Sex Differences in Outcome After Endovascular Stroke Therapy for Acute Ischemic Stroke

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Abstract

We determine the effect of sex on outcome after endovascular stroke therapy (EST) in acute ischemic stroke (AIS), including lifelong disability outcomes. We analyzed patients treated with the Solitaire stent retriever in the combined SWIFT, STAR, and SWIFT-PRIME cohorts. Ordinal and logistic regression were used to examine known factors influencing outcome after EST and study the effect of sex on the association between these factors and outcomes, including age and time to reperfusion. Years of optimal life after thrombectomy were defined as disability adjusted life-year (DALYs) and calculated by projecting disability through adjusted post-stroke life expectancy (LE) by sex. Among 389 patients treated with EST, 55% were females, and median NIHSS was 17 [IQR 8–28]. There were no differences between females vs. males in presenting deficit severity (NIHSS 17 vs. 17, p=0.21), occlusion location (69% vs. 64% M1, p=0.62), presenting infarct extent (ASPECTS 8 vs. 8, p=0.24), rate of substantial reperfusion (TICI 2b/3, 87% vs. 83%, p=0.37), onset to reperfusion time (294 vs. 302 mins, p=0.46). Despite older ages (69 vs. 64, p<0.001) and higher rate of atrial fibrillation (45% vs. 30%, p=0.002) for females compared to males, adjusted rates of functional independence at 90 days were similar (odds ratio, 1.0; 95% CI, 0.6–1.6). After adjusting for age at presentation and stroke severity, females had more years of optimal life (DALYs) following EST, 10.6 vs. 8.5 years (p<0.001). Despite greater age and higher rate of atrial fibrillation, females experienced comparable functional outcomes and greater years of optimal life after intervention compared to males.

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Sex differences in stroke epidemiology: a systematic review.

Peter Appelros, Birgitta Stegmayr, Andreas Terént (2009)

Epidemiological studies, mainly based on Western European surveys, have shown that stroke is more common in men than in women. In recent years, sex-specific data on stroke incidence, prevalence, subtypes, severity and case-fatality have become available from other parts of the world. The purpose of this article is to give a worldwide review on sex differences in stroke epidemiology. We searched PubMed, tables-of-contents, review articles, and reference lists for community-based studies including information on sex differences. In some areas, such as secular trends, ischemic subtypes and stroke severity, noncommunity-based studies were also reviewed. Male/female ratios were calculated. We found 98 articles that contained relevant sex-specific information, including 59 incidence studies from 19 countries and 5 continents. The mean age at first-ever stroke was 68.6 years among men, and 72.9 years among women. Male stroke incidence rate was 33% higher and stroke prevalence was 41% higher than the female, with large variations between age bands and between populations. The incidence rates of brain infarction and intracerebral hemorrhage were higher among men, whereas the rate of subarachnoidal hemorrhage was higher among women, although this difference was not statistically significant. Stroke tended to be more severe in women, with a 1-month case fatality of 24.7% compared with 19.7% for men. Worldwide, stroke is more common among men, but women are more severely ill. The mismatch between the sexes is larger than previously described.

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Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study).

P M Rothwell, A Coull, M F Giles … (2004)

The incidence of stroke is predicted to rise because of the rapidly ageing population. However, over the past two decades, findings of randomised trials have identified several interventions that are effective in prevention of stroke. Reliable data on time-trends in stroke incidence, major risk factors, and use of preventive treatments in an ageing population are required to ascertain whether implementation of preventive strategies can offset the predicted rise in stroke incidence. We aimed to obtain these data. We ascertained changes in incidence of transient ischaemic attack and stroke, risk factors, and premorbid use of preventive treatments from 1981-84 (Oxford Community Stroke Project; OCSP) to 2002-04 (Oxford Vascular Study; OXVASC). Of 476 patients with transient ischaemic attacks or strokes in OXVASC, 262 strokes and 93 transient ischaemic attacks were incident events. Despite more complete case-ascertainment than in OCSP, age-adjusted and sex-adjusted incidence of first-ever stroke fell by 29% (relative incidence 0.71, 95% CI 0.61-0.83, p=0.0002). Incidence declined by more than 50% for primary intracerebral haemorrhage (0.47, 0.27-0.83, p=0.01) but was unchanged for subarachnoid haemorrhage (0.83, 0.44-1.57, p=0.57). Thus, although 28% more incident strokes (366 vs 286) were expected in OXVASC due to demographic change alone (33% increase in those aged 75 or older), the observed number fell (262 vs 286). Major reductions were recorded in mortality rates for incident stroke (0.63, 0.44-0.90, p=0.02) and in incidence of disabling or fatal stroke (0.60, 0.50-0.73, p<0.0001), but no change was seen in case-fatality due to incident stroke (17.2% vs 17.8%; age and sex adjusted relative risk 0.85, 95% CI 0.57-1.28, p=0.45). Comparison of premorbid risk factors revealed substantial reductions in the proportion of smokers, mean total cholesterol, and mean systolic and diastolic blood pressures and major increases in premorbid treatment with antiplatelet, lipid-lowering, and blood pressure lowering drugs (all p<0.0001). The age-specific incidence of major stroke in Oxfordshire has fallen by 40% over the past 20 years in association with increased use of preventive treatments and major reductions in premorbid risk factors.

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Sex Differences in Stroke Incidence, Prevalence, Mortality and Disability-Adjusted Life Years: Results from the Global Burden of Disease Study 2013

Suzanne Barker-Collo, Derrick A Bennett, Rita V Krishnamurthi … (2015)

Background: Accurate information on stroke burden in men and women are important for evidence-based healthcare planning and resource allocation. Previously, limited research suggested that the absolute number of deaths from stroke in women was greater than in men, but the incidence and mortality rates were greater in men. However, sex differences in various metrics of stroke burden on a global scale have not been a subject of comprehensive and comparable assessment for most regions of the world, nor have sex differences in stroke burden been examined for trends over time. Methods: Stroke incidence, prevalence, mortality, disability-adjusted life years (DALYs) and healthy years lost due to disability were estimated as part of the Global Burden of Disease (GBD) 2013 Study. Data inputs included all available information on stroke incidence, prevalence and death and case fatality rates. Analysis was performed separately by sex and 5-year age categories for 188 countries. Statistical models were employed to produce globally comprehensive results over time. All rates were age-standardized to a global population and 95% uncertainty intervals (UIs) were computed. Findings: In 2013, global ischemic stroke (IS) and hemorrhagic stroke (HS) incidence (per 100,000) in men (IS 132.77 (95% UI 125.34-142.77); HS 64.89 (95% UI 59.82-68.85)) exceeded those of women (IS 98.85 (95% UI 92.11-106.62); HS 45.48 (95% UI 42.43-48.53)). IS incidence rates were lower in 2013 compared with 1990 rates for both sexes (1990 male IS incidence 147.40 (95% UI 137.87-157.66); 1990 female IS incidence 113.31 (95% UI 103.52-123.40)), but the only significant change in IS incidence was among women. Changes in global HS incidence were not statistically significant for males (1990 = 65.31 (95% UI 61.63-69.0), 2013 = 64.89 (95% UI 59.82-68.85)), but was significant for females (1990 = 64.892 (95% UI 59.82-68.85), 2013 = 45.48 (95% UI 42.427-48.53)). The number of DALYs related to IS rose from 1990 (male = 16.62 (95% UI 13.27-19.62), female = 17.53 (95% UI 14.08-20.33)) to 2013 (male = 25.22 (95% UI 20.57-29.13), female = 22.21 (95% UI 17.71-25.50)). The number of DALYs associated with HS also rose steadily and was higher than DALYs for IS at each time point (male 1990 = 29.91 (95% UI 25.66-34.54), male 2013 = 37.27 (95% UI 32.29-45.12); female 1990 = 26.05 (95% UI 21.70-30.90), female 2013 = 28.18 (95% UI 23.68-33.80)). Interpretation: Globally, men continue to have a higher incidence of IS than women while significant sex differences in the incidence of HS were not observed. The total health loss due to stroke as measured by DALYs was similar for men and women for both stroke subtypes in 2013, with HS higher than IS. Both IS and HS DALYs show an increasing trend for both men and women since 1990, which is statistically significant only for IS among men. Ongoing monitoring of sex differences in the burden of stroke will be needed to determine if disease rates among men and women continue to diverge. Sex disparities related to stroke will have important clinical and policy implications that can guide funding and resource allocation for national, regional and global health programs.

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Author and article information

Journal

Title: Stroke

Abbreviated Title: Stroke

Publisher: Ovid Technologies (Wolters Kluwer Health)

ISSN (Print): 0039-2499

ISSN (Electronic): 1524-4628

Publication date Created: September 2019

Publication date (Print): September 2019

Volume: 50

Issue: 9

Pages: 2420-2427

Affiliations

[1 ]From the Department of Neurology, McGovern School of Medicine, University of Texas Health Science Center at Houston (S.A.S., S.L., L.D.M.)

[2 ]Department of Neurology, Dell School of Medicine, University of Texas at Austin (S.J.W.)

[3 ]Department of Neuroradiology, Inselspital, University Hospital, Berne, Switzerland (J.G.)

[4 ]Department of Radiological Sciences, Ronald Reagan UCLA Medical Center, Santa Monica (R.J.)

[5 ]Department of Radiology and Clinical Neurosciences, University of Calgary, AB, Canada (M.G.)

[6 ]Department of Neurology, Emory School of Medicine, Atlanta, GA (R.G.N.)

[7 ]Department of Neurosurgery, Mercy Health, Toledo, OH (O.O.Z.)

[8 ]Department of Medical Imaging, Toronto Western Hospital, ON, Canada (V.M.P.)

[9 ]Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, NY (A.S.)

[10 ]Department of Neurology, Oregon Health and Science University, Portland (H.L.).

[11 ]Department of Neurology, Ronald Reagan UCLA Medical Center, Santa Monica (D.S.L., J.L.S.)

Article

DOI: 10.1161/STROKEAHA.118.023867

PMC ID: 6710145

PubMed ID: 31412752

SO-VID: 3a67adbb-474a-46fc-9e81-cb4e673a82f3

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Sex Differences in Outcome After Endovascular Stroke Therapy for Acute Ischemic Stroke

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Most cited references 33

Sex differences in stroke epidemiology: a systematic review.

Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study).

Sex Differences in Stroke Incidence, Prevalence, Mortality and Disability-Adjusted Life Years: Results from the Global Burden of Disease Study 2013

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