke and to better understand and target remaining gender differences in management.

The association between arsenic exposure from drinking water and cerebrovascular disease mortality in Taiwan

BACKGROUND

Chronic arsenic exposure is associated with a variety of diseases, including cancer, peripheral vascular disease, and diabetes. However, its association with cerebrovascular diseases (CVD) has not yet been resolved. The aim of this study is to explore this association in Taiwan using nation-wide data.

MATERIALS AND METHODS

We analyzed mortality data in Taiwan from 1971 to 2005 and choose two geographic areas with populations suffering from chronic exposure to arsenic in drinking water for study, the blackfoot disease endemic area (BFDEA) in the southwest and Lan-Yang Basin (LYB) in the northeast parts of Taiwan. The Chia-Yi and Tainan Counties, which surround the BFDEA, and the nation of Taiwan as a whole were used as reference populations. Direct standardized mortality rates and gender-specific indirect standardized mortality ratios (SMRs) were calculated for the four populations.

RESULTS

The direct standardized mortality rate for CVD in Taiwan decreased from 2.46/10(3) person-year in 1971 to 0.63/10(3) person-year in 2005, and women had significantly lower mortality than men (SMR = 0.80; p < 0.05). The CVD mortality rates of populations with chronic arsenic exposure were significantly higher than the reference populations (SMR ranging from 1.06 to 1.09 in men and 1.12 to 1.14 in women; p < 0.05). The BFDEA had higher CVD mortality rates than the LYB, with SMR = 1.05 (p < 0.05) in men and SMR = 1.04 (p = 0.05) in women.

CONCLUSION

In Taiwan, while CVD mortality decreased in both genders between 1971 and 2005, chronic arsenic exposure from drinking water was associated with increased risks of CVD.

Effect of sex on outcome after recurrent stroke in African Americans: results from the African American Antiplatelet Stroke Prevention Study

BACKGROUND

Sex-related disparities in stroke have been previously reported. However, the influence of sex on the outcome of recurrent stroke in African Americans is less clear. Our objective was to investigate the effect of sex on the outcome of recurrent nonfatal stroke in the African American Antiplatelet Stroke Prevention Study (AAASPS).

METHODS

The AAASPS is a double-blind, randomized, controlled trial of recurrent stroke prevention in African Americans. Participants (967 women and 842 men) with noncardioembolic ischemic stroke were assigned to receive ticlopidine or aspirin and were followed up for up to 2 years. The National Institutes of Health Stroke Scale (NIHSS) score, modified Barthel score (mBS), and Glasgow Outcome Scale (GOS) score were determined at enrollment, at prespecified times thereafter, and at the time of recurrent stroke. Survival analysis was used to test for a significant difference in the time to recurrent stroke between women and men.

RESULTS

Of the total 1809 subjects enrolled in AAASPS, 186 (89 women and 97 men) experienced recurrent nonfatal stroke. At enrollment, the NIHSS score (2.87 for women and 3.00 for men; P=.73), the mBS (18.26 for women and 18.52 for men; P=.47) and the GOS score (1.49 for women and 1.51 for men; P=.86) were not significantly different. In follow-up and at the time of stroke recurrence, the NIHSS score, mBS, and GOS score were similar for both groups, except for the mBS at the 6-month visit, which was lower in women (18.49) than in men (19.37) (P=.02). In the survival analysis, no significant difference in the time to recurrent stroke was found between women and men (P=.69).

CONCLUSIONS

Although sex-related stroke disparities have been reported, in the AAASPS cohort outcomes for recurrent nonfatal noncardioembolic ischemic stroke for women were not significantly different than for men. Differences in study populations and methodologies may explain discrepancies in results from the various studies.

Gender differences in patients with acute ischemic stroke

Stroke has a greater effect on women than men owing to the fact that women have more stroke events and are less likely to recover. Age-specific stroke rates are higher in men; however, because of women's longer life expectancy and the much higher incidence of stroke at older ages, women have more stroke events than men overall. The aims of this prospective study in consecutive patients were to assess whether there are gender differences in stroke risk factors, treatment or outcome. Consecutive patients with ischemic stroke were included in this prospective study at four study centers. Disability was assessed using a modified Rankin Scale score (>or=3 indicating disabling stroke) in both genders at 90 days. Outcomes and risk factors in both genders were compared using the chi(2) test. Multiple logistic regression analysis was used to identify any independent predictors of outcome. A total of 1136 patients were included in this study; of these, 494 (46%) were female. Women were statistically older compared with men: 76.02 (+/- 12.93) and 72.68 (+/- 13.27) median years of age, respectively. At admission, females had higher NIH Stroke Scale scores compared with males (9.4 [+/- 6.94] vs 7.6 [+/- 6.28] for men; p = 0.0018). Furthermore, females tended to have more cardioembolic strokes (153 [30%] vs 147 [23%] for men; p = 0.004). Males had lacunar and atherosclerotic strokes more often (146 [29%] vs 249 [39%] for men; p = 0.002, and 68 [13%] vs 123 [19%] for men; p = 0.01, respectively). The mean modified Rankin Scale score at 3 months was also significantly different between genders, at 2.5 (+/- 2.05) for women and 2.1 (+/- 2.02) for men (p = 0.003). However, at multivariate analysis, female gender was not an indicator for negative outcome. It was concluded that female gender was not an independent factor for negative outcome. In addition, both genders demonstrated different stroke pathophysiologies. These findings should be taken into account when diagnostic workup and treatment are being planned.

Emergency department arrival times, treatment, and functional recovery in women with acute ischemic stroke

BACKGROUND

Sex disparities have been well documented in patients with ischemic stroke. Previous studies have suggested that female sex is a risk factor for delay in arrival time to the emergency department (ED) and may contribute to ineligibility for thrombolytic therapy. With the increase in education efforts targeting women, we investigated whether ED arrival times, rates of thrombolytic use, and functional outcomes continue to differ in men and women with acute ischemic stroke (AIS).

METHODS

This study was a retrospective database analysis of patients with AIS (2001-2008). All AIS patients presenting within 24 hours with a known time of symptom onset and a documented admission National Institutes of Health Stroke Scale (NIHSS) were included. The Modified Barthel Index (MBI) assessed patients' functional status preadmission (historical), admission, and at 3 and 12 months poststroke.

RESULTS

Included in the analysis were 480 (50.6%) women and 468 (49.4%) men. Women were significantly older than men (70.6 +/- 0.7 vs. 65.3 years +/- 0.6, p

CONCLUSIONS

Women arrive at the ED at equivalent speed as men after AIS. Women had greater functional impairments at 3 months and 12 months poststroke despite equivalent prestroke MBI and admission NIHSS. Female sex contributes to poorer chronic functional outcomes after AIS.

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MESH Headings

• Acute Disease
• Age Factors
• Aged
• Brain Ischemia/therapy
• Databases, Factual
• Emergency Service, Hospital/statistics & numerical data
• Female
• Humans
• Male
• Outcome and Process Assessment, Health Care
• Patient Admission/statistics & numerical data
• Patient Admission/trends
• Recovery of Function
• Retrospective Studies
• Risk Factors
• Sex Factors
• State Medicine
• Time Factors

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Grants

• R01 NS050505 NINDS NIH HHS
• R01 NS055215 NINDS NIH HHS
• R0I NS050505 NINDS NIH HHS
• R0I NS055215 NINDS NIH HHS

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Affiliation(s)

Wesley Knauft Department of Neurology, Yale University, New Haven, Connecticut
Jyoti Chhabra Research Program, Hartford Hospital, Hartford, Connecticut
Louise D. McCullough Department of Neurology and Neuroscience, University of Connecticut Health Center, Farmington, Connecticut

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