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Otite FO, Morris N. Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke. Crit Care Clin 2024; 40:709-740. [PMID: 39218482 DOI: 10.1016/j.ccc.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.
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Affiliation(s)
- Fadar Oliver Otite
- Cerebrovascular Division, Upstate Neurological Institute, Syracuse, NY, USA.
| | - Nicholas Morris
- Neurocritical Care Division, Department of Neurology, University of Maryland, Baltimore, MD, USA
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Dylla L, Higgins HM, Stephenson D, Reisz JA, Vu T, Poisson SN, Herson PS, Monte AA. Sex Differences in the Blood Metabolome During Acute Response to Ischemic Stroke. J Womens Health (Larchmt) 2024; 33:1378-1384. [PMID: 38946610 DOI: 10.1089/jwh.2023.1133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Introduction: Females suffer greater lifetime risk of stroke and greater morbidity and mortality from stroke compared with males. This study's objective was to identify differences in metabolomic profiling of females and males with stroke and which differences were associated with neurological outcome. Methods: Females and males with acute ischemic stroke enrolled in the Emergency Medicine Specimen Bank at a comprehensive stroke center provided whole blood samples upon arrival for mass spectrometry-based metabolomics. We used descriptive statistics to characterize the cohort. A linear regression model was fit for individual metabolites to determine differences in relative abundance between males and females while controlling for covariates (age, race/ethnicity, postmenopausal status, cardiovascular risk factors, depression, time between sample collection and last known well, and initial National Institutes of Health Stroke Scale [NIHSS] score). For each differentially expressed metabolite, a linear regression model was fit to determine the association between the metabolite and NIHSS at 24 hours after admission while controlling for the covariates and acute treatments. Results: After adjusting for covariates, eight metabolites differed in females and males with a stroke. These included amino acids or their metabolites (proline and tryptophan), nucleotides (guanosine diphosphate [GDP], and inosine-3',5'-cyclic monophosphate), citrate, dehydroascorbate, choline, and acylcarnitine-(5-OH). GDP and dehydroascorbate were significantly associated with 24-hour NIHSS (p = 0.0991). Conclusions: Few metabolites were differentially abundant in blood after a stroke when comparing females with males and controlling for confounders, but the interactions between biological sex and GDP, as well as biological sex and dehydroascorbate, were associated with 24-hour neurological function. This has important implications for future studies that evaluate the therapeutic potential of these metabolites in ischemic stroke.
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Affiliation(s)
- Layne Dylla
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hannah M Higgins
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Daniel Stephenson
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julie A Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Thao Vu
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Sharon N Poisson
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Paco S Herson
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Andrew A Monte
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Rocky Mountain Poisson and Drug Center, Denver Health, Denver, Colorado, USA
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Chen H, Khunte M, Colasurdo M, Chaturvedi S, Malhotra A, Gandhi D. Mediators of sex-specific differences in rates of stroke mimics among patients treated with intravenous thrombolysis: A nationwide analysis of 174,995 patients. J Stroke Cerebrovasc Dis 2024; 33:108021. [PMID: 39303869 DOI: 10.1016/j.jstrokecerebrovasdis.2024.108021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 09/15/2024] [Accepted: 09/17/2024] [Indexed: 09/22/2024] Open
Abstract
INTRODUCTION Women are at higher risk of stroke mimics; however, the underlying reasons are unclear. METHODS In this retrospective cohort study of the 2016-2020 National Inpatient Sample database, we identified patients treated with intravenous thrombolysis (IVT). Demographic information, vascular risk factors, comorbidities, and presence of known risk factors for stroke mimics (seizures, migraines, demyelinating diseases, psychiatric illnesses, and functional neurological disorders [FND]) were identified using ICD-10 codes. Rates of no cerebral infarction (NCI) were compared between men and women. Mediation analyses were conducted to identify significant drivers of sex-specific differences in the rate of NCI. RESULTS 174,995 IVT-treated patients were identified; 41,605 (23.8 %) had NCI. Female patients had significantly higher rates of NCI compared to men (26.2 % vs. 20.9 %, p < 0.001). Women had significantly higher rates of stroke mimic risk factors (seizures, migraines, demyelinating disease, anxiety, depression, FND, and electrolyte derangements; all p < 0.001). Mediation analyses revealed that 39.8 %, 19.1 % of female sex's association with higher rates of NCI were mediated by higher rates of migraines and FND among women, respectively (both p < 0.001). CONCLUSIONS IVT-treated women were more likely to have NCI than men. This relationship was largely mediated by higher rates of migraine and FND among women.
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Affiliation(s)
- Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA; Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA; Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Mihir Khunte
- Warren Alpert Medical School, Brown University, Providence, RI, USA; Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Marco Colasurdo
- Department of Interventional Radiology, Oregon Health and Sciences University, Oregon, OR, USA
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Dheeraj Gandhi
- Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore, MD, USA; Department of Neurology, University of Maryland Medical Center, Baltimore, MD, USA
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Marko M, Miksova D, Haidegger M, Schneider J, Ebner J, Lang MB, Serles W, Kiechl S, Knoflach M, Sykora M, Ferrari J, Gattringer T, Greisenegger S. Trends in sex differences of functional outcome after intravenous thrombolysis in patients with acute ischemic stroke. Int J Stroke 2024:17474930241273696. [PMID: 39086256 DOI: 10.1177/17474930241273696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) is an approved treatment for patients with acute ischemic stroke irrespective of sex. However, the current literature on sex differences in functional outcomes following IVT is inconsistent. So far, a number of studies-including a previous analysis based on data from the Austrian Stroke Unit Registry (ASUR)-detected significant sex-related differences in functional outcome, while others did not report any differences between women and men. In addition, currently there is a lack of data on how sex-related differences evolve over time. AIMS To assess time trends of sex-related differences in functional outcome of ischemic stroke in a large nationwide cohort and to investigate associations of patient characteristics with functional outcome post thrombolysis in women and men. These data will offer crucial insights into whether sex differences in functional outcome persist despite the large advances in acute stroke treatment. METHODS We analyzed retrospective data of consecutive patients with acute ischemic stroke treated with IVT in 39 stroke centers contributing to the ASUR between 2006 and 2021. We included patients over 18 years of age diagnosed with an acute ischemic stroke who received IVT and with available data on functional outcome at 3 months after treatment. The primary outcome parameter was favorable functional outcome (modified Rankin Scale (mRS) of 0-2) at 3 months. Multivariable logistic regression analysis was performed in the overall population and stratified by sex to assess associations of baseline characteristics with functional outcome. RESULTS Among 11,840 patients receiving IVT, 2489 of 5503 (45.4%) women achieved favorable functional outcome compared to 3787 of 6337 (59.8%) men. Overall, female sex was a statistically significant predictor of functional outcome after thrombolysis, but additional predictors of outcome differed between women and men. Female sex was independently associated with decreased chances of achieving functional independency (adjusted odds ratio (adjOR) = 0.87, 95% confidence interval (CI) = 0.79-0.96, p = 0.005) and we detected a statistically significant improvement in functional outcome over time only in men (year of treatment, adjOR (per year) = 1.04, 95% CI = 1.02-1.06, p < 0.001) but not in women (adjOR (per year) = 1.01, 95% CI = 0.99-1.03, p = 0.280). Hypertension, smoking, and longer or unknown onset-to-door times were statistically significant predictors of outcome only in male patients, whereas atrial fibrillation, prior myocardial infarction, and longer door-to-needle times were significantly associated with outcome only in women. CONCLUSIONS Sex differences in functional outcome after IVT for acute ischemic stroke are persisting over the past years. Results of our analysis can increase awareness and a resulting focus on sex differences in predictors of outcome could be helpful in mitigating these differences in the future by supporting a more individualized patient care in clinical routine. Follow-up analyses are needed to assess this potential impact and its effect in the future. DATA ACCESS STATEMENT Data from the Austrian Stroke Unit Registry can only be accessed by the employed statistician (D.M.), access inquiries have to be addressed to the registry's academic review board.
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Affiliation(s)
- Martha Marko
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | | | | | - Jakob Schneider
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Johanna Ebner
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Marie B Lang
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Wolfgang Serles
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage-Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage-Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
| | - Marek Sykora
- Department of Neurology, Krankenhaus Barmherzige Brüder Wien, Wien, Austria
| | - Julia Ferrari
- Department of Neurology, Krankenhaus Barmherzige Brüder Wien, Wien, Austria
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van der Meij A, Holswilder G, Bernsen MLE, van Os HJA, Hofmeijer J, Spaander FHM, Martens JM, van den Wijngaard IR, Lingsma HF, Konduri PR, BLM Majoie C, Schonewille WJ, Dippel DWJ, Kruyt ND, Nederkoorn PJ, van Walderveen MAA, Wermer MJH. Sex differences in clot, vessel and tissue characteristics in patients with a large vessel occlusion treated with endovascular thrombectomy. Eur Stroke J 2024; 9:600-612. [PMID: 38420950 PMCID: PMC11418468 DOI: 10.1177/23969873241231125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION To improve our understanding of the relatively poor outcome after endovascular treatment (EVT) in women we assessed possible sex differences in baseline neuroimaging characteristics of acute ischemic stroke patients with large anterior vessel occlusion (LVO). PATIENTS AND METHODS We included all consecutive patients from the MR CLEAN Registry who underwent EVT between 2014 and 2017. On baseline non-contrast CT and CT angiography, we assessed clot location and clot burden score (CBS), vessel characteristics (presence of atherosclerosis, tortuosity, size, and collateral status), and tissue characteristics with the Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Radiological outcome was assessed with the extended thrombolysis in cerebral infarction score (eTICI) and functional outcome with the modified Rankin Scale score (mRS) at 90 days. Sex-differences were assessed with multivariable regression analyses with adjustments for possible confounders. RESULTS 3180 patients were included (median age 72 years, 48% women). Clots in women were less often located in the intracranial internal carotid artery (ICA) (25%vs 28%, odds ratio (OR) 0.85;95% confidence interval: 0.73-1.00). CBS was similar between sexes (median 6, IQR 4-8). Intracranial (aOR 0.73;95% CI:0.62-0.87) and extracranial (aOR 0.64;95% CI:0.43-0.95) atherosclerosis was less prevalent in women. Vessel tortuosity was more frequent in women in the cervical ICA (aOR 1.89;95% CI:1.39-2.57) and women more often had severe elongation of the aortic arch (aOR 1.38;95% CI:1.00-1.91). ICA radius was smaller in women (2.3vs 2.5 mm, mean difference 0.22;95% CI:0.09-0.35) while M1 radius was essentially equal (1.6vs 1.7 mm, mean difference 0.09;95% CI:-0.02-0.21). Women had better collateral status (⩾50% filling in 62%vs 53% in men, aOR 1.48;95% CI:1.29-1.70). Finally, ASPECT scores were equal between women and men (median 9 in both sexes, IQR 8-10vs 9-10). Reperfusion rates were similar between women and men (acOR 0.94;95% CI:0.83-1.07). However, women less often reached functional independence than men (34%vs 46%, aOR 0.68;95% CI:0.53-0.86). DISCUSSION AND CONCLUSION On baseline imaging of this Dutch Registry, men and women with LVO mainly differ in vessel characteristics such as atherosclerotic burden, extracranial vessel tortuosity, and collateral status. These sex differences do not result in different reperfusion rates and are, therefore, not likely to explain the worse functional outcome in women after EVT.
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Affiliation(s)
- Anne van der Meij
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Ghislaine Holswilder
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marie Louise E Bernsen
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Hendrikus JA van Os
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health & Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, The Netherlands
| | | | - Jasper M Martens
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Ido R van den Wijngaard
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Praneeta R Konduri
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marieke JH Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
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Wells B, Nasreldein A, Hall JR, Bachhuber M, Khedr EM, Abd-Allah F, Fassbender KC, van Wijck F, Walter S. Challenges in Prehospital Diagnosis of Acute Stroke in Women: A Case-Based Reflection. Stroke 2024; 55:e238-e241. [PMID: 38818722 DOI: 10.1161/strokeaha.124.046112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Affiliation(s)
- Brittany Wells
- Research Centre for Health, Glasgow Caledonian University, Scotland (B.W., J.R.H., F.v.W.)
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom (B.W., S.W.)
- Department of Neurology, Saarland University, Homburg, Germany (B.W., M.B., K.C.F., S.W.)
| | - Ahmed Nasreldein
- Department of Neurology, Assiut University Hospitals, Egypt (A.N., E.M.K.)
| | - Joseph R Hall
- Research Centre for Health, Glasgow Caledonian University, Scotland (B.W., J.R.H., F.v.W.)
| | - Monika Bachhuber
- Department of Neurology, Saarland University, Homburg, Germany (B.W., M.B., K.C.F., S.W.)
| | - Eman M Khedr
- Department of Neurology, Assiut University Hospitals, Egypt (A.N., E.M.K.)
| | - Foad Abd-Allah
- Department of Neurology, Kasralainy School of Medicine, Cairo University, Egypt (F.A.-A.)
| | - Klaus C Fassbender
- Department of Neurology, Saarland University, Homburg, Germany (B.W., M.B., K.C.F., S.W.)
| | - Frederike van Wijck
- Research Centre for Health, Glasgow Caledonian University, Scotland (B.W., J.R.H., F.v.W.)
| | - Silke Walter
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom (B.W., S.W.)
- Department of Neurology, Saarland University, Homburg, Germany (B.W., M.B., K.C.F., S.W.)
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Medlin F, Strambo D, Lambrou D, Caso V, Michel P. Service delivery in acute ischemic stroke patients: Does sex matter? Eur J Neurol 2024; 31:e16287. [PMID: 38553933 PMCID: PMC11235595 DOI: 10.1111/ene.16287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 07/28/2024]
Abstract
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.
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Affiliation(s)
- Friedrich Medlin
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University HospitalLausanneSwitzerland
- Stroke and Neurology UnitFribourg HospitalFribourgSwitzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University HospitalLausanneSwitzerland
| | - Dimitris Lambrou
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University HospitalLausanneSwitzerland
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia HospitalUniversity of PerugiaPerugiaItaly
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University HospitalLausanneSwitzerland
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Comer AR, Jawed A, Roeder H, Kramer N. The impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke. J Stroke Cerebrovasc Dis 2024; 33:107820. [PMID: 38876458 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVES In this review, we examine the impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke and discuss the current theories, available evidence, and gaps in the literature. METHODS A scoping review of the literature was conducted to determine gender differences on advanced stroke interventions and end-of-life outcomes after stroke. The study team utilized PubMed to conduct a review of the literature and included research studies related to sex, gender, advanced stroke interventions, and end-of-life outcomes after stroke. The PRISMA process for conducting a scoping review was followed. RESULTS This review found that although evidence regarding gender differences in advanced stroke interventions and end-of-life care after stroke is disparate, some gender differences do indeed exist. Women are less likely to receive thrombectomy or alteplase, women are more likely to receive palliative care intervention, hospice, and women experience stroke mortality at higher rates. CONCLUSIONS Gender differences in end-of-life care after stroke are apparent with women experiencing lower rates of life sustaining interventions, and higher rates of mortality, palliative and hospice care. More research is needed to identify variables associated with or responsible for gender differences during advance interventions and end-of-life care after stroke.
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Affiliation(s)
- Amber R Comer
- American Medical Association, Indiana University, United States.
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Pérez-Sánchez S, Barragán-Prieto A, Loscertales JB, Cabezas Rodríguez JA, Zapata-Arriaza E, Amaya Pascasio L, Hermosín Gómez A, Gamero García MÁ, Galeano B, Fernández J, Pardo Galiana B, Domínguez Mayoral A, Ainz Gómez L, Fernández Navarro J, Del Toro C, Medina M, de Torres R, Baena P, Moniche F, Valverde Moyano R, Martínez P, González A, Montaner J. Closing the Sex-Based Differences in Stroke Care: Insights from a Large Telestroke Network on Treatment and Postacute Management. Health Equity 2024; 8:301-306. [PMID: 39011077 PMCID: PMC11249131 DOI: 10.1089/heq.2023.0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 07/17/2024] Open
Abstract
Background The evolution of ischemic stroke is different accordin'g to sex and is one of the main causes of death in women. Previous studies have shown that women are less likely to receive acute treatment, and stroke center type is an important predictor of door-to-needle times. We investigated whether women are attended in a similar way to men in the telestroke network with specialized stroke physicians. Methods A prospective registry of ischemic strokes recorded in the centralized Andalusian telestroke network was analyzed, focusing on sex differences. Demographic data, clinical characteristics, neuroimaging data, treatment intervals, follow-up visits, and clinical outcomes were collected. Results A total of 3009 suspected stroke patients were attended to in the telestroke network from 2019 to 2023, of which 42.74% were women. Women were older (p < 0.001) and less independent upon arrival (p = 0.006) than men. There was no difference in the treatment received or in the treatment time intervals between the groups. Importantly, there was no difference in modified Rankin scale scores at 3 months between sexes. At 3 months post-stroke follow-up, women had fewer imaging tests (p = 0.018) and fewer outpatient visits (p < 0.001) than men. Conclusions No significant difference between men and women has been found in the acute treatment of stroke in a large telestroke network. However, the same is not true for the follow-up and management of patients after the acute phase. This fact supports that strict adherence to protocols and specialization of care lead to equal care that avoids sex differences in stroke treatment and functional outcomes.
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Affiliation(s)
- Soledad Pérez-Sánchez
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Ana Barragán-Prieto
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Juan Bautista Loscertales
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Juan Antonio Cabezas Rodríguez
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Elena Zapata-Arriaza
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | - Miguel Ángel Gamero García
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Benito Galeano
- Department of Neurology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Javier Fernández
- Department of Neurology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Blanca Pardo Galiana
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ana Domínguez Mayoral
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Leire Ainz Gómez
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Cristina Del Toro
- Department of Neurology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Manuel Medina
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Reyes de Torres
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Pablo Baena
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Francisco Moniche
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Patricia Martínez
- Department of Neurology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Alejandro González
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
- Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Joan Montaner
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Neurovascular Research Group, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
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10
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Kulasekere DA, Royan R, Shan Y, Reyes AM, Thomas AC, Lundberg AL, Feinglass JM, Stey AM. Appendicitis Hospitalization Care Costs Among Patients With Delayed Diagnosis of Appendicitis. JAMA Netw Open 2024; 7:e246721. [PMID: 38619839 PMCID: PMC11019393 DOI: 10.1001/jamanetworkopen.2024.6721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/17/2024] [Indexed: 04/16/2024] Open
Abstract
Importance Delayed appendicitis diagnosis is associated with worse outcomes. Appendicitis hospital care costs associated with delayed diagnosis are unknown. Objective To determine whether delayed appendicitis diagnosis was associated with increased appendicitis hospital care costs. Design, Setting, and Participants This cohort study used data from patients receiving an appendectomy aged 18 to 64 years in 5 states (Florida, Maryland, Massachusetts, New York, Wisconsin) that were captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department databases for the years 2016 and 2017 with no additional follow-up. Data were analyzed January through April 2023. Exposures Delayed diagnosis was defined as a previous emergency department or inpatient hospital encounter with an abdominal diagnosis other than appendicitis, and no intervention 7 days prior to appendectomy encounter. Main Outcomes and Measures The main outcome was appendicitis hospital care costs. This was calculated from aggregated charges of encounters 7 days prior to appendectomy, the appendectomy encounter, and 30 days postoperatively. Cost-to-charge ratios were applied to charges to obtain costs, which were then adjusted for wage index, inflation to 2022 US dollar, and with extreme outliers winsorized. A multivariable Poisson regression estimated appendicitis hospital care costs associated with a delayed diagnosis while controlling for age, sex, race and ethnicity, insurance status, care discontinuity, income quartile, hospital size, teaching status, medical school affiliation, percentage of Black and Hispanic patient discharges, core-based statistical area, and state. Results There were 76 183 patients (38 939 female [51.1%]; 2192 Asian or Pacific Islander [2.9%], 14 132 Hispanic [18.5%], 8195 non-Hispanic Black [10.8%], 46 949 non-Hispanic White [61.6%]) underwent appendectomy, and 2045 (2.7%) had a delayed diagnosis. Delayed diagnosis patients had median (IQR) unadjusted cost of $11 099 ($6752-$17 740) compared with $9177 ($5575-$14 481) for nondelayed (P < .001). Patients with delayed diagnosis had 1.23 times (95% CI, 1.16-1.28 times) adjusted increased appendicitis hospital care costs. The mean marginal cost of delayed diagnosis was $2712 (95% CI, $2083-$3342). Even controlling for delayed diagnosis, non-Hispanic Black patients had 1.22 times (95% CI, 1.17-1.28 times) the adjusted increased appendicitis hospital care costs compared with non-Hispanic White patients. Conclusions and Relevance In this cohort study, delayed diagnosis of appendicitis was associated with increased hospital care costs.
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Affiliation(s)
| | - Regina Royan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Ying Shan
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ana M. Reyes
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | | | - Alexander L. Lundberg
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Joe M. Feinglass
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anne M. Stey
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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11
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Anelli V, Armeni E, Paschou SA, Lambrinoudaki I. Statin use and incident type 2 diabetes mellitus in women after menopause. Maturitas 2024; 181:107914. [PMID: 38245965 DOI: 10.1016/j.maturitas.2024.107914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/06/2024] [Accepted: 01/09/2024] [Indexed: 01/23/2024]
Abstract
Menopause is associated with adverse cardiometabolic changes which increase the risk of new-onset type 2 diabetes (T2DM) and cardiovascular disease (CVD). Statins are widely used for primary and secondary CVD prevention, given their beneficial effects on the lipid profile and the vessel wall. On the other hand, statins increase the risk of T2DM. This association has been evaluated mainly in mixed-gender studies, without gender-specific evaluation. This narrative review evaluates the use of statins and the related risk of new-onset T2DM among postmenopausal women. Studies that incorporated a gender-specific analysis report a higher risk of new-onset T2DM in women than in men on treatment with statins. Fewer studies evaluated female-only samples; these confirm the observed association between statin use and new-onset T2DM. Factors influencing the association between statin use and T2DM include the type and dose of statin and the baseline metabolic status. Women may benefit from stratification of their metabolic risk before initiating a statin for CVD prevention.
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Affiliation(s)
- Valentina Anelli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Eleni Armeni
- 2nd Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece; Royal Free Hospital NHS Trust, Medical School, University College London, London, UK
| | - Stavroula A Paschou
- 2nd Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Irene Lambrinoudaki
- 2nd Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece.
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12
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Sandset EC, Hov MR, Walter S. Prehospital Stroke Detection in Women Is More Than Identifying LVOs. Stroke 2024; 55:555-557. [PMID: 38406857 DOI: 10.1161/strokeaha.124.046407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Affiliation(s)
- Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Norway (E.C.S., M.R.H.)
- The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S., M.R.H.)
- Institute of Clinical Medicine, University of Oslo, Norway (E.C.S.)
| | - Maren Ranhoff Hov
- Department of Neurology, Oslo University Hospital, Norway (E.C.S., M.R.H.)
- The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S., M.R.H.)
- Department of Health Science, Oslo Metropolitan University, Norway (M.R.H.)
| | - Silke Walter
- Department of Neurology, Saarland University, Saarbrücken, Germany (S.W.)
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13
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Ali M, Dekker L, Daems JD, Ali M, van Zwet EW, Steyerberg EW, Duvekot MHC, Nguyen TTM, Moudrous W, van de Wijdeven RM, Visser MC, de Laat KF, Kerkhoff H, van den Wijngaard IR, Dippel DWJ, Roozenbeek B, Kruyt ND, Wermer MJH. Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients With Suspected Stroke. Stroke 2024; 55:548-554. [PMID: 38299328 PMCID: PMC10896195 DOI: 10.1161/strokeaha.123.044898] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Differences in clinical presentation of acute ischemic stroke between men and women may affect prehospital identification of anterior circulation large vessel occlusion (aLVO). We assessed sex differences in diagnostic performance of 8 prehospital scales to detect aLVO. METHODS We analyzed pooled individual patient data from 2 prospective cohort studies (LPSS [Leiden Prehospital Stroke Study] and PRESTO [Prehospital Triage of Patients With Suspected Stroke Study]) conducted in the Netherlands between 2018 and 2019, including consecutive patients ≥18 years suspected of acute stroke who presented within 6 hours after symptom onset. Ambulance paramedics assessed clinical items from 8 prehospital aLVO detection scales: Los Angeles Motor Scale, Rapid Arterial Occlusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Cincinnati Prehospital Stroke Scale, Prehospital Acute Stroke Severity, gaze-face-arm-speech-time, Conveniently Grasped Field Assessment Stroke Triage, and Face-Arm-Speech-Time Plus Severe Arm or Leg Motor Deficit. We assessed the diagnostic performance of these scales for identifying aLVO at prespecified cut points for men and women. RESULTS Of 2358 patients with suspected stroke (median age, 73 years; 47% women), 231 (10%) had aLVO (100/1114 [9%] women and 131/1244 [11%] men). The area under the curve of the scales ranged from 0.70 (95% CI, 0.65-0.75) to 0.77 (95% CI, 0.73-0.82) in women versus 0.69 (95% CI, 0.64-0.73) to 0.75 (95% CI, 0.71-0.79) in men. Positive predictive values ranged from 0.23 (95% CI, 0.20-0.27) to 0.29 (95% CI, 0.26-0.31) in women versus 0.29 (95% CI, 0.24-0.33) to 0.37 (95% CI, 0.32-0.43) in men. Negative predictive values were similar (0.95 [95% CI, 0.94-0.96] to 0.98 [95% CI, 0.97-0.98] in women versus 0.94 [95% CI, 0.93-0.95] to 0.96 [95% CI, 0.94-0.97] in men). Sensitivity of the scales was slightly higher in women than in men (0.53 [95% CI, 0.43-0.63] to 0.76 [95% CI, 0.68-0.84] versus 0.49 [95% CI, 0.40-0.57] to 0.63 [95% CI, 0.55-0.73]), whereas specificity was lower (0.79 [95% CI, 0.76-0.81] to 0.87 [95% CI, 0.84-0.89] versus 0.82 [95% CI, 0.79-0.84] to 0.90 [95% CI, 0.88-0.91]). Rapid arterial occlusion evaluation showed the highest positive predictive values in both sexes (0.29 in women and 0.37 in men), reflecting the different event rates. CONCLUSIONS aLVO scales show similar diagnostic performance in both sexes. The rapid arterial occlusion evaluation scale may help optimize prehospital transport decision-making in men as well as in women with suspected stroke.
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Affiliation(s)
- Mariam Ali
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Luuk Dekker
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Jasper D Daems
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (J.D.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Erik W van Zwet
- Department of Biomedical Data Sciences (E.W.v.Z., E.W.S.), Leiden University Medical Center, the Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences (E.W.v.Z., E.W.S.), Leiden University Medical Center, the Netherlands
| | - Martijne H C Duvekot
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., H.K.)
| | - T Truc My Nguyen
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands (W.M.)
| | - Ruben M van de Wijdeven
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marieke C Visser
- Department of Neurology (M.C.V.)
- Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands (M.C.V.)
| | - Karlijn F de Laat
- Department of Neurology, Haga Hospital, the Hague, the Netherlands (K.F.d.L.)
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., H.K.)
| | - Ido R van den Wijngaard
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- Department of Neurology, Haaglanden Medical Center, the Hague, the Netherlands (I.R.v.d.W.)
- University Neurovascular Center Leiden-The Hague, the Netherlands (I.R.v.d.W., N.D.K.)
| | - Diederik W J Dippel
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- University Neurovascular Center Leiden-The Hague, the Netherlands (I.R.v.d.W., N.D.K.)
| | - Marieke J H Wermer
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- Department of Neurology, University Medical Centre Groningen, University of Groningen, the Netherlands (M.J.H.W.)
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14
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Lewey J, Beckie TM, Brown HL, Brown SD, Garovic VD, Khan SS, Miller EC, Sharma G, Mehta LS. Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e330-e346. [PMID: 38346104 PMCID: PMC11185178 DOI: 10.1161/cir.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.
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15
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Higgins HM, Chen L, Ravare BC, Jeppson KA, Bina HT, Herson PS, Monte AA, Poisson SN, Dylla L. Sex differences in acute ischemic stroke presentation are a matter of infarct location. Am J Emerg Med 2023; 74:95-99. [PMID: 37802001 PMCID: PMC10843056 DOI: 10.1016/j.ajem.2023.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023] Open
Abstract
INTRODUCTION Recognition of stroke by Emergency Medical Services (EMS) is critical to initiate rapid emergency department treatment. Most prehospital stroke screening tools rely heavily on presentation with the classic symptoms of facial droop, speech changes, unilateral weakness. However, women may be less likely to present with classic symptoms and may also have different distributions of stroke by anatomical location. This study seeks to determine the association between biological sex, presentation with classic symptoms, and the location of the infarcted tissue. METHODS This is a retrospective cohort study. Data from electronic health records were extracted for patients with acute ischemic stroke who presented via EMS to a single Comprehensive Stroke Center between January 1, 2018 and December 31, 2020. We used descriptive statistics characterize the cohort. Multivariable logistic regression identified factors associated with classic symptom presentation (facial droop, speech changes, and/or unilateral weakness). Biological sex, location of the infarct, stroke etiology, age and the interaction between sex and infarct location were assessed as covariates. RESULTS There were 364 (58.6%) males and 257 (41.1%) females with an acute ischemic stroke included in this study. EMS documented one or more classic symptoms in 125 (72.3%) males and 161 (67.9%) females. There were no baseline differences in infarct location or presentation with classic symptoms as documented by EMS comparing males and females. Multivariate logistic regression found no association between biological sex and presentation with classic symptoms (Odds Ratio 1.08; 95% CI 0.58 to 1.55) after controlling for age, stroke location, etiology of stroke or the interaction between sex and infarct location. Presence of an anterior circulation infarct compared to posterior circulation infarct was positively associated with a classic presentation to EMS (Odds Ratio 3.41; 95% CI 2.15 to 5.41). CONCLUSIONS This study found no difference in the frequency of patient presentation with classic stroke symptoms based on biological sex alone, nor a significant different in distribution of infarcts between males and females. Infarct location (i.e., involving the anterior circulation) was associated with a classic presentation. This suggests that the likelihood of presenting with classic stroke symptoms is not influenced by sex, but rather the location of the infarct.
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Affiliation(s)
- Hannah M Higgins
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Lucia Chen
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Brandy C Ravare
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Kerri A Jeppson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Heather T Bina
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Paco S Herson
- Department of Neurological Surgery, The Ohio State University, College of Medicine, Columbus, OH, United States of America
| | - Andrew A Monte
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Sharon N Poisson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Layne Dylla
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America.
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16
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Ali M, van der Meij A, van Os HJA, Ali M, Van Zwet EW, Spaander FHM, Hofmeijer J, Nederkoorn PJ, van den Wijngaard IR, Majoie CBLM, van Es ACGM, Schonewille WJ, van Walderveen MAA, Dippel DWJ, Visser MC, Kruyt ND, Wermer MJH. Sex differences in onset to hospital arrival time, prestroke disability, and clinical symptoms in patients with a large vessel occlusion: a MR CLEAN Registry substudy. J Neurointerv Surg 2023; 15:e255-e261. [PMID: 36379704 DOI: 10.1136/jnis-2022-019670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women have been reported to have worse outcomes after endovascular treatment (EVT), despite a similar treatment effect in non-clinical trial populations. We aimed to assess sex differences at hospital presentation with respect to workflow metrics, prestroke disability, and presenting clinical symptoms. METHODS We included consecutive patients from the Multicentre Randomised Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in The Netherlands (MR CLEAN) Registry (2014-2018) who received EVT for anterior circulation large vessel occlusion (LVO). We assessed sex differences in workflow metrics, prestroke disability (modified Rankin Scale (mRS) score ≥1), and stroke severity and symptoms according to the National Institutes of Health Stroke Scale (NIHSS) score on hospital admission with logistic and linear regression analyses and calculated the adjusted OR (aOR). RESULTS We included 4872 patients (47.6% women). Compared with men, women were older (median age 76 vs 70 years) and less often achieved good functional outcome at 90 days (mRS ≤2: 35.2% vs 46.4%, aOR 0.70, 95% CI 0.60 to 0.82). Mean onset-to-door time was longer in women (2 hours 16 min vs 2 hours 7 min, adjusted delay 9 min, 95% CI 4 to 13). This delay contributed to longer onset-to-groin times (3 hours 26 min in women vs 3 hours 13 min in men, adjusted delay 13 min, 95% CI 9 to 17). Women more often had prestroke disability (mRS ≥1: 41.1% vs 29.1%, aOR 1.57, 95% CI 1.36 to 1.82). NIHSS on admission was essentially similar in men and women (mean 15±6 vs 15±6, NIHSS <10 vs ≥10, aOR 0.91, 95% CI 0.78 to 1.06). There were no clear sex differences in the occurrence of specific stroke symptoms. CONCLUSION Women with LVO had longer onset-to-door times and more often prestroke disability than men. Raising awareness of these differences at hospital presentation and investigating underlying causes may help to improve outcome after EVT in women.
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Affiliation(s)
- Mariam Ali
- Neurology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Anne van der Meij
- Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Mahsoem Ali
- Surgery, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Erik W Van Zwet
- Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jeanette Hofmeijer
- Neurology, Rijnstate Hospital, Arnhem, The Netherlands
- University of Twente Faculty of Science and Technology, Enschede, The Netherlands
| | | | - Ido R van den Wijngaard
- Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Neurology, HMC Westeinde, The Hague, The Netherlands
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Adriaan C G M van Es
- Radiology and Nuclear Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | - Marieke C Visser
- Neurology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Nyika D Kruyt
- Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Lackovic M, Nikolic D, Jankovic M, Rovcanin M, Mihajlovic S. Stroke vs. Preeclampsia: Dangerous Liaisons of Hypertension and Pregnancy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1707. [PMID: 37893425 PMCID: PMC10608338 DOI: 10.3390/medicina59101707] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/08/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023]
Abstract
Stroke during pregnancy and preeclampsia are two distinct but interrelated medical conditions, sharing a common denominator-blood control failure. Along with cardiovascular diseases, diabetes, dyslipidemia, and hypercoagulability, hypertension is undoubtedly a major risk factor associated with stroke. Even though men have higher age-specific stroke rates, women are facing higher life-long stroke risk, primarily due to longer life expectancy. Sex hormones, especially estrogen and testosterone, seem to play a key link in the chain of blood pressure control differences between the genders. Women affected with stroke are more susceptible to experience some atypical stroke manifestations, which might eventually lead to delayed diagnosis establishment, and result in higher morbidity and mortality rates in the population of women. Preeclampsia is a part of hypertensive disorder of pregnancy spectrum, and it is common knowledge that women with a positive history of preeclampsia are at increased stroke risk during their lifetime. Preeclampsia and stroke display similar pathophysiological patterns, including hypertension, endothelial dysfunction, dyslipidemia, hypercoagulability, and cerebral vasomotor reactivity abnormalities. High-risk pregnancies carrying the burden of hypertensive disorder of pregnancy have up to a six-fold higher chance of suffering from stroke. Resemblance shared between placental and cerebral vascular changes, adaptations, and sophisticated auto-regulatory mechanisms are not merely coincidental, but they reflect distinctive and complex cardiovascular performances occurring in the maternal circulatory system during pregnancy. Placental and cerebral malperfusion appears to be in the midline of both of these conditions; placental malperfusion eventually leads to preeclampsia, and cerebral to stoke. Suboptimal performances of the cardiovascular system are proposed as a primary cause of uteroplacental malperfusion. Placental dysfunction is therefore designated as a secondary condition, initiated by the primary disturbances of the cardiovascular system, rather than an immunological disorder associated with abnormal trophoblast invasion. In most cases, with properly and timely applied measures of prevention, stroke is predictable, and preeclampsia is a controllable condition. Understanding the differences between preeclampsia and stroke in pregnancy is vital for healthcare providers to enhance their clinical decision-making strategies, improve patient care, and promote positive maternal and pregnancy outcomes. Management approaches for preeclampsia and stroke require a multidisciplinary approach involving obstetricians, neurologists, and other healthcare professionals.
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Affiliation(s)
- Milan Lackovic
- University Hospital “Dragisa Misovic”, Heroja Milana Tepica 1, 11000 Belgrade, Serbia; (M.L.); (S.M.)
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Department of Physical Medicine and Rehabilitation, University Children’s Hospital, 11000 Belgrade, Serbia
| | - Milena Jankovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Neurology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Rovcanin
- Clinic for Gynecology and Obstetrics “Narodni Front”, 11000 Belgrade, Serbia;
| | - Sladjana Mihajlovic
- University Hospital “Dragisa Misovic”, Heroja Milana Tepica 1, 11000 Belgrade, Serbia; (M.L.); (S.M.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
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18
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Ekkert A, Milmantienė D, Jokimaitytė U, Jatužis D. Posterior Circulation Stroke Patients Receive Less Reperfusion Therapy Because of Late Arrival and Relative Contraindications: A Retrospective Study. J Clin Med 2023; 12:5181. [PMID: 37629223 PMCID: PMC10455447 DOI: 10.3390/jcm12165181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Reperfusion treatment (RT) is administered to individuals with posterior circulation strokes (PCS) later and less frequently. We aimed to study the impact of demographic and clinical factors on the decision for RT in PCS. METHODS We conducted a retrospective analysis of the data from 500 subjects admitted to the tertiary stroke centre's emergency department between 2018 and 2020 due to PCS. Demographic and clinical factors were analysed among three groups: the RT group, the group with no RT because of absolute contraindications (ACI), and the group with no RT because of relative contraindications (RCI). RESULTS Of the patients, 202 (40.3%) were female. The median NIHSS was four (4), and the subjects' median age was 69 (18). RT was performed on 120 (24%) subjects. FAST symptoms (OR-5.62, 95% CI [2.90-12.28]) and higher NIHSS (OR-1.13, 95% CI [1.09-1.18]) at presentation, atrial fibrillation (OR-1.56, 95% CI [1.02-2.38]), hypertension (OR-2.19, 95% CI [1.17-4.53]) and diabetes (OR-1.70, 95% CI [1.06-2.71]) increased the chance of RT. Late arrival was the most prevalent ACI for 291 (58.2%) patients. FAST-negative subjects (OR-2.92, 95% CI [1.84-4.77]) and males (OR-1.58, 95% CI [1.11-2.28]) had a higher risk of arriving late. Because of RCI, 50 (10%) subjects did not receive RT; the majority were above 80 and had NIHSS ≤ 5. Subjects with RCI who received the RT had a higher NIHSS (4 vs. 3, p < 0.001), higher hypertension (59 (92.2%) vs. 35 (77.8%), p = 0.032) and heart failure (23 (35.9%) vs. 7 (15.6%), p = 0.018) prevalence. There was a trend for less RT in females with RCI. CONCLUSIONS Late arrival was the most common barrier to RT, and the male gender increased this risk. because of relative contraindications, 10% of subjects were not considered for RT. The presence of FAST symptoms, vascular risk factors, and a higher NIHSS increased the chance of RT.
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Affiliation(s)
- Aleksandra Ekkert
- Faculty of Medicine, Vilnius University, LT-03225 Vilnius, Lithuania; (D.M.); (U.J.); (D.J.)
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Kalasapudi L, Williamson S, Shipper AG, Motta M, Esenwa C, Otite FO, Chaturvedi S, Morris NA. Scoping Review of Racial, Ethnic, and Sex Disparities in the Diagnosis and Management of Hemorrhagic Stroke. Neurology 2023; 101:e267-e276. [PMID: 37202159 PMCID: PMC10382273 DOI: 10.1212/wnl.0000000000207406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/28/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In the United States, Black, Hispanic, and Asian Americans experience excessively high incidence rates of hemorrhagic stroke compared with White Americans. Women experience higher rates of subarachnoid hemorrhage than men. Previous reviews detailing racial, ethnic, and sex disparities in stroke have focused on ischemic stroke. We performed a scoping review of disparities in the diagnosis and management of hemorrhagic stroke in the United States to identify areas of disparities, research gaps, and evidence to inform efforts aimed at health equity. METHODS We included studies published after 2010 that assessed racial and ethnic or sex disparities in the diagnosis or management of patients aged 18 years or older in the United States with a primary diagnosis of spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage. We did not include studies assessing disparities in incidence, risks, or mortality and functional outcomes of hemorrhagic stroke. RESULTS After reviewing 6,161 abstracts and 441 full texts, 59 studies met our inclusion criteria. Four themes emerged. First, few data address disparities in acute hemorrhagic stroke. Second, racial and ethnic disparities in blood pressure control after intracerebral hemorrhage exist and likely contribute to disparities in recurrence rates. Third, racial and ethnic differences in end-of-life care exist, but further work is required to understand whether these differences represent true disparities in care. Fourth, very few studies specifically address sex disparities in hemorrhagic stroke care. DISCUSSION Further efforts are necessary to delineate and correct racial, ethnic, and sex disparities in the diagnosis and management of hemorrhagic stroke.
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Affiliation(s)
- Lakshman Kalasapudi
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Stacey Williamson
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Andrea G Shipper
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Melissa Motta
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Charles Esenwa
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Fadar Oliver Otite
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Seemant Chaturvedi
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Nicholas A Morris
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse.
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20
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El Nahas N, Aref H, Kenawy FF, Georgy S, Abushady EM, Dawood NL, Hamdy S, Abdelmohsen N, Hassan Abdel Hamid Y, Roushdy T, Shokri H. Stroke in women: experience in a developing country. BMC Neurol 2023; 23:271. [PMID: 37460962 DOI: 10.1186/s12883-023-03314-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 06/30/2023] [Indexed: 07/20/2023] Open
Abstract
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.
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Affiliation(s)
- Nevine El Nahas
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, PO, 11591, Egypt
| | - Hany Aref
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, PO, 11591, Egypt
| | - Fatma Fathalla Kenawy
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, PO, 11591, Egypt.
| | - Shady Georgy
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, PO, 11591, Egypt
| | - Eman Mones Abushady
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, PO, 11591, Egypt
| | - Noha Lotfy Dawood
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, PO, 11591, Egypt
| | - Sara Hamdy
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, PO, 11591, Egypt
| | - Nourhan Abdelmohsen
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, PO, 11591, Egypt
| | | | - Tamer Roushdy
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, PO, 11591, Egypt
| | - Hossam Shokri
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, PO, 11591, Egypt
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21
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Miller EC, Kauko A, Tom SE, Laivuori H, Niiranen T, Bello NA. Risk of Midlife Stroke After Adverse Pregnancy Outcomes: The FinnGen Study. Stroke 2023; 54:1798-1805. [PMID: 37212139 PMCID: PMC10330298 DOI: 10.1161/strokeaha.123.043052] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/25/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Adverse pregnancy outcomes (APO) contribute to higher risk of maternal cerebrovascular disease, but longitudinal data that include APO and stroke timing are lacking. We hypothesized that APO are associated with younger age at first stroke, with a stronger relationship in those with >1 pregnancy with APO. METHODS We analyzed longitudinal Finnish nationwide health registry data from the FinnGen Study. We included women who gave birth after 1969 when the hospital discharge registry was established. We defined APO as a pregnancy affected by gestational hypertension, preeclampsia, eclampsia, preterm birth, small for gestational age infant, or placental abruption. We defined stroke as first hospital admission for ischemic stroke or nontraumatic intracerebral or subarachnoid hemorrhage, excluding stroke during pregnancy or within 1 year postpartum. We used Kaplan-Meier survival curves and multivariable-adjusted Cox and generalized linear models to assess the relationship between APO and future stroke. RESULTS We included 144 306 women with a total of 316 789 births in the analysis sample, of whom 17.9% had at least 1 pregnancy with an APO and 2.9% experienced an APO in ≥2 pregnancies. Women with APO had more comorbidities including obesity, hypertension, heart disease, and migraine. Median age at first stroke was 58.3 years in those with no APO, 54.8 years in those with 1 APO, and 51.6 years in those with recurrent APO. In models adjusted for sociodemographic characteristics and stroke risk factors, risk of stroke was greater in women with 1 APO (adjusted hazard ratio, 1.3 [95% CI, 1.2-1.4]) and recurrent APO (adjusted hazard ratio, 1.4 [95% CI, 1.2-1.7]) compared with those with no APO. Women with recurrent APO had more than twice the stroke risk before age 45 (adjusted odds ratio, 2.1 [95% CI, 1.5-3.1]) compared with those without APO. CONCLUSIONS Women who experience APO have earlier onset of cerebrovascular disease, with the earliest onset in those with more than 1 affected pregnancy.
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Affiliation(s)
- Eliza C Miller
- Department of Neurology, Columbia University, New York (E.C.M., S.E.T.)
| | - Anni Kauko
- Department of Internal Medicine, University of Turku, Finland (A.K., T.N.)
| | - Sarah E Tom
- Department of Neurology, Columbia University, New York (E.C.M., S.E.T.)
- Department of Epidemiology, Columbia University, New York (S.E.T.)
| | - Hannele Laivuori
- Department of Obstetrics and Gynecology, Tampere University Hospital, Finland (H.L.)
- Center for Child, Adolescent, and Maternal Health Research, Tampere University, Finland (H.L.)
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Tampere University (H.L.)
| | - Teemu Niiranen
- Department of Internal Medicine, University of Turku, Finland (A.K., T.N.)
- Department of Health, Finnish Institute for Health and Welfare (T.N.)
| | - Natalie A Bello
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (N.A.B.)
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22
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Silva Y, Sánchez-Cirera L, Terceño M, Dorado L, Valls A, Martínez M, Abilleira S, Rubiera M, Quesada H, Llull L, Rodríguez-Campello A, Martí-Fàbregas J, Seró L, Purroy F, Payo I, García S, Cánovas D, Krupinski J, Mas N, Palomeras E, Cocho D, Font MÀ, Catena E, Puiggròs E, Pedroza C, Marín G, Carrión D, Costa X, Almendros MC, Torres I, Colom C, Velasquez JA, Diaz G, Jiménez X, Subirats T, Deulofeu A, Hidalgo V, Salvat-Plana M, Pérez de la Ossa N. Sex and gender differences in acute stroke care: metrics, access to treatment and outcome. A territorial analysis of the Stroke Code System of Catalonia. Eur Stroke J 2023; 8:557-565. [PMID: 37231687 PMCID: PMC10334164 DOI: 10.1177/23969873231156260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/23/2023] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Previous studies have reported differences in the management and outcome of women stroke patients in comparison with men. We aim to analyze sex and gender differences in the medical assistance, access to treatment and outcome of acute stroke patients in Catalonia. PATIENTS AND METHODS Data were obtained from a prospective population-based registry of stroke code activations in Catalonia (CICAT) from January/2016 to December/2019. The registry includes demographic data, stroke severity, stroke subtype, reperfusion therapy, and time workflow. Centralized clinical outcome at 90 days was assessed in patients receiving reperfusion therapy. RESULTS A total of 23,371 stroke code activations were registered (54% men, 46% women). No differences in prehospital time metrics were observed. Women more frequently had a final diagnosis of stroke mimic, were older and had a previous worse functional situation. Among ischemic stroke patients, women had higher stroke severity and more frequently presented proximal large vessel occlusion. Women received more frequently reperfusion therapy (48.2% vs 43.1%, p < 0.001). Women tended to present a worse outcome at 90 days, especially for the group receiving only IVT (good outcome 56.7% vs 63.8%; p < 0.001), but not for the group of patients treated with IVT + MT or MT alone, although sex was not independently associated with clinical outcome in logistic regression analysis (OR 1.07; 95% CI, 0.94-1.23; p = 0.27) nor in the analysis after matching using the propensity score (OR 1.09; 95% CI, 0.97-1.22). DISCUSSION AND CONCLUSION We found some differences by sex in that acute stroke was more frequent in older women and the stroke severity was higher. We found no differences in medical assistance times, access to reperfusion treatment and early complications. Worse clinical outcome at 90 days in women was conditioned by stroke severity and older age, but not by sex itself.
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Affiliation(s)
| | | | | | - Laura Dorado
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Adrián Valls
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Marina Martínez
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Marta Rubiera
- Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Helena Quesada
- Hospital Universitari de Bellvitge, L’Hospitalet de llobregat, Spain
| | - Laura Llull
- Hospital Clínic of Barcelona, Barcelona, Spain
| | | | | | - Laia Seró
- Hospital Universitari Joan XXIII, Tarragona, Spain
| | | | - Iago Payo
- Hospital Verge de la Cinta, Tortosa, Spain
| | - Sònia García
- Complex Hospitalari Moisès Broggi, Sant Joan Despí, Spain
| | | | | | | | | | | | | | - Esther Catena
- Consorci Sanitari Alt Penedès-Garraf, Vilafranca del Penedès, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mercè Salvat-Plana
- Pla Director de les Malalties Vasculars Cerebrals. Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS) CIBER en Epidemiolgia i Salut Pública (CBERESP), Departament de Salut, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Pla Director de les Malalties Vasculars Cerebrals. Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS) CIBER en Epidemiolgia i Salut Pública (CBERESP), Departament de Salut, Barcelona, Spain
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23
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Zhang P, Li H, Wang J, Zhang F, Xiao L, Fang Y, Yan D, Xu G, Liu C, Huang Z, Gu M, Zhang H, Sun W. Sex differences in outcomes after endovascular treatment of patients with vertebrobasilar artery occlusion. Eur Stroke J 2023; 8:566-574. [PMID: 37231678 PMCID: PMC10334174 DOI: 10.1177/23969873221151142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/30/2022] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Current studies on the role of sex in the prognosis of acute vertebrobasilar artery occlusion (VBAO) are limited. We aimed to explore whether there are sex differences on outcomes in patients treated with endovascular therapy (EVT) for VBAO. METHODS Patients from December 2015 to December 2018 with acute VBAO within 24 h of the estimated occlusion time in 21 stroke centers in China were retrospectively analyzed. Baseline data between sexes were compared in the total population cohort and propensity score (PS)-matched cohort. Multivariate logistic regression and ordinal regression were used to analyze the association of sex with outcomes. Mixed-effects regression model was performed for changes in modified Rankin Scale (mRS) scores in men and women from 90 days to 1 year after discharge. RESULTS A total of 577 patients (28.4% women) were finally included. Multivariate logistic regression showed that women had a lower probability of favorable outcome (mRS score 0-3 at 90 days; OR 0.544; 95% CI 0.329-0.899) and functional independence (mRS score 0-2 at 90 days; OR 0.391; 95% CI 0.228-0.670) as well as a higher possibility of shifting to worse mRS (OR 1.484; 95% CI 1.020-2.158) than men. After PS matching, 391 patients (39.4% women) were analyzed, confirming the same results regarding favorable outcome (OR 0.580; 95% CI 0.344-0.977), functional independence (OR 0.394; 95% CI 0.218-0.712), and shift mRS (OR 1.504; 95% CI 1.023-2.210). However, the results of repeated ANOVA showed that men and women had a comparable functional recovery from 90 days to 1 year. CONCLUSIONS Stroke due to VBAO treated with EVT is associated with worse outcomes in women than in men. However, men and women showed similar long-term improvement trends.
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Affiliation(s)
- Pan Zhang
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Hao Li
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Jinjing Wang
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Feng Zhang
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Lulu Xiao
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Yirong Fang
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Dingyi Yan
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Guoqiang Xu
- Department of Neurology, The First People’s Hospital of Yongkang, Yongkang, Zhejiang, China
| | - Chaolai Liu
- Department of Neurology, The First People’s Hospital of Jining, Jining, Shandong, China
| | - Zhixin Huang
- Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Mengmeng Gu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hanhong Zhang
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Wen Sun
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
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Jameie M, Jameie M, Farahmand G, Ilkhani S, Magrouni H, Ranjbar Z, Heydari S, Shahbazi M, Kaeedi M, Amani K, Amiri R, Alizade F, Balali P, Amanollahi M, Pourghaz B, Ghabaee M. The Effect of Easily Implementable Changes to the "D's of Stroke Care" in Reducing Sex Disparity in Door-to-Needle Time. Neurologist 2023; 28:198-203. [PMID: 36054454 DOI: 10.1097/nrl.0000000000000467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Melika Jameie
- Iranian Center of Neurological Research, Neuroscience Institute
| | - Mana Jameie
- Tehran Heart Center, Cardiovascular Diseases Research Institute
| | - Ghasem Farahmand
- Department of Neurology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences
| | - Saba Ilkhani
- Department of Surgery and Vascular Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hana Magrouni
- Department of Neurology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences
| | - Zahra Ranjbar
- Department of Neurology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences
| | - Sanaz Heydari
- Department of Neurology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences
| | - Mojtaba Shahbazi
- Department of Neurology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences
| | - Maryam Kaeedi
- Department of Neurology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences
| | - Kiana Amani
- Department of Neurology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences
| | - Rosita Amiri
- Iranian Center of Neurological Research, Neuroscience Institute
| | - Fateme Alizade
- Department of Neurology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences
| | - Pargol Balali
- Iranian Center of Neurological Research, Neuroscience Institute
| | | | | | - Mojdeh Ghabaee
- Iranian Center of Neurological Research, Neuroscience Institute
- Department of Neurology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences
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25
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Noseda R, Rea F, Pagnamenta A, Agazzi P, Bianco G, Sihabdeen S, Seiffge D, Michel P, Nedeltchev K, Bonati L, Kägi G, Niederhauser J, Nyffeler T, Luft A, Wegener S, Schelosky L, Medlin F, Rodic B, Peters N, Renaud S, Mono ML, Carrera E, Fischer U, Ceschi A, Cereda CW. Sex Differences in Outcomes of Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Preadmission Use of Antiplatelets. CNS Drugs 2023; 37:351-361. [PMID: 36976463 PMCID: PMC10126038 DOI: 10.1007/s40263-023-00997-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/29/2023]
Abstract
AIM To compare safety and functional outcomes of intravenous thrombolysis (IVT) between females and males with acute ischaemic stroke (AIS) in relation to preadmission use of antiplatelets. METHODS Multicentre cohort study of patients admitted from 1 January 2014 to 31 January 2020 to hospitals participating in the Swiss Stroke Registry, presenting with AIS and receiving IVT. Primary safety outcome was in-hospital symptomatic intracerebral haemorrhage (sICH). Primary functional outcome was functional independence at 3 months after discharge. Multivariable logistic regression models were fitted to assess the association between sex and each outcome according to preadmission use of antiplatelets. RESULTS The study included 4996 patients (42.51 % females, older than males, median age 79 vs 71 years, p < 0.0001). Comparable proportions of females (39.92 %) and males (40.39 %) used antiplatelets before admission (p = 0.74). In total, 3.06 % females and 2.47 % males developed in-hospital sICH (p = 0.19), with similar odds (adjusted odds ratio, [AOR] 0.93, 95 % confidence interval, [CI] 0.63-1.39). No interaction was found between sex and preadmission use of either single or dual antiplatelets in relation to in-hospital sICH (p = 0.94 and p = 0.23). Males had higher odds of functional independence at 3 months (AOR 1.34, 95 % CI 1.09-1.65), regardless of preadmission use of antiplatelets (interaction between sex and preadmission use of either single or dual antiplatelets p = 0.41 and p = 0.58). CONCLUSION No sex differences were observed in the safety of IVT regarding preadmission use of antiplatelets. Males showed more favourable 3-month functional independence than females; however, this sex difference was apparently not explained by a sex-specific mechanism related to preadmission use of antiplatelets.
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Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Federico Rea
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Alberto Pagnamenta
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Intensive Care, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Division of Pneumology, University of Geneva, Geneva, Switzerland
| | - Pamela Agazzi
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - Giovanni Bianco
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - Shairin Sihabdeen
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - David Seiffge
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | - Thomas Nyffeler
- Center of Neurology and Neurorehabilitation, Luzerner Kantonsspital, Luzern, Switzerland
| | - Andreas Luft
- Universitätsspital Zürich, Neurology, Zürich, Switzerland
| | | | - Ludwig Schelosky
- Division of Neurology, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Friedrich Medlin
- Division of Neurology, HFR Fribourg, Stroke Unit, Fribourg, Switzerland
| | - Biljana Rodic
- Kantonsspital Winterthur, Neurology, Winterthur, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, Hirslanden Hospital, Zurich, Switzerland
| | - Susanne Renaud
- Division of Neurology, Pourtalès Hospital, Neuchatel, Switzerland
| | | | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Carlo Walter Cereda
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland.
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland.
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26
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Li L, Han Z, Wang R, Fan J, Zheng Y, Huang Y, Yang Z, Yan F, Liu P, Zhao H, Ma Q, Luo Y. Association of admission neutrophil serine proteinases levels with the outcomes of acute ischemic stroke: a prospective cohort study. J Neuroinflammation 2023; 20:70. [PMID: 36906528 PMCID: PMC10007819 DOI: 10.1186/s12974-023-02758-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 03/07/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Neutrophil serine proteinases (NSPs), released by activated neutrophils, are key proteins involved in the pathophysiologic processes of stroke. NSPs are also implicated in the process and response of thrombolysis. This study aimed to analyze three NSPs (neutrophil elastase, cathepsin G, and proteinase 3) in relation to acute ischemic stroke (AIS) outcomes and in relation to the outcomes of patients treated with intravenous recombinant tissue plasminogen activator (IV-rtPA). METHODS Among 736 patients prospectively recruited at the stroke center from 2018 to 2019, 342 patients diagnosed with confirmed AIS were included. Plasma neutrophil elastase (NE), cathepsin G (CTSG), and proteinase 3 (PR3) concentrations were measured on admission. The primary endpoint was unfavorable outcome defined as modified Rankin Scale score 3-6 at 3 months, and the secondary endpoints were symptomatic intracerebral hemorrhage (sICH) within 48 h, and mortality within 3 months. In the subgroup of patients who received IV-rtPA, post-thrombolysis early neurological improvement (ENI) (defined as National Institutes of Health Stroke Scale score = 0 or decrease of ≥ 4 within 24 h after thrombolysis) was also included as the secondary endpoint. Univariate and multivariate logistic regression analyses were performed to evaluate the association between NSPs levels and AIS outcomes. RESULTS Higher NE and PR3 plasma levels were associated with the 3-month mortality and 3-month unfavorable outcome. Higher NE plasma levels were also associated with the risk of sICH after AIS. After adjusting for potential confounders, plasma NE level > 229.56 ng/mL (odds ratio [OR] = 4.478 [2.344-8.554]) and PR3 > 388.77 ng/mL (OR = 2.805 [1.504-5.231]) independently predicted the 3-month unfavorable outcome. Regarding rtPA treatment, patients with NE plasma concentration > 177.22 ng/mL (OR = 8.931 [2.330-34.238]) or PR3 > 388.77 ng/mL (OR = 4.275 [1.045-17.491]) were over 4 times more likely to suffer unfavorable outcomes after rtPA treatment. The addition of NE and PR3 to clinical predictors of unfavorable functional outcome after AIS and the outcome after rtPA treatment improved discrimination as well as reclassification (integrated discrimination improvement = 8.2% and 18.1%, continuous net reclassification improvement = 100.0% and 91.8%, respectively). CONCLUSIONS Plasma NE and PR3 are novel and independent predictors of 3-month functional outcomes after AIS. Plasma NE and PR3 also possess predictive value to identify patients with unfavorable outcomes after rtPA treatment. NE is probably an important mediator of the effects of neutrophils on stroke outcomes, which worth further investigation.
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Affiliation(s)
- Lingzhi Li
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Ziping Han
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Rongliang Wang
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Junfen Fan
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Yangmin Zheng
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Yuyou Huang
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Zhenhong Yang
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Feng Yan
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Ping Liu
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Haiping Zhao
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China
| | - Qingfeng Ma
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Yumin Luo
- Institute of Cerebrovascular Diseases Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, China. .,Beijing Institute for Brain Disorders, Beijing, China.
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27
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Sex Differences in Functional Outcomes Following Endovascular Treatment for Acute Ischemic Stroke. Can J Neurol Sci 2023; 50:174-181. [PMID: 35220985 DOI: 10.1017/cjn.2022.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Sex disparities have been reported across many aspects of acute ischemic stroke (AIS) care; however, there is a relative paucity of research examining sex differences in outcomes following endovascular treatment (EVT). Some studies report worse functional independence for females following EVT. Few, if any of these studies account for differences in age, baseline function, and comorbidity burden. This retrospective cohort study aimed to assess for sex differences in functional outcomes following EVT by comparing 90-day modified Rankin Scale (mRS) of males and females while controlling for baseline function and comorbidity burden. METHODS Baseline demographic and clinical data, and stroke severity were compared for 230 consecutive patients undergoing EVT for AIS between October 2014 and July 2019 at a tertiary stroke centre in Toronto, Canada. Effect of sex on likelihood of functional independence post-EVT was assessed using regression analysis with and without correction for age, baseline mRS, and Charlson Comorbidity Index (CCI). RESULTS Females undergoing EVT for AIS were older (75 ± 13 vs. 66 ± 15, p < 0.0001), with worse clinical and functional baselines. Unadjusted, males were more functionally independent (90-day mRS < 3) [OR = 1.831, 95%CI 1.082-3.098]. After controlling for age, baseline mRS and CCI, there was no difference between groups [OR 1.21, 95%CI 0.61-2.37]. CONCLUSIONS This study provides evidence that prior findings of sex disparities in function after EVT may be accounted for by differences in age, baseline clinical status and functional independence between males and females when a comprehensive measure of comorbidity burden is utilized.
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28
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Kapral MK. Kenton Award Lecture-Stroke Disparities Research: Learning From the Past, Planning for the Future. Stroke 2023; 54:379-385. [PMID: 36689593 DOI: 10.1161/strokeaha.122.039562] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/15/2022] [Indexed: 01/24/2023]
Abstract
Inequities in stroke care and outcomes have been documented both within and among countries based on factors, such as race, geography, and socioeconomic status. Research can help us to identify, understand, and address inequities, and this article offers considerations for scientists working in this area. These include designing research aimed at identifying the underlying causes of inequities, recognizing the importance of the social determinants of health, considering interventions that go beyond the individual patient and provider to include policies and systems, acknowledging the role of structural racism, performing community-engaged participatory research, considering intersecting social identities, learning from cross-national comparisons, maintaining the data sources needed for inequities research, using terminology that advances health equity, and improving diversity across the research enterprise.
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Affiliation(s)
- Moira K Kapral
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Canada (M.K.K.)
- ICES, Toronto, Canada (M.K.K.)
- Toronto General Hospital Research Institute, Canada (M.K.K.)
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29
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Oliveira LC, Ponciano A, Tuozzo C, Viswanathan A, Rost NS, Etherton MR. Poststroke Disability: Association Between Sex and Patient-Reported Outcomes. Stroke 2023; 54:345-353. [PMID: 36689580 DOI: 10.1161/strokeaha.122.041502] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Ischemic stroke (IS) is a leading cause of long-term disability with sex-specific differences in outcomes. Identifying the influential factors that contribute to sex-specific disparities in stroke outcomes, therefore, holds potential to develop individualized interventions for reducing long-term disability. Further, investigating the association between sex and Patient-Reported Outcome Measures (PROMs) provides additional information on the individual impact and heterogeneity of IS. We aimed to identify sex-specific differences in stroke outcomes and relationship with PROMs in IS patients with 3-month follow-up. METHODS Between February 2017 and February 2020, a total of 410 patients admitted with IS to the Massachusetts General Hospital, in Boston, were enrolled in this prospective cohort. At 3-month poststroke, patients were assessed for Barthel Index, modified Rankin Scale, and PROM-10 questionnaires. T scores for physical and mental health were determined from the summing of PROM-10 responses in each domain. Regression analysis was performed to identify sex-specific determinants of functional and patient-reported outcomes. RESULTS At baseline, 242 participants were male (mean age, 65 years) and 168 were female (mean age, 70 years). Groups had similar rates of cardiovascular risk factors, admission National Institutes of Health Stroke Scale, and discharge modified Rankin Scale. At follow-up, male participants were more likely to have better rates of T Physical and Barthel Index. In regression analysis, PROMs T Physical (odds ratio, 1.06; P=0.01), Barthel Index (odds ratio, 1.06; P=0.01), and modified Rankin Scale score of ≥2 (odds ratio, 2.60; P=0.01) were associated with female sex. Female sex was also associated with lower scores for PROMs Physical subcomponents and with patient-reported general health and emotional problems. CONCLUSIONS Women have worse outcomes after ischemic stroke, including objective measures of functional disability and patient-reported outcomes. Incorporating PROMs into IS outcome measures may offer additional insight into sex-specific differences in stroke recovery and outcomes.
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Affiliation(s)
- Lara C Oliveira
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.C.O., A.P., C.T., A.V., N.S.R.)
| | - Ana Ponciano
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.C.O., A.P., C.T., A.V., N.S.R.)
| | - Carissa Tuozzo
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.C.O., A.P., C.T., A.V., N.S.R.)
| | - Anand Viswanathan
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.C.O., A.P., C.T., A.V., N.S.R.)
| | - Natalia S Rost
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.C.O., A.P., C.T., A.V., N.S.R.)
| | - Mark R Etherton
- Biogen Inc, Stroke/Acute Neurology Neurovascular Therapeutics Development Unit, Cambridge, MA (M.R.E.)
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30
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Ouyang M, Shajahan S, Liu X, Sun L, Carcel C, Harris K, Anderson CS, Woodward M, Wang X. Sex differences in the utilization and outcomes of endovascular treatment after acute ischemic stroke: A systematic review and meta-analysis. Front Glob Womens Health 2023; 3:1032592. [PMID: 36741299 PMCID: PMC9889638 DOI: 10.3389/fgwh.2022.1032592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/22/2022] [Indexed: 01/20/2023] Open
Abstract
Background Studies of sex differences in the use and outcomes of endovascular treatment (EVT) for acute ischemic stroke report inconsistent results. Methods We systematically searched PubMed and Embase databases for studies examining sex-specific utilization of EVT for acute ischemic stroke published before 31 December 2021. Estimates were compared by study type: randomized clinical trials (RCTs) and non-RCTs (hospital-based, registry-based or administrative data). Random effects odds ratios (ORs) were generated to quantify sex differences in EVT use. To estimate sex differences in functional outcome on the modified Rankin scale after EVT, the female:male ratio of ORs and 95% confidence intervals (CIs) were obtained from ordinal or binary analysis. Results 6,396 studies were identified through database searching, of which 594 qualified for a full review. A total of 51 studies (36 non-RCT and 15 RCTs) reporting on sex-specific utilization of EVT were included, and of those 10 estimated the sex differences of EVT on functional outcomes. EVT use was similar in women and men both in non-RCTs (OR: 1.03, 95% CI: 0.96-1.11) and RCTs (1.02, 95% CI: 0.89-1.16), with consistent results across years of publication and regions of study, except that in Europe EVT treatment was higher in women than men (1.15, 95% CI: 1.13-1.16). No sex differences were found in the functional outcome by either ordinal and binary analyses (ORs 0.95, 95% CI: 0.68-1.32] and 0.90, 95% CI: 0.65-1.25, respectively). Conclusions No sex differences in EVT utilization or on functional outcomes were evident after acute ischemic stroke from large-vessel occlusion. Further research may be required to examine sex differences in long-term outcomes, social domains, and quality of life. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=226100, identifier: CRD42021226100.
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Affiliation(s)
- Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Stroke Division, TheGeorge Institute for Global Health, Beijing, China
| | - Sultana Shajahan
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xiaoying Liu
- Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Lingli Sun
- Stroke Division, TheGeorge Institute for Global Health, Beijing, China
| | - Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Katie Harris
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Correspondence: Xia Wang
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31
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Yu AYX, Austin PC, Rashid M, Fang J, Porter J, Vyas MV, Smith EE, Joundi RA, Edwards JD, Reeves MJ, Kapral MK. Sex Differences in Intensity of Care and Outcomes After Acute Ischemic Stroke Across the Age Continuum. Neurology 2023; 100:e163-e171. [PMID: 36180239 DOI: 10.1212/wnl.0000000000201372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/23/2022] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Amy Ying Xin Yu
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada.
| | - Peter C Austin
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Mohammed Rashid
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Jiming Fang
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Joan Porter
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Manav V Vyas
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Eric E Smith
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Raed A Joundi
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Jodi D Edwards
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Mathew J Reeves
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Moira K Kapral
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
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Kremer C, Lorenzano S, Kruuse C. Editorial: Sex differences in cerebrovascular diseases. Front Neurol 2023; 13:1128177. [PMID: 36712426 PMCID: PMC9878284 DOI: 10.3389/fneur.2022.1128177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Affiliation(s)
- Christine Kremer
- Neurology Department, Skåne University Hospital Malmö, Malmö, Sweden,Department of Clinical Sciences, Lund University, Lund, Sweden,*Correspondence: Christine Kremer ✉
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Christina Kruuse
- Stroke Unit and Neurovascular Research Unit, Neurology Department, University of Copenhagen Herlev Gentofte Hospital, Hellerup, Denmark
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Ospel J, Singh N, Ganesh A, Goyal M. Sex and Gender Differences in Stroke and Their Practical Implications in Acute Care. J Stroke 2023; 25:16-25. [PMID: 36746379 PMCID: PMC9911850 DOI: 10.5853/jos.2022.04077] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 12/27/2022] [Indexed: 02/04/2023] Open
Abstract
There are several controversies regarding the role of sex and gender in the pathophysiology and management of acute stroke. Assessing the role of sex, i.e., biological/pathophysiological factors, and gender, i.e., sociocultural factors, in isolation is often not possible since they are closely intertwined with each other. To complicate matters even more, the functional baseline status of women and men at the time of their first stroke is substantially different, whereby women have, on average, a poorer reported/ascertained baseline function compared to men. These differences in baseline variables account for a large part of the differences in post-stroke outcomes between women and men. Adjusting for these baseline differences is difficult, and in many cases, residual confounding cannot be excluded. Despite these obstacles, a better understanding of how patient sex and gender differences influence acute stroke and stroke care pathways is crucial to avoid biases and allow us to provide the best possible care for all acute stroke patients. Disregarding patient sex and gender on one hand and ignoring potential confounding factors in sex- and gender-stratified analyses on the other hand, may cause researchers to come to erroneous conclusions and physicians to provide suboptimal care. This review outlines sex- and gender-related factors in key aspects of acute stroke, including acute stroke epidemiology, diagnosis, access to care, treatment outcomes, and post-acute care. We also attempt to outline knowledge gaps, which deserve to be studied in further detail, and practical implications for physicians treating acute stroke patients in their daily practice.
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Affiliation(s)
- Johanna Ospel
- Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada,Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Nishita Singh
- Department of Neurology, University of Manitoba, Winnipeg, MB, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada,Department of Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada,Correspondence: Mayank Goyal Departments of Radiology and Clinical Neurosciences, Foothills Medical Center, University of Calgary, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada Tel: +1-403-9443379 E-mail:
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Oostema JA, Nickles A, Luo Z, Reeves MJ. Emergency Medical Services Stroke Care Performance Variability in Michigan: Analysis of a Statewide Linked Stroke Registry. J Am Heart Assoc 2022; 12:e026834. [PMID: 36537345 PMCID: PMC9973590 DOI: 10.1161/jaha.122.026834] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Emergency medical services (EMS) compliance with recommended prehospital care for patients with acute stroke is inconsistent; however, sources of variability in compliance are not well understood. The current analysis utilizes a linkage between a statewide stroke registry and EMS information system data to explore patient and EMS agency-level contributions to variability in prehospital care. Methods and Results This is a retrospective analysis of a cohort of confirmed stroke cases transported by EMS to hospitals participating in a statewide stroke registry. Using EMS information system data, the authors quantified EMS compliance with 6 performance measures derived from national guidelines for prehospital stroke care: prehospital stroke scale performance, glucose check, stroke recognition, on-scene time ≤15 minutes, time last known well documentation, and hospital prenotification. Multilevel multivariable logistic regression analysis was then used to examine associations between patient-level demographic and clinical characteristics and EMS compliance while accounting for and quantifying the variation attributable to agency of transport and recipient hospital. Over an 18-month period, EMS and stroke registry records were linked for 5707 EMS-transported stroke cases. Compliance ranged from 24% of cases for last known well documentation to 82% for documentation of a glucose check. The other measures were documented in approximately half of cases. Older age, higher National Institutes of Health Stroke Scale, and earlier presentation were associated with more compliant prehospital care. EMS agencies accounted for more than half of the variation in EMS prehospital stroke scale documentation and last known well documentation and 27% of variation in glucose check but <10% of stroke recognition and prenotification variability. Conclusions EMS stroke care remains highly variable across different performance measures and EMS agencies. EMS agency and electronic medical record type are important sources of variability in compliance with key prehospital performance metrics for stroke.
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Affiliation(s)
- J. Adam Oostema
- Department of Emergency MedicineMichigan State University College of Human Medicine, Secchia CenterGrand RapidsMI
| | - Adrienne Nickles
- Michigan Department of Health and Human Services, Lifecourse Epidemiology and Genomics DivisionLansingMI
| | - Zhehui Luo
- Department of Epidemiology and BiostatisticsMichigan State University College of Human MedicineEast LansingMI
| | - Mathew J. Reeves
- Department of Epidemiology and BiostatisticsMichigan State University College of Human MedicineEast LansingMI
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Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes. Can J Cardiol 2022; 38:1865-1880. [PMID: 36116747 DOI: 10.1016/j.cjca.2022.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/21/2022] [Accepted: 09/11/2022] [Indexed: 12/14/2022] Open
Abstract
Defined as a prejudice either for or against something, biases at the provider, patient, and societal level all contribute to differences in cardiovascular disease recognition and treatment, resulting in outcome disparities between sexes and genders. Provider bias in the under-recognition of female-predominant cardiovascular disease and risks might result in underscreened and undertreated patients. Furthermore, therapies for female-predominant phenotypes including nonobstructive coronary artery disease and heart failure with preserved ejection fraction are less well researched, contributing to undertreated female patients. Conversely, women are less likely to seek urgent medical attention, potentially related to societal bias to put others first, which contributes to diagnostic delays. Furthermore, women are less likely to have discussions around risk factors for coronary artery disease compared with men, partially because they are less likely to consider themselves at risk for heart disease. Provider bias in interpreting a greater number of presenting symptoms, some of which have been labelled as "atypical," can lead to mislabelling presentations as noncardiovascular. Furthermore, providers might avoid discussions around certain therapies including thrombolysis for stroke, and cardiac resynchronization therapy in heart failure, because it is incorrectly assumed that women are not interested in pursuing options deemed more invasive. To mitigate bias, organizations should aim to increase the visibility and involvement of women in research, health promotion, and clinical and leadership endeavours. More research needs to be done to identify effective interventions to mitigate sex and gender bias and the resultant cardiovascular outcome discrepancies.
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Sabetta A, Lombardi L, Stefanini L. Sex differences at the platelet-vascular interface. Intern Emerg Med 2022; 17:1267-1276. [PMID: 35576047 PMCID: PMC9352612 DOI: 10.1007/s11739-022-02994-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/16/2022] [Indexed: 12/24/2022]
Abstract
Platelets are multifunctional cells that ensure the integrity of the vascular wall and modulate the immune response at the blood/vascular interface. Their pathological activation results in both thrombosis and inflammation and implicates them in the pathogenesis of vascular disease. Vascular diseases are sexually dimorphic in terms of incidence, clinical presentation, outcome, and efficacy of anti-platelet therapy. We here provide an overview of what is known about the role of platelets in the initiation and progression of vascular diseases and summarize what is known about the sex differences in platelet reactivity and in the thromboinflammatory mechanisms that drive these diseases, with a particular focus on atherosclerosis, obstructive and non-obstructive coronary artery disease, and ischemic stroke. Understanding the sex differences at the platelet-vascular interface is clinically relevant as it will enable: (1) to design new therapeutic strategies that prevent the detrimental effects of the immune-modulatory function of platelets taking sex into account, and (2) to evaluate if sex-specific anti-platelet drug regimens should be used to reduce the risk not only of thrombosis but also of vascular disease progression.
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Affiliation(s)
- Annamaria Sabetta
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell'Università, 37, 00185, Rome, Italy
| | - Ludovica Lombardi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell'Università, 37, 00185, Rome, Italy
| | - Lucia Stefanini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell'Università, 37, 00185, Rome, Italy.
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Wang X, Carcel C, Hsu B, Shajahan S, Miller M, Peters S, Randall DA, Havard A, Redfern J, Anderson CS, Jorm L, Woodward M. Differences in the pre-hospital management of women and men with stroke by emergency medical services in New South Wales. Med J Aust 2022; 217:143-148. [PMID: 35831059 PMCID: PMC9541458 DOI: 10.5694/mja2.51652] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/29/2022] [Accepted: 05/10/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES To examine whether pre-hospital emergency medical service care differs for women and men subsequently admitted to hospital with stroke. DESIGN, SETTING, PARTICIPANTS Population-based cohort study; analysis of linked Admitted Patient Data Collection and NSW Ambulance data for people admitted to New South Wales hospitals with a principal diagnosis of stroke at separation, 1 July 2005 - 31 December 2018. MAIN OUTCOME MEASURES Emergency medical service assessments, protocols, and management for patients subsequently diagnosed with stroke, by sex. RESULTS Of 202 231 people hospitalised with stroke (mean age, 73 [SD, 14] years; 98 599 women [51.0%]), 101 357 were conveyed to hospital by ambulance (50.1%). A larger proportion of women than men travelled by ambulance (52.4% v 47.9%; odds ratio [OR], 1.09; 95% CI, 1.07-1.11), but time between the emergency call and emergency department admission was similar for both sexes. The likelihood of being assessed as having a stroke (adjusted OR [aOR], 0.97; 95% CI, 0.93-1.01) or subarachnoid haemorrhage (aOR, 1.22; 95% CI, 0.73-2.03) was similar for women and men, but women under 70 years of age were less likely than men to be assessed as having a stroke (aOR, 0.89; 95% CI, 0.82-0.97). Women were more likely than men to be assessed by paramedics as having migraine, other headache, anxiety, unconsciousness, hypertension, or nausea. Women were less likely than men to be managed according to the NSW Ambulance pre-hospital stroke care protocol (aOR, 0.95; 95% CI, 0.92-0.97), but the likelihood of basic pre-hospital care was similar for both sexes (aOR, 1.01; 95% CI, 0.99-1.04). CONCLUSION Our large population-based study identified sex differences in pre-hospital management by emergency medical services of women and men admitted to hospital with stroke. Paramedics should receive training that improves the recognition of stroke symptoms in women.
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Affiliation(s)
- Xia Wang
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
| | - Cheryl Carcel
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
| | - Benjumin Hsu
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Sultana Shajahan
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
| | - Matthew Miller
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Sanne Peters
- The George Institute for Global HealthOxfordUnited Kingdom
| | - Deborah A Randall
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Alys Havard
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Julie Redfern
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW,School of Health Sciences, Faculty of Medicine and HealthUniversity of Sydney, NSW
| | - Craig S Anderson
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW,Royal Prince Alfred HospitalSydneyNSW
| | - Louisa Jorm
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Mark Woodward
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
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Carcel C, Caso V, Aguiar de Sousa D, Sandset EC. Sex differences in neurovascular disorders. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:69-99. [PMID: 36038210 DOI: 10.1016/bs.irn.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Neurovascular disorders is a heterogenous group of diseases, including one of the most time critical disorders in emergency medicine; stroke. Sex differences are extensively described in neurovascular disorders, ranging from differences in symptom presentation, risk factors, treatment and outcomes. For example, women with stroke, more often present with generalized weakness, reduced consciousness and headache than men. Furthermore, there are differences in risk factors, outcomes and in the effect of secondary prevention. Women have a higher risk of cerebral venous thrombosis and developing cerebral aneurysms. In general, women have been underrepresented in trials on neurovascular disorders. This chapter provides an extensive overview of sex differences in stroke in general and in the differences specially seen in ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage and in cerebral venous thrombosis.
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Affiliation(s)
- Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital University of Perugia, Perugia, Italy
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, Lisbon, Portugal; CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway; The Norwegian Air Ambulance Foundation, Oslo, Norway.
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Demel SL, Reeves M, Xu H, Xian Y, Mac Grory B, Fonarow GC, Matsouaka R, Smith EE, Saver J, Schwamm L. Sex Differences in Endovascular Therapy for Ischemic Stroke: Results From the Get With The Guidelines-Stroke Registry. Stroke 2022; 53:3099-3106. [PMID: 35880521 DOI: 10.1161/strokeaha.122.038491] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2015, endovascular therapy (EVT) for large vessel occlusions became standard of care for acute ischemic stroke. Lower utilization of IV alteplase has been reported in women, but whether sex differences in EVT use in the United States exists has not been established. METHODS We identified all acute ischemic stroke discharges from Get With The Guidelines-Stroke hospitals between 2012 and 2019 who were potentially eligible for EVT, based on National Institutes of Health Stroke Scale score ≥6 and arrival <6 hours, according to 2018 American Heart Association/ASA guidelines. Multivariable regression analyses were used to determine the association between sex and EVT utilization, and outcomes (including mortality, discharge home, functional status) after EVT. Separate analyses were conducted for the 2 time periods: 2012 to 2014, and 2015 to 2019. RESULTS Of 302 965 patients potentially eligible for EVT, 42 422 (14%) received EVT. Before 2015, EVT treatment rates were 5.3% in women and 6.6% in men. From 2015 to 2019, treatment rates increased in both sexes to 16.7% in women and 18.5% in men. The adjusted odds ratio for EVT in women compared with men was 0.93 (95% CI, 0.87-0.99) before 2015, and 0.98 (95% CI, 0.96-1.01) after 2015. There were no significant sex differences in outcomes except that after 2015, women were less able to ambulate at discharge (adjusted odds ratio, 0.95 [95% CI, 0.95-0.99]) and had lower in-hospital mortality (adjusted odds ratio, 0.93 [95% CI, 0.88-0.99]). CONCLUSIONS EVT utilization has increased dramatically in both women and men since EVT approval in 2015. Following statistical adjustment, women were less likely to receive EVT initially, but after 2015, women were as likely as men to receive EVT. After EVT, women were more likely to be disabled at discharge but less likely to experience in-hospital death compared with men.
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Affiliation(s)
- Stacie L Demel
- Department of Neurology, University of Cincinnati, OH (S.L.D.)
| | - Mathew Reeves
- Dsepartment of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.R.)
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (H.X.)
| | - Ying Xian
- UT Southwestern Medical Center, Department of Neurology, Dallas, TX (Y.X.)
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC. (B.M.G.)
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Roland Matsouaka
- Department of Medicine, Duke University School of Medicine, Durham, NC. (R.M.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Jeff Saver
- Department of Neurology, David Geffen School of Medicine, UCLA, Los Angeles, CA (J.S.)
| | - Lee Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.S.)
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Casetta I, Fainardi E, Pracucci G, Saia V, Sallustio F, da Ros V, Nappini S, Nencini P, Bigliardi G, Vinci S, Grillo F, Bracco S, Tassi R, Bergui M, Cerrato P, Saletti A, De Vito A, Gasparotti R, Magoni M, Simonetti L, Zini A, Ruggiero M, Longoni M, Castellan L, Malfatto L, Castellini P, Cosottini M, Comai A, Franchini E, Lozupone E, Della Marca G, Puglielli E, Casalena A, Baracchini C, Savio D, Duc E, Ricciardi G, Cappellari M, Chiumarulo L, Petruzzellis M, Cavallini A, Cavasin N, Critelli A, Burdi N, Boero G, Giorgianni A, Versino M, Biraschi F, Nicolini E, Comelli S, Melis M, Padolecchia R, Tassinari T, Paolo Nuzzi N, Marcheselli S, Sacco S, Invernizzi P, Gallesio I, Ferrandi D, Fancello M, Valeria Saddi M, Russo M, Pischedda A, Baule A, Mannino M, Florio F, Inchingolo V, Elena Flacco M, Romano D, Silvagni U, Inzitari D, Mangiafico S, Toni D. Sex differences in outcome after thrombectomy for acute ischemic stroke. A propensity score-matched study. Eur Stroke J 2022; 7:151-157. [PMID: 35647312 PMCID: PMC9134778 DOI: 10.1177/23969873221091648] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/14/2022] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND AND PURPOSE We sought to investigate whether there are gender differences in clinical outcome after stroke due to large vessel occlusion (LVO) after mechanical thrombectomy (EVT) in a large population of real-world patients. METHODS From the Italian Registry of Endovascular Thrombectomy, we extracted clinical and outcome data of patients treated for stroke due to large vessel occlusion. We compared clinical and safety outcomes in men and women who underwent EVT alone or in combination with intravenous thrombolysis (IVT) in the total population and in a Propensity Score matched set. RESULTS Among 3422 patients included in the study, 1801 (52.6%) were women. Despite older age at onset (mean 72.4 vs 68.7; p < 0.001), and higher rate of atrial fibrillation (41.7% vs 28.6%; p < 0.001), women had higher probability of 3-month functional independence (adjusted odds ratio-adjOR 1.19; 95% CI 1.02-1.38), of complete recanalization (adjOR 1.25; 95% CI 1.09-1.44) and lower probability of death (adjOR 0.75; 95% CI 0.62-0.90). After propensity-score matching, a well-balanced cohort comprising 1150 men and 1150 women was analyzed, confirming the same results regarding functional outcome (3-month functional independence: OR 1.25; 95% CI 1.04-1.51), and complete recanalization (OR 1.29; 95% CI 1.09-1.53). CONCLUSIONS Subject to the limitations of a non-randomized comparison, women with stroke due to LVO treated with mechanical thrombectomy had a better chance to achieve complete recanalization, and 3-month functional independence than men. The results could be driven by women who underwent combined treatment.
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Affiliation(s)
- Ilaria Casetta
- Clinical Neurology, University of
Ferrara, Ferrara, Italy
| | | | | | - Valentina Saia
- Hospital Santa Corona Pietra Ligure,
Pietra Ligure, Italy
| | | | | | | | | | | | | | | | | | | | | | | | - Andrea Saletti
- Azienda Ospedaliero Universitaria di
Ferrara, Ferrara, Italy
| | | | | | - Mauro Magoni
- Azienda Socio Sanitaria Territoriale
degli Spedali Civili di Brescia, Brescia, Italy
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze
Neurologiche di Bologna, Bologna, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Enrica Duc
- Ospedale San Giovanni Bosco, Torino,
Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Francesco Florio
- Fondazione di Religione e di Culto
Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Vincenzo Inchingolo
- Fondazione di Religione e di Culto
Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | | | | | | | | | | | - Danilo Toni
- University of Rome La Sapienza, RM,
Roma, Italy
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Nappi RE, Chedraui P, Lambrinoudaki I, Simoncini T. Menopause: a cardiometabolic transition. Lancet Diabetes Endocrinol 2022; 10:442-456. [PMID: 35525259 DOI: 10.1016/s2213-8587(22)00076-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
Abstract
Menopause is often a turning point for women's health worldwide. Increasing knowledge from experimental data and clinical studies indicates that cardiometabolic changes can manifest at the menopausal transition, superimposing the effect of ageing onto the risk of cardiovascular disease. The menopausal transition is associated with an increase in fat mass (predominantly in the truncal region), an increase in insulin resistance, dyslipidaemia, and endothelial dysfunction. Exposure to endogenous oestrogen during the reproductive years provides women with protection against cardiovascular disease, which is lost around 10 years after the onset of menopause. In particular, women with vasomotor symptoms during menopause seem to have an unfavourable cardiometabolic profile. Early management of the traditional risk factors of cardiovascular disease (ie, hypertension, obesity, diabetes, dyslipidaemia, and smoking) is essential; however, it is important to recognise in the reproductive history the female-specific conditions (ie, gestational hypertension or diabetes, premature ovarian insufficiency, some gynaecological diseases such as functional hypothalamic amenorrhoea, and probably others) that could enhance the risk of cardiovascular disease during and after the menopausal transition. In this Review, the first of a Series of two papers, we provide an overview of the literature for understanding cardiometabolic changes and the management of women at midlife (40-65 years) who are at higher risk, focusing on the identification of factors that can predict the occurrence of cardiovascular disease. We also summarise evidence about preventive non-hormonal strategies in the context of cardiometabolic health.
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Affiliation(s)
- Rossella E Nappi
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Peter Chedraui
- Instituto de Investigación e Innovación en Salud Integral and Laboratorio de Biomedicina, Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
| | - Irene Lambrinoudaki
- Menopause Unit, 2nd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Tommaso Simoncini
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Siotto M, Germanotta M, Santoro M, Canali R, Pascali S, Insalaco S, Cipollini V, Papadopoulou D, Antonacci E, Aprile I. Oxidative Stress Status in Post Stroke Patients: Sex Differences. Healthcare (Basel) 2022; 10:healthcare10050869. [PMID: 35628006 PMCID: PMC9140331 DOI: 10.3390/healthcare10050869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 11/16/2022] Open
Abstract
After a cerebral stroke insult, there is an overproduction of Reactive Oxygen Species (ROS), which overcome the antioxidant defenses, causing further tissues damage. The status of oxidative stress in stroke patients over time, particularly in those undergoing rehabilitation treatments, has been poorly investigated. We analyzed the oxidative stress status in 61 subacute stroke patients (33 females and 28 males) admitted to our rehabilitation center by measuring, in serum: hydroperoxides levels (d-ROMs), antioxidant activity (BAP test), and the relative antioxidant capacity (OSI index). We also analyzed patients for glucose levels and lipid profile. In addition, we analyzed the correlation between oxidative stress status biomarkers and motor deficits, disability, and pain. Almost all patients showed high or very high levels of d-ROMs, while BAP levels were apparently in the reference range of normality. Females had lower BAP values (females: 2478 ± 379; males: 2765 ± 590; p = 0.034) and lower OSI index (females: 5.7 ± 1.9; males: 6.8 ± 1.9; p = 0.043). Moreover, in the male group, the correlation with motor impairment and disability showed a worsened motor performance when oxidative stress is higher. Female group, on the other hand, had an unexpected different trend of correlation, probably due to an unbalanced systemic oxidative stress. Further research is needed to see if sex differences in oxidative stress status in subacute stroke patients persist after rehabilitation.
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Affiliation(s)
- Mariacristina Siotto
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Florence, Italy; (M.G.); (R.C.); (S.P.); (S.I.); (V.C.); (D.P.); (E.A.); (I.A.)
- Correspondence: ; Tel.: +39-0633086552
| | - Marco Germanotta
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Florence, Italy; (M.G.); (R.C.); (S.P.); (S.I.); (V.C.); (D.P.); (E.A.); (I.A.)
| | - Massimo Santoro
- Energy and Sustainable Economic Development, Division of Health Protection Technologies ENEA-Italian National Agency for New Technologies, 00123 Rome, Italy;
| | - Raffaella Canali
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Florence, Italy; (M.G.); (R.C.); (S.P.); (S.I.); (V.C.); (D.P.); (E.A.); (I.A.)
| | - Simona Pascali
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Florence, Italy; (M.G.); (R.C.); (S.P.); (S.I.); (V.C.); (D.P.); (E.A.); (I.A.)
| | - Sabina Insalaco
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Florence, Italy; (M.G.); (R.C.); (S.P.); (S.I.); (V.C.); (D.P.); (E.A.); (I.A.)
| | - Valeria Cipollini
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Florence, Italy; (M.G.); (R.C.); (S.P.); (S.I.); (V.C.); (D.P.); (E.A.); (I.A.)
| | - Dionysia Papadopoulou
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Florence, Italy; (M.G.); (R.C.); (S.P.); (S.I.); (V.C.); (D.P.); (E.A.); (I.A.)
| | - Erika Antonacci
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Florence, Italy; (M.G.); (R.C.); (S.P.); (S.I.); (V.C.); (D.P.); (E.A.); (I.A.)
| | - Irene Aprile
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, 50143 Florence, Italy; (M.G.); (R.C.); (S.P.); (S.I.); (V.C.); (D.P.); (E.A.); (I.A.)
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Peng Y, Ngo L, Hay K, Alghamry A, Colebourne K, Ranasinghe I. Long-Term Survival, Stroke Recurrence, and Life Expectancy After an Acute Stroke in Australia and New Zealand From 2008-2017: A Population-Wide Cohort Study. Stroke 2022; 53:2538-2548. [PMID: 35418238 DOI: 10.1161/strokeaha.121.038155] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data on long-term outcomes following an acute stroke are sparse. We assessed survival, risk of recurrent stroke and loss in life expectancy following an acute stroke using population-wide data from Australia and New Zealand. METHODS We included all adults with the first stroke hospitalization during 2008 and 2017 at all public and most private hospitals. Patients were followed up to 10 years after the stroke by linkage to each region's Registry of Deaths and subsequent hospitalizations. Flexible parametric survival modeling was used to estimate all-cause mortality, stroke recurrence, and loss in life expectancy. Competing risk model was used when estimating the risk of stroke recurrence. RESULTS Three hundred thirteen thousand one hundred sixty-two patients were included (mean age 73.0±14.6 y, 52.0% males) with ischemic stroke (175 547, 56.1%) being the most common, followed by hemorrhagic stroke (77 940, 24.9%) and unspecified stroke (59 675, 19.1%). The overall survival probability was 79.4% at 3 months, 73.0% at 1 year, 52.8% at 5 years, and 36.4% at 10 years. Cumulative incidence of stroke recurrence was 7.8% at 3 months, 11.0% at 1 year, 19.8% at 5 years, and 26.8% at 10 years. Hemorrhagic stroke was associated with greater mortality (hazard ratio, 2.02 [95% CI, 1.99-2.04]) and recurrent stroke (hazard ratio, 1.63 [95% CI, 1.59-1.67]) compared with ischemic stroke. Female sex (hazard ratio, 1.10 [95% CI, 1.09-1.11]) and increasing age (≥85 years versus 18-54 years: hazard ratio, 7.36 [95% CI, 7.15-7.57]) were also associated with increased mortality. Several risk factors including atherosclerotic coronary and noncoronary vascular disease, cardiac arrhythmia, and diabetes were associated with increased risk of mortality and recurrent stroke. Compared with the general population, an acute stroke was associated with a loss of 5.5 years of life expectancy, or 32.7% of the predicted life expectancy, and was pronounced in patients with a hemorrhagic stroke (7.4 years and 38.5% of predicted life expectancy lost). CONCLUSIONS In this population-wide study, death and recurrence of stroke were common after an acute stroke and an acute stroke was associated with considerable loss in life expectancy. Further improvements in treatment and secondary prevention of stroke are needed to reduce these risks.
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Affiliation(s)
- Yang Peng
- School of Clinical Medicine, The University of Queensland, Brisbane, Australia (Y.P., L.N., K.H., A.A., I.R.).,Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia (Y.P., L.N., I.R.)
| | - Linh Ngo
- School of Clinical Medicine, The University of Queensland, Brisbane, Australia (Y.P., L.N., K.H., A.A., I.R.).,Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia (Y.P., L.N., I.R.).,Cardiovascular Centre, E Hospital, Hanoi, Vietnam (L.N.)
| | - Karen Hay
- School of Clinical Medicine, The University of Queensland, Brisbane, Australia (Y.P., L.N., K.H., A.A., I.R.).,QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia (K.H.)
| | - Alaa Alghamry
- School of Clinical Medicine, The University of Queensland, Brisbane, Australia (Y.P., L.N., K.H., A.A., I.R.).,Internal Medicine Services, The Prince Charles Hospital, Brisbane, QLD, Australia (A.A., K.C.)
| | - Kathryn Colebourne
- Internal Medicine Services, The Prince Charles Hospital, Brisbane, QLD, Australia (A.A., K.C.)
| | - Isuru Ranasinghe
- School of Clinical Medicine, The University of Queensland, Brisbane, Australia (Y.P., L.N., K.H., A.A., I.R.).,Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia (Y.P., L.N., I.R.)
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Walter S, Phillips D, Wells B, Moon R, Bertsch T, Grunwald IQ, Fassbender K. Detection to Hospital Door: Gender Differences of Patients With Acute Stroke Symptoms. Front Neurol 2022; 13:833933. [PMID: 35463123 PMCID: PMC9021751 DOI: 10.3389/fneur.2022.833933] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 03/09/2022] [Indexed: 12/02/2022] Open
Abstract
Although prehospital stroke management is challenging, it is a crucial part of the acute stroke chain to enable equal access to highly specialised stroke care. It involves a critical understanding of players usually not specialized in acute stroke treatments. There is contradictory information about gender inequity in prehospital stroke detection, dispatch, and delivery to hospital stroke centers. The aim of this narrative review is to summarize the knowledge of gender differences in the first three stages of acute stroke management. Information on the detection of acute stroke symptoms by patients, their relatives, and bystanders is discussed. Women seem to have a better overall knowledge about stroke, although general understanding needs to be improved. However, older age and different social situations of women could be identified as reasons for reduced and delayed help-seeking. Dispatch and delivery lie within the responsibility of the emergency medical service. Differences in clinical presentation with symptoms mainly affecting general conditions could be identified as a crucial challenge leading to gender inequity in these stages. Improvement of stroke education has to be applied to tackle this inequal management. However, specifically designed projects and analyses are needed to understand more details of sex differences in prehospital stroke management, which is a necessary first step for the potential development of substantially improving strategies.
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Affiliation(s)
- Silke Walter
- Neurology, Saarland University, Homburg, Germany
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
- *Correspondence: Silke Walter
| | - Daniel Phillips
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Brittany Wells
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Robert Moon
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Iris Q. Grunwald
- Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, United Kingdom
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Eddelien HS, Butt JH, Christensen T, Danielsen AK, Kruuse C. Sex and Age Differences in Patient-Reported Acute Stroke Symptoms. Front Neurol 2022; 13:846690. [PMID: 35386418 PMCID: PMC8978710 DOI: 10.3389/fneur.2022.846690] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/11/2022] [Indexed: 11/20/2022] Open
Abstract
Background Identification of sex- and age-related differences in the presentation of atypical symptoms at stroke onset may reduce prehospital delay and improve stroke treatment if acknowledged at first contact. Aim To explore sex- and age-related differences in patient-reported typical and atypical symptoms of a stroke. Methods We used data from a cross-sectional survey at two non-comprehensive stroke units in the Capital Region of Denmark. Patient-reported symptoms, stroke knowledge, and behavioral response were analyzed by the Chi-square test or a Fisher's exact test separated by sex. Multivariable logistic regression adjusted for covariates were used to explore sex- and age-related differences according to each patient-reported typical or atypical symptoms. Results In total, 479 patients with acute stroke were included (median age 74 years [25th to 75th percentile: 64–80], and 40.1% were women). Female sex was associated with higher odds of presenting with atypical symptoms, such as loss of consciousness (OR 2.12 [95% CI 1.08–4.18]) and nausea/vomiting (OR 2.33 [95% CI 1.24–4.37]), and lower odds of presenting with lower extremity paresis (OR 0.59 [95% CI 0.39–0.89). With each year of age, the odds decreased of presenting with sensory changes (OR 0.95 [95% CI 0.94–0.97]) and upper extremity paresis (OR 0.98 [95% CI 0.96–0.99]), whereas odds of presenting with dysphagia (OR 1.06 [95% CI 1.02–1.11]) increased. Conclusions Patients of female sex and younger age reported on admission more frequently atypical stroke symptoms. Attention should be drawn to this possible atypical first presentation to facilitate correct identification and early stroke revascularization treatment to improve the outcome for both sexes.
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Affiliation(s)
- Heidi S. Eddelien
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Heidi S. Eddelien
| | - Jawad H. Butt
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Thomas Christensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Nordsjællands Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne K. Danielsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Gastroenterology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Guido G, Crivellaro E, De Fortunato G, Melloni L. Sex and age dimorphism of the gut-brain axis in ischemic stroke: a systematic review of preliminary studies. Brain Res 2022; 1784:147888. [DOI: 10.1016/j.brainres.2022.147888] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/13/2022] [Accepted: 03/16/2022] [Indexed: 01/04/2023]
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Pacheco C, Mullen KA, Coutinho T, Jaffer S, Parry M, Van Spall HG, Clavel MA, Edwards JD, Sedlak T, Norris CM, Dhukai A, Grewal J, Mulvagh SL. The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 5: Sex- and Gender-Unique Manifestations of Cardiovascular Disease. CJC Open 2022; 4:243-262. [PMID: 35386135 PMCID: PMC8978072 DOI: 10.1016/j.cjco.2021.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/17/2021] [Indexed: 12/15/2022] Open
Abstract
This Atlas chapter summarizes sex- and some gender-associated, and unique aspects and manifestations of cardiovascular disease (CVD) in women. CVD is the primary cause of premature death in women in Canada and numerous sex-specific differences related to symptoms and pathophysiology exist. A review of the literature was done to identify sex-specific differences in symptoms, pathophysiology, and unique manifestations of CVD in women. Although women with ischemic heart disease might present with chest pain, the description of symptoms, delay between symptom onset and seeking medical attention, and prodromal symptoms are often different in women, compared with men. Nonatherosclerotic causes of angina and myocardial infarction, such as spontaneous coronary artery dissection are predominantly identified in women. Obstructive and nonobstructive coronary artery disease, aortic aneurysmal disease, and peripheral artery disease have worse outcomes in women compared with men. Sex differences exist in valvular heart disease and cardiomyopathies. Heart failure with preserved ejection fraction is more often diagnosed in women, who experience better survival after a heart failure diagnosis. Stroke might occur across the lifespan in women, who are at higher risk of stroke-related disability and age-specific mortality. Sex- and gender-unique differences exist in symptoms and pathophysiology of CVD in women. These differences must be considered when evaluating CVD manifestations, because they affect management and prognosis of cardiovascular conditions in women.
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Affiliation(s)
- Christine Pacheco
- Hôpital Pierre-Boucher, Centre Hospitalier de l’Université de Montréal (CHUM), Longueuil, Quebec, Canada
| | - Kerri-Anne Mullen
- University of Ottawa Heart Institute, Division of Cardiac Prevention and Rehabilitation, Canadian Women’s Heart Health Centre, Ottawa, Ontario, Canada
| | - Thais Coutinho
- University of Ottawa Heart Institute, Division of Cardiac Prevention and Rehabilitation, Canadian Women’s Heart Health Centre, Ottawa, Ontario, Canada
| | - Shahin Jaffer
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Jodi D. Edwards
- University of Ottawa Heart Institute, Division of Cardiac Prevention and Rehabilitation, Canadian Women’s Heart Health Centre, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Tara Sedlak
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Abida Dhukai
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Jasmine Grewal
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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48
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Hoyer C, Schlenker J, Sandikci V, Ebert A, Wittayer M, Platten M, Szabo K. Sex-Specific Differences in Pre-Stroke Characteristics Reveal Vulnerability of Elderly Women. J Pers Med 2022; 12:jpm12030344. [PMID: 35330344 PMCID: PMC8951678 DOI: 10.3390/jpm12030344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
While the sexually dimorphic character of ischemic stroke has been acknowledged along several dimensions, age-specific sex disparities regarding pre-stroke characteristics in particular have received comparatively little attention. This study aimed to identify age-dependent associations between sex and risk factors, premorbidity, and living situation in patients with ischemic stroke to foster the continuing development of dedicated preventative strategies. In a retrospective single-center study, data of patients with acute ischemic stroke (AIS) admitted to the Department of Neurology, University Hospital Mannheim, Germany, between June 2004−June 2020 were included; AIS frequency, vascular risk factors, premorbidity, living situation, and stroke etiology were analyzed across sexes and different age spectra. From a total of 11,003 patients included in the study, 44.1% were female. Women aged >70−≤90 years showed a pronounced increase in stroke frequency, lived alone significantly more frequently, and had a significantly higher degree of pre-stroke disability than men; however, only hypertension and atrial fibrillation were more prevalent in women in this age segment. The seventh and eighth decades are a critical time in which the pre-stroke risk profile changes resulting in an increase in stroke morbidity in women. This emphasizes the relevance of and need for an approach to stroke prevention that is both targeted and integrative.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
- CCU Healthy Brain, Competence Network Preventive Medicine Baden-Württemberg, 68167 Mannheim, Germany
| | - Jan Schlenker
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
| | - Vesile Sandikci
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
| | - Anne Ebert
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
| | - Matthias Wittayer
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
- CCU Healthy Brain, Competence Network Preventive Medicine Baden-Württemberg, 68167 Mannheim, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
| | - Kristina Szabo
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
- CCU Healthy Brain, Competence Network Preventive Medicine Baden-Württemberg, 68167 Mannheim, Germany
- Correspondence:
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49
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Abstract
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.
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Affiliation(s)
- Kathryn M. Rexrode
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Tracy E. Madsen
- Division of Sex and Gender in Emergency Medicine, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Department of Epidemiology, Brown University School of Public Health, Providence RI
| | - Amy Y. X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cheryl Carcel
- Neurology Program, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Eliza C. Miller
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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50
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Bonkhoff AK, Bretzner M, Hong S, Schirmer MD, Cohen A, Regenhardt RW, Donahue KL, Nardin MJ, Dalca AV, Giese AK, Etherton MR, Hancock BL, Mocking SJT, McIntosh EC, Attia J, Benavente OR, Bevan S, Cole JW, Donatti A, Griessenauer CJ, Heitsch L, Holmegaard L, Jood K, Jimenez-Conde J, Kittner SJ, Lemmens R, Levi CR, McDonough CW, Meschia JF, Phuah CL, Rolfs A, Ropele S, Rosand J, Roquer J, Rundek T, Sacco RL, Schmidt R, Sharma P, Slowik A, Söderholm M, Sousa A, Stanne TM, Strbian D, Tatlisumak T, Thijs V, Vagal A, Wasselius J, Woo D, Zand R, McArdle PF, Worrall BB, Jern C, Lindgren AG, Maguire J, Fox MD, Bzdok D, Wu O, Rost NS. Sex-specific lesion pattern of functional outcomes after stroke. Brain Commun 2022; 4:fcac020. [PMID: 35282166 PMCID: PMC8914504 DOI: 10.1093/braincomms/fcac020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/30/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Abstract
Stroke represents a considerable burden of disease for both men and women. However, a growing body of literature suggests clinically relevant sex differences in the underlying causes, presentations and outcomes of acute ischaemic stroke. In a recent study, we reported sex divergences in lesion topographies: specific to women, acute stroke severity was linked to lesions in the left-hemispheric posterior circulation. We here determined whether these sex-specific brain manifestations also affect long-term outcomes. We relied on 822 acute ischaemic patients [age: 64.7 (15.0) years, 39% women] originating from the multi-centre MRI-GENIE study to model unfavourable outcomes (modified Rankin Scale >2) based on acute neuroimaging data in a Bayesian hierarchical framework. Lesions encompassing bilateral subcortical nuclei and left-lateralized regions in proximity to the insula explained outcomes across men and women (area under the curve = 0.81). A pattern of left-hemispheric posterior circulation brain regions, combining left hippocampus, precuneus, fusiform and lingual gyrus, occipital pole and latero-occipital cortex, showed a substantially higher relevance in explaining functional outcomes in women compared to men [mean difference of Bayesian posterior distributions (men - women) = -0.295 (90% highest posterior density interval = -0.556 to -0.068)]. Once validated in prospective studies, our findings may motivate a sex-specific approach to clinical stroke management and hold the promise of enhancing outcomes on a population level.
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Affiliation(s)
- Anna K. Bonkhoff
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Martin Bretzner
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Univ. Lille, Inserm, CHU Lille, U1171—LilNCog (JPARC)—Lille Neurosciences & Cognition, Lille F-59000, France
| | - Sungmin Hong
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Markus D. Schirmer
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Clinic for Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Alexander Cohen
- Center for Brain Circuit Therapeutics, Department of Neurology, Psychiatry, and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W. Regenhardt
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathleen L. Donahue
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco J. Nardin
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adrian V. Dalca
- Computer Science and Artificial Intelligence Lab, Massachusetts Institute of Technology, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - Anne-Katrin Giese
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark R. Etherton
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brandon L. Hancock
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - Steven J. T. Mocking
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - Elissa C. McIntosh
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - John Attia
- Hunter Medical Research Institute, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Oscar R. Benavente
- Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Stephen Bevan
- School of Life Sciences, University of Lincoln, Lincoln, UK
| | - John W. Cole
- Department of Neurology, University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | - Amanda Donatti
- School of Medical Sciences, University of Campinas (UNICAMP) and the Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, SP, Brazil
| | - Christoph J. Griessenauer
- Department of Neurosurgery, Geisinger, Danville, PA, USA
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, MO, USA
- Department of Neurology, Washington University School of Medicine & Barnes-Jewish Hospital, St Louis, MO, USA
| | - Lukas Holmegaard
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jordi Jimenez-Conde
- Department of Neurology, Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d’Investigacions Mèdiques), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Steven J. Kittner
- Department of Neurology, University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease (LIND), KU Leuven—University of Leuven, Leuven, Belgium
- Department of Neurology, VIB, Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Leuven, Belgium
| | - Christopher R. Levi
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | | | - Chia-Ling Phuah
- Department of Neurology, Washington University School of Medicine & Barnes-Jewish Hospital, St Louis, MO, USA
| | | | - Stefan Ropele
- Department of Neurology, Clinical Division of Neurogeriatrics, Medical University Graz, Graz, Austria
| | - Jonathan Rosand
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jaume Roquer
- Department of Neurology, Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d’Investigacions Mèdiques), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Tatjana Rundek
- Department of Neurology and Evelyn F. McKnight Brain Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Ralph L. Sacco
- Department of Neurology and Evelyn F. McKnight Brain Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Reinhold Schmidt
- Department of Neurology, Clinical Division of Neurogeriatrics, Medical University Graz, Graz, Austria
| | - Pankaj Sharma
- Institute of Cardiovascular Research Royal Holloway, University of London (ICR2UL), London, UK
- St Peter’s and Ashford Hospital, Egham, UK
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Martin Söderholm
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund and Malmö, Malmo, Sweden
| | - Alessandro Sousa
- School of Medical Sciences, University of Campinas (UNICAMP) and the Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, SP, Brazil
| | - Tara M. Stanne
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- Department of Neurology, Austin Health, Heidelberg, Australia
| | - Achala Vagal
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Johan Wasselius
- Department of Clinical Sciences Lund, Radiology, Lund University, Lund, Sweden
- Department of Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ramin Zand
- Department of Neurology, Geisinger, Danville, PA, USA
| | - Patrick F. McArdle
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradford B. Worrall
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Christina Jern
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Genetics and Genomics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Arne G. Lindgren
- Department of Neurology, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | - Jane Maguire
- University of Technology Sydney, Sydney, Australia
| | - Michael D. Fox
- Center for Brain Circuit Therapeutics, Department of Neurology, Psychiatry, and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Danilo Bzdok
- Department of Biomedical Engineering, McConnell Brain Imaging Centre, Montreal Neurological Institute, Faculty of Medicine, School of Computer Science, McGill University, Montreal, Canada
- Mila—Quebec Artificial Intelligence Institute, Montreal, Canada
| | - Ona Wu
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Natalia S. Rost
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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