Sex differences in stroke

Assessing the causal association of pregnancy complications with diabetes and cardiovascular disease

Background

To the best of our knowledge, numerous observational studies have linked pregnancy complications to increased risks of diabetes and cardiovascular disease (CVD), causal evidence remains lacking. Our aim was to estimate the association of adverse pregnancy outcomes with diabetes and cardiovascular diseases.

Methods

A two-sample Mendelian randomization (MR) analysis was employed, which is not subject to potential reverse causality. Data for pregnancy complications were obtained from the FinnGen consortium. For primary analysis, outcome data on diabetes, related traits, stroke, and coronary heart disease (CHD) were extracted from the GWAS Catalog, MAGIC, MEGASTROKE, and CARDIoGRAMplusC4D consortium. The MAGIC and UKB consortium datasets were used for replication and meta-analysis. Causal effects were appraised using inverse variance weighted (IVW), weighted median (WM), and MR-Egger. Sensitivity analyses were implemented with Cochran's Q test, MR-Egger intercept test, MR-PRESSO, leave-one-out (LOO) analysis and the funnel plot.

Results

Genetically predicted gestational diabetes mellitus (GDM) was causally associated with an increased diabetes risk (OR=1.01, 95% CI=1-1.01, P<0.0001), yet correlated with lower 2-hour post-challenge glucose levels (OR=0.89, 95% CI=0.82-0.97, P=0.006). Genetic liability for pregnancy with abortive outcomes indicated decreased fasting insulin levels (OR=0.97, 95% CI=0.95-0.99, P=0.02), but potentially elevated glycated hemoglobin levels (OR=1.02, 95% CI=1.01-1.04, P=0.01). Additionally, hypertensive disorders in pregnancy was tentatively linked to increased risks of stroke (OR=1.11, 95% CI=1.04-1.18, P=0.002) and CHD (OR=1.3, 95% CI=1.2-1.4, P=3.11E-11). Gestational hypertension might have a potential causal association with CHD (OR=1.11, 95% CI=1.01-1.22, P=0.04). No causal associations were observed between preterm birth and diabetes, stroke, or CHD.

Conclusion

The findings of this study provide genetic evidence that gestational diabetes, pregnancy with abortive outcomes, and hypertensive disorders in pregnancy may serve as early indicators for metabolic and cardiovascular risks. These insights are pivotal for the development of targeted screening and preventive strategies.

Sex in cardiovascular disease: Why this biological variable should be considered in in vitro models

Cardiovascular disease (CVD), the world's leading cause of death, exhibits notable epidemiological, clinical, and pathophysiological differences between sexes. Many such differences can be linked back to cardiovascular sexual dimorphism, yet sex-specific in vitro models are still not the norm. A lack of sex reporting and apparent male bias raises the question of whether in vitro CVD models faithfully recapitulate the biology of intended treatment recipients. To ensure equitable treatment for the overlooked female patient population, sex as a biological variable (SABV) inclusion must become commonplace in CVD preclinical research. Here, we discuss the role of sex in CVD and underlying cardiovascular (patho)physiology. We review shortcomings in current SABV practices, describe the relevance of sex, and highlight emerging strategies for SABV inclusion in three major in vitro model types: primary cell, stem cell, and three-dimensional models. Last, we identify key barriers to inclusive design and suggest techniques for overcoming them.

Sex and stroke risk factors: A review of differences and impact

OBJECTIVES

There is an increase in stroke incidence risk over the lifetime of women, given their longer life expectancy. However, an alarming trend for sex disparities, particularly in certain stroke risk factors, shows a concerning need for focus on sex differences in stroke prevention and treatment for women. In this article, we are addressing sex differences in both traditional and sex-specific stroke risk factors.

METHODS

We searched PubMed from inception to December 2022 for articles related to sex differences and risk factors for stroke. We reviewed full-text articles for relevance and ultimately included 152 articles for this focused review.

RESULTS

Women are at increased risk for stroke from both traditional and non-traditional stroke risk factors. As women age, they have a higher disease burden of atrial fibrillation, increased risk of stroke related to diabetes, worsening lipid profiles, and higher prevalence of hypertension and obesity compared to men. Further, women carry sex hormone-specific risk factors for stroke, including the age of menarche, menopause, pregnancy, and its complications, as well as hormonal therapy. Men have a higher prevalence of tobacco use and atrial fibrillation, as well as an increased risk for stroke related to hyperlipidemia. Additionally, men have sex-specific risks related to low testosterone levels.

CONCLUSIONS

By identifying biological sex-specific risk factors for stroke, developing robust collaborations, researching, and applying the knowledge for risk reduction strategies, we can begin to tailor prevention and reduce the global burden of stroke morbidity and mortality.

Exploring sex differences: insights into gene expression, neuroanatomy, neurochemistry, cognition, and pathology

Increased knowledge about sex differences is important for development of individualized treatments against many diseases as well as understanding behavioral and pathological differences. This review summarizes sex chromosome effects on gene expression, epigenetics, and hormones in relation to the brain. We explore neuroanatomy, neurochemistry, cognition, and brain pathology aiming to explain the current state of the art. While some domains exhibit strong differences, others reveal subtle differences whose overall significance warrants clarification. We hope that the current review increases awareness and serves as a basis for the planning of future studies that consider both sexes equally regarding similarities and differences.

Hyperperfusion profiles after recanalization differentially associate with outcomes in a rat ischemic stroke model

Futile recanalization hampers prognoses of ischemic stroke after successful mechanical thrombectomy, hypothetically through post-recanalization perfusion deficits, onset-to-groin delays and sex effects. Clinically, acute multiparametric imaging studies remain challenging. We assessed possible relationships between these factors and disease outcome after experimental cerebral ischemia-reperfusion, using translational MRI, behavioral testing and multi-model inference analyses. Male and female rats (N = 60) were subjected to 45-/90-min filament-induced transient middle cerebral artery occlusion. Diffusion, T2- and perfusion-weighted MRI at occlusion, 0.5 h and four days after recanalization, enabled tracking of tissue fate, and relative regional cerebral blood flow (rrCBF) and -volume (rrCBV). Lesion areas were parcellated into core, salvageable tissue and delayed injury, verified by histology. Recanalization resulted in acute-to-subacute lesion volume reductions, most apparently in females (n = 19). Hyperacute normo-to-hyperperfusion in the post-ischemic lesion augmented towards day four, particularly in males (n = 23). Tissue suffering delayed injury contained higher ratios of hypoperfused voxels early after recanalization. Regressed against acute-to-subacute lesion volume change, increased rrCBF associated with lesion growth, but increased rrCBV with lesion reduction. Similar relationships were detected for behavioral outcome. Post-ischemic hyperperfusion may develop differentially in males and females, and can be beneficial or detrimental to disease outcome, depending on which perfusion parameter is used as explanatory variable.

Preconditioning with interleukin-1 alpha is required for the neuroprotective properties of mesenchymal stem cells after ischemic stroke in mice

Mesenchymal stem cell (MSC) pre-conditioning with interleukin-1 alpha (IL-1ɑ) drives MSCs toward a potent anti-inflammatory phenotype. The aim of this study was to assess the therapeutic potential of intra-arterially administered IL-1ɑ preconditioned MSCs, after experimental cerebral ischaemia in mice. After 3 h from the start of middle cerebral artery occlusion, animals were treated with vehicle, 9.1 × 104 non-conditioned or IL-1ɑ preconditioned MSCs by intra-arterial administration. Animals were allowed to recover for 1.5 h after treatment to measure cerebral blood flow (CBF), and 3 days or 14 days post-stroke to evaluate lesion volume and functional outcomes. At 3-days post-stroke preconditioned MSCs reduced (by 67%) lesion volume and increased CBF (by 32%) compared to vehicle, while non-conditioned MSCs had no effect. A separate cohort of animals recovered to 14 days post-stroke also showed reduced infarct volume (by 51%) at 48 h (assessed by MRI) and better functional recovery at 14 days when treated with preconditioned MSCs when compared to vehicle. Preconditioning MSCs with IL-1α increases their neuroprotective capability and improves functional recovery after delayed intra-arterial administration. With increasing use of thrombectomy, the adjunct use of preconditioned MSCs therefore represents a highly relevant therapy to improve outcomes in ischemic stroke.

Hyperacute autonomic and cortical function recovery following cardiac arrest resuscitation in a rodent model

OBJECTIVE

There is a complex interaction between nervous and cardiovascular systems, but sparse data exist on brain-heart electrophysiological responses to cardiac arrest resuscitation. Our aim was to investigate dynamic changes in autonomic and cortical function during hyperacute stage post-resuscitation.

METHODS

Ten rats were resuscitated from 7-min cardiac arrest, as indicators of autonomic response, heart rate (HR), and its variability (HRV) were measured. HR was monitored through continuous electrocardiography, while HRV was assessed via spectral analysis, whereby the ratio of low-/high-frequency (LF/HF) power indicates the balance between sympathetic/parasympathetic activities. Cortical response was evaluated by continuous electroencephalography and quantitative analysis. Parameters were quantified at 5-min intervals over the first-hour post-resuscitation. Neurological outcome was assessed by Neurological Deficit Score (NDS, range 0-80, higher = better outcomes) at 4-h post-resuscitation.

RESULTS

A significant increase in HR was noted over 15-30 min post-resuscitation (p < 0.01 vs.15-min, respectively) and correlated with higher NDS (rs = 0.56, p < 0.01). LF/HF ratio over 15-20 min was positively correlated with NDS (rs = 0.75, p < 0.05). Gamma band power surged over 15-30 min post-resuscitation (p < 0.05 vs. 0-15 min, respectively), and gamma band fraction during this period was associated with NDS (rs ≥0.70, p < 0.05, respectively). Significant correlations were identified between increased HR and gamma band power during 15-30 min (rs ≥0.83, p < 0.01, respectively) and between gamma band fraction and LF/HF ratio over 15-20 min post-resuscitation (rs = 0.85, p < 0.01).

INTERPRETATIONS

Hyperacute recovery of autonomic and cortical function is associated with favorable functional outcomes. While this observation needs further validation, it presents a translational opportunity for better autonomic and neurologic monitoring during early periods post-resuscitation to develop novel interventions.

The Pattern of Neurological Conditions in a Tertiary Institution in Nigeria: Six Years Experience in Ekiti State, Nigeria

Background

Neurological disorders constitute major causes of morbidity, and globally, they are the leading causes of death. There is a dearth of neurologists in most African countries and the very few available ones are concentrated in urban areas. The cardiovascular and communicable risk factors responsible for most cases of acute and chronic neurological disorders are also prevalent in rural areas. Although patients from the neighbouring states attend the study centre, the majority are indigent. Therefore, there is a need to observe the pattern of these disorders in Ekiti, to appreciate the disease burden as it would help in the judicious allocation of human and other healthcare resources.

Methodology

We reviewed the case files of patients seen at the neurology clinic and admitted via the emergency department into the Federal Teaching Hospital, Ido-Ekiti, over a period of 6 years (2016 to 2021).

Results

A total of 881patients were seen during the study period, and they were mostly elderly male patients with chronic disorders in which stroke was the most common neurological disorder (44.9%) followed by seizure disorder (13.1%), and neurodegenerative disorders (9.9%). Tumors and myopathies were the least seen disorders.

Conclusion

Health literacy on cardiovascular risk factors and even the distribution of manpower and material resources will help reduce the burden of neurological disorders among the attendees of the Ekiti tertiary health institution.

Clinical characteristic of a Haitian stroke cohort and a scoping review of the literature of stroke among the Haitian population

Background and Aim

There are significant disparities in stroke care and outcomes between low- and middle-income countries compared to high-income countries. Haiti, a lower-middle-income country, suffers from a lack of resources for acute stroke management. This study is the first to report the epidemiological profile of the Haitian population presenting with stroke symptoms at the largest academic hospital in the nation.

Methods

This is an observational study conducted over a period of 5 months from April 2021 to August 2021 in the Internal Medicine Department of the State University Hospital of Haiti. There were 51 included patients who were suspected to have had an acute stroke. A descriptive statistical analysis was conducted. A scoping review of the literature was also conducted.

Results

Over 50% of included patients were between 19 and 65 years old. The mean age at presentation was 61 years, and patients were predominantly female (64.7%). The prevalence of severe motor deficits was over 96%. The mean National Institutes of Health Stroke Scale was 12. Only 15.7% of patients (8/51) had a computed tomography (CT) scan during their hospitalization. The median time to CT scan was 84 h after symptom onset. About 80% of those with complications took more than 24 h to arrive at the hospital after the onset of symptoms. Eleven percent of patients had complications, and the mortality rate was 3.9%. There was a significant association between the Modified Rankin Scale and the occurrence of complications (p = 0.016). National Institutes of Health Stroke Scale (NIHSS) score had a significant association with the Glasgow score (F = 6.3; p < 0.001) where an inversely proportional correlation was observed between them (r = -0.7; p < 0.001) and a proportional correlation with the Rankin prediction score and the NIHSS (r = 0.3, p = 0.04). Little is known about the epidemiology of stroke patients in Haiti, and this limits the ability to develop targeted interventions to improve outcomes. In our scoping review, only three pertinent studies were identified over a 25-year period, this leads to a lack of data in regard to stroke care in Haiti mainly due to the absence of trained personnel.

Conclusion

In our cohort, stroke is mainly affecting female patients. The majority of stroke patients have moderate to severe motor deficits and took more than 24 h to arrive at the hospital. Urgent assistance is needed to strengthen personnel and infrastructure dedicated to stroke. Neurological assessment based on NIHSS and Rankin score should be systematic in stroke evaluation in Haiti.

Relevance for Patients

This study is relevant for patients because it emphasizes the challenges of stroke management in Haiti due to the non-availability of reference drugs, the time to arrive at the hospital to start treatment, as well as the means of diagnosis which are limited, like the CT scan. While stroke prevalence is on the rise in the country, it is the highest in the Caribbean and Latin America region.

Association of admission plasma glucose level and cerebral computed tomographic perfusion deficit volumes

INTRODUCTION

Hyperglycemia in acute ischemic stroke (AIS) is frequent and associated with worse outcome. Yet, strict glycemic control in AIS patients has failed to yield beneficial outcome. So far, the underlying pathophysiological mechanisms of admission hyperglycemia in AIS have remained not fully understood. We aimed to evaluate the yet equivocal association of hyperglycemia with computed tomographic perfusion (CTP) deficit volumes.

PATIENTS AND METHODS

We included 832 consecutive AIS and transient ischemic attack (TIA) patients who underwent CTP as a part of screening for recanalization treatment (stroke code) between 3/2018 and 10/2020, from the prospective cohort of Helsinki Stroke Quality Registry. Associations of admission glucose level (AGL) and CTP deficit volumes, namely ischemic core, defined as relative cerebral blood flow <30%, and hypoperfusion lesions Time-to-maximum (Tmax) >6 s and Tmax >10s, as determined with RAPID® software, were analyzed with a linear regression model adjusted for age, sex, C-reactive protein, and time from symptom onset to imaging.

RESULTS

AGL median was 6.8 mmol/L (interquartile range 5.9-8.0 mmol/L), and 222 (27%) patients were hyperglycemic (glucose >7.8 mmol/L) on admission. In non-diabetic patients (643 [77%]), AGL was significantly associated with volume of Tmax. >6 s (regression coefficient [RC] 4.8, 95% confidence interval [CI] 0.49-9.1), of Tmax >10s (RC 4.6, 95% CI 1.2-8.1), and of ischemic core (RC 2.6, 95% CI 0.64-4.6). No significant associations were shown in diabetic patients.

CONCLUSION

Admission hyperglycemia appears to be associated with both larger volume of hypoperfusion lesions and of ischemic core in non-diabetic stroke code patients with AIS and TIA.

Venous thromboembolism-related genetic determinant F11 rs4253417 is a potential prognostic factor in ischaemic stroke

Ischaemic stroke (IS) and venous thromboembolism (VTE) are two forms of thromboembolism that, although distinct, seem to share numerous risk factors. Concerning genetic risk factors, while many VTE genetic markers have been reported, inclusively by genome-wide association studies (GWAS), the identification and validation of genetic determinants underlying IS pathogenesis have been challenging. Considering that IS and VTE shared biological pathways and aetiological factors, the severity of IS might be also influenced by VTE-related genetic variants. Thus, the present study was designed to analyse the impact of six VTE GWAS-identified genetic variants on the clinical outcome of 363 acute IS patients. Results revealed that the single-nucleotide polymorphism (SNP) F11 rs4253417 was an independent predictor of the 5-year risk of death among patients with total anterior circulation infarct (TACI). Namely, the ones carrying the SNP C allele presented a fourfold increase in the 5-year risk of death compared to TT genotype carriers (CC/CT vs. TT; adjusted HR, 4.240; 95% CI, 1.260-14.270; P = 0.020). This SNP is known to be associated with coagulation factor XI (FXI) levels, thus with implications in haemostasis and inflammation. As such, F11 rs4253417 might be a promising prognostic biomarker among TACI patients to aid in clinical decision-making. However, additional investigation is required to confirm the study's results and dissect the underlying mechanisms.

Ischemic stroke-related gene expression profiles across species: a meta-analysis

Stroke patients are often left with permanent disabilities with no regenerative treatment options. Unbiased RNA sequencing studies decoding the transcriptional signature of stroked tissue hold promise to identify new potential targets and pathways directed to improve treatment for stroke patients. Here, gene expression profiles of stroked tissue across different time points, species, and stroke models were compared using NCBI GEO database. In total, 34 datasets from mice, rats, humans, and primates were included, exploring gene expression differences in healthy and stroked brain tissue. Distinct changes in gene expression and pathway enrichment revealed the heterogenicity of the stroke pathology in stroke-related pathways e.g., inflammatory responses, vascular repair, remodelling and cell proliferation and adhesion but also in diverse general, stroke-unrelated pathways that have to be carefully considered when evaluating new promising therapeutic targets.

Talking about Sexuality in Stroke Individuals: The New Era of Sexual Rehabilitation

One of the largest causes of mortality and disability worldwide is stroke. In the last twenty years significant objectives have been achieved in the early and chronic treatment of motor and cognitive dysfunctions, increasing the quality of life in patients and their caregivers. However, there is an unresolved clinical issue that remains: sexual dysfunctions. Multiple etiologies, including organic (such as lesion localization, premorbid medical problems, and drugs) and psychosocial (such as fear of recurrences, loss of self-esteem, role shifts, anxiety, and depression), are associated with sexual deficits. In this perspective review, we reported the last piece of evidence about this crucial topic which drastically affects the quality of life of these patients. Indeed, although patients may often not disclose their sexual concerns, literature demonstrates that they seek help concerning this issue. On the other side, clinicians working in the rehabilitation field are not always comfortable or prepared to deal with sexuality and sexual function in neurological patients. A new phase of the training course should be launched including different physicians, nurses, rehabilitation specialists, and social workers, to learn how to deal with topics related to sexuality. As a result, professional sexual counselors should now become a structured part of stroke settings and rehabilitation with new effective tools (i.e., PLISSIT model; TDF program) for improving quality of life.

Effects of air pollution control policies on intracerebral hemorrhage mortality among residents in Tianjin, China

BACKGROUND

Exposure to air pollution is an important risk factor for intracerebral hemorrhage (ICH), which is a major cause of death worldwide. However, the relationship between ICH mortality and air quality improvement has been poorly studied. This study aims to evaluate the impact of the air pollution control policies in the Beijing-Tianjin-Hebei region on ICH mortality among Tianjin residents.

METHODS

This study used an interrupted time series analysis. We fitted autoregressive integrated moving average (ARIMA) models to assess the changes in ICH deaths before and after the interventions of air pollution control policies based on the data of ICH deaths in Tianjin collected by the Tianjin Center for Disease Control and Prevention.

RESULTS

Between 2009 and 2020, there were 63,944 ICH deaths in Tianjin, and there was an overall decreasing trend in ICH mortality. The intervention conducted in June 2014 resulted in a statistically significant (p = 0.03) long-term trend change, reducing the number of deaths from ICH by 0.69 (95% confidence interval [CI]: -1.30 to -0.07) per month. The intervention in October 2017 resulted in a statistically significant (p = 0.04) immediate decrease of 25.74 (95% CI: -50.62 to -0.85) deaths from ICH in that month. The intervention in December 2017 caused a statistically significant (p = 0.04) immediate reduction of 26.58 (95% CI: -52.02 to -1.14) deaths from ICH in that month. The intervention in March 2018 resulted in a statistically significant (p = 0.02) immediate decrease of 30.40 (95% CI: -56.41 to -4.40) deaths from ICH in that month. No significant differences were observed in the changes of male ICH mortality after any of the four interventions. However, female ICH deaths showed statistically significant long-term trend change after the intervention in June 2014 and immediate changes after the interventions in December 2017 and March 2018. Overall, the interventions prevented an estimated 5984.76 deaths due to ICH.

CONCLUSION

During the study period, some interventions of air pollution control policies were significantly associated with the reductions in the number of deaths from ICH among residents in Tianjin. ICH survivors and females were more sensitive to the protective effects of the interventions. Interventions for air pollution control can achieve public health gains in cities with high levels of air pollution.

Comparison of peripheral and cerebral vascular function between premenopausal, early and late postmenopausal females

NEW FINDINGS

What is the central question of this study? We sought to investigate whether peripheral and cerebrovascular function are impaired in early and late postmenopausal females compared with premenopausal females, while also accounting for nitric oxide and estradiol levels. What is the main finding and its importance? We observed no differences in peripheral vascular and cerebrovascular function between healthy and physically active premenopausal females and early and late postmenopausal females. Our findings contradict previous cross-sectional observations of vascular and cerebrovascular dysfunction across menopause. Longitudinal studies assessing vascular and cerebrovascular outcomes across the menopausal transition are warranted.

ABSTRACT

The risk of cardiovascular and cerebrovascular disease increases in ageing females, coinciding with the onset of menopause. Differences in peripheral and cerebrovascular function across menopausal stages, however, are poorly characterized. The aim of this study was to compare peripheral and cerebrovascular function between healthy premenopausal (PRE), early (1-6 years after final menstrual period; E-POST) and late (>6 years after final menstrual period; L-POST) postmenopausal females. We also explored the association between reproductive hormones, NO bioavailability and cerebrovascular function. In 39 females (40-65 years of age), we measured arterial stiffness, brachial artery flow-mediated dilatation, and cerebrovascular reactivity (CVR) to hypercapnia in the middle (MCAv) and internal (ICA) carotid arteries. Follicle-stimulating hormone, estradiol, progesterone and plasma nitrate and nitrite concentrations were also measured. Years since final menstrual period (PRE, 0 ± 0 years; E-POST, 3 ± 1 years; L-POST, 11 ± 4 years; P < 0.001) and estradiol levels (PRE, 145.5 ± 65.6 pg ml-1 ; E-POSTm 30.2 ± 81.2 pg ml-1 ; L-POST, 7.7 ± 11.3 pg ml-1 ; P < 0.001) were different between groups. All groups exceeded the guidelines for recommended physical activity. There were no group differences in blood pressure (P = 0.382), arterial stiffness (P = 0.129), flow-mediated dilatation (P = 0.696) or MCAv CVR (P = 0.442). The ICA CVR blood flow response was lower in PRE compared with L-POST (26.5 ± 19.2 vs. 47.8 ± 12.6%; P = 0.010), but after adjusting for age these differences were no longer present. Flow-mediated dilatation (r = 0.313, P = 0.105) and ICA CVR (r = -0.154, P = 0.495) were not associated with the estradiol concentration. There were no associations between the estradiol concentration and NO bioavailability. These results suggest that in healthy, physically active early and late postmenopausal females, vascular and cerebrovascular function is generally well preserved.

Large Burden of Stroke Incidence in People with Cardiac Disease: A Linked Data Cohort Study

Purpose

People with cardiac disease have 2-4 times greater risk of stroke than the general population. We measured stroke incidence in people with coronary heart disease (CHD), atrial fibrillation (AF) or valvular heart disease (VHD).

Methods

We used a person-linked hospitalization/mortality dataset to identify all people hospitalized with CHD, AF or VHD (1985-2017), and stratified them as pre-existing (hospitalized 1985-2012 and alive at October 31, 2012) or new (first-ever cardiac hospitalization in the five-year study period, 2012-2017). We identified first-ever strokes occurring from 2012 to 2017 in patients aged 20-94 years and calculated age-specific and age-standardized rates (ASR) for each cardiac cohort.

Results

Of the 175,560 people in the cohort, most had CHD (69.9%); 16.3% had multiple cardiac conditions. From 2012-17, 5871 first-ever strokes occurred. ASRs were greater in females than males in single and multiple condition cardiac groups, largely driven by rates in females aged ≥75 years, with stroke incidence in this age group being at least 20% greater in females than males in each cardiac subgroup. In females aged 20-54 years, stroke incidence was 4.9-fold greater in those with multiple versus single cardiac conditions. This differential declined with increasing age. Non-fatal stroke incidence was greater than fatal stroke in all age groups except in the 85-94 age group. Incidence rate ratios were up to 2-fold larger in new versus pre-existing cardiac disease.

Conclusion

Stroke incidence in people with cardiac disease is substantial, with older females, and younger patients with multiple cardiac conditions, at elevated risk. These patients should be specifically targeted for evidence-based management to minimize the burden of stroke.

Enhanced cognitive interference during visuomotor tasks may cause eye-hand dyscoordination

In complex visuomotor tasks, such as cooking, people make many saccades to continuously search for items before and during reaching movements. These tasks require cognitive resources, such as short-term memory and task-switching. Cognitive load may impact limb motor performance by increasing demands on mental processes, but mechanisms remain unclear. The Trail-Making Tests, in which participants sequentially search for and make reaching movements to 25 targets, consist of a simple numeric variant (Trails-A) and a cognitively challenging variant that requires alphanumeric switching (Trails-B). We have previously shown that stroke survivors and age-matched controls make many more saccades in Trails-B, and those increases in saccades are associated with decreases in speed and smoothness of reaching movements. However, it remains unclear how patients with neurological injuries, e.g., stroke, manage progressive increases in cognitive load during visuomotor tasks, such as the Trail-Making Tests. As Trails-B trial progresses, switching between numbers and letters leads to progressive increases in cognitive load. Here, we show that stroke survivors with damage to frontoparietal areas and age-matched controls made more saccades and had longer fixations as they progressed through the 25 alphanumeric targets in Trails-B. Furthermore, when stroke survivors made saccades during reaching movements in Trails-B, their movement speed slowed down significantly. Thus, damage to frontoparietal areas serving cognitive motor functions may cause interference between oculomotor, visual, and limb motor functions, which could lead to significant disruptions in activities of daily living. These findings augment our understanding of the mechanisms that underpin cognitive-motor interference during complex visuomotor tasks.

Relationship between time of referral for physiotherapy and length of stay after stroke in a Nigerian tertiary hospital: a retrospective study

Background

Despite the known benefits of physiotherapy, the relationship between its time of referral and the length of stay (LOS) of stroke patients in developing countries has been understudied. This relationship was investigated in this study as we determined the relationships between LOS and time of referral and LOS and the number of physiotherapy sessions received.

Methods

Medical records of stroke patients admitted at Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife between January 2007 and December 2016 were retrieved. Descriptive statistics were used to summarize the data, independent samples t test, and one-way analysis of variance were used to determine differences, and Pearson correlation was used to determine relationships.

Results

A total of 585 medical records were retrieved. With an inpatient mortality rate of 40.7%, only 243 case records were included in the study. The mean LOS was 17 ± 13 days, and 63.4% received inpatient physiotherapy. Patients who were referred for physiotherapy (p = 0.019) and those who utilized physiotherapy (p = 0.001) had higher LOS. Also, there were significant correlations between LOS and the time of referral for physiotherapy (r = 0.575, p = 0.001) and LOS and the number of physiotherapy sessions received (r = 0.293, p = 0.001).

Conclusions

Stroke patients who utilized physiotherapy had longer LOS. The longer the time of referral and the higher the number of physiotherapy sessions, the longer the LOS. Early referral and commencement of physiotherapy optimize physiotherapy utilization, which may reduce the LOS of stroke patients.

Sex differences in the mouse photothrombotic stroke model investigated with X-ray fluorescence microscopy and Fourier transform infrared spectroscopic imaging

Stroke is a leading cause of death and disability around the world. To date, the majority of pre-clinical research has been performed using male lab animals and results are commonly generalized to both sexes. In clinical stoke cases females have a higher incidence of ischemic stroke and poorer outcomes, compared to males. Best practices for improving translatability of findings for stroke, encourage the use of both sexes in studies. Since estrogen and progesterone have recognized neuroprotective effects, it is important to compare the size, severity and biochemical composition of the brain tissue following stroke in female and male animal models. In this study a photothrombotic focal stroke was induced in male and female mice. Vaginal secretions were collected twice daily to track the stage of estrous. Mice were euthanized at 24 h post-stroke. Histological staining, Fourier transform infrared imaging and X-ray fluorescence imaging were performed to better define the size and metabolic markers in the infarct core and surrounding penumbra. Our results show while the female mice had a significantly lower body mass than males, the cross-sectional area of the brain and the size of infarct and penumbra were not significantly different between the groups. In addition to the general expected sex-linked differences of altered NADH levels between males and females, estrus females had significantly elevated glycogen in the penumbra compared with males and total phosphorus levels were noted to be higher in the penumbra of estrus females. Elevated glycogen reserves in the tissue bordering the infarct core in females may present alternatives for improved functional recovery in females in the early post-stroke phase.

The Impact of Depression on the Functional Outcome of the Elderly Stroke Victim from a Gender Perspective: A Systematic Review

(1) Background: The aim of this systematic review focused on analyzing the impact of depression on the functional outcome of the elderly stroke victim and how this disorder affects both the female and the male population. (2) Methods: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review was registered in PROSPERO (ID 346284). The systematic search for clinical trials was performed in the databases Pubmed, Otseeker, Scopus, Web of Science, Psycinfo, Medline Complete, ScienceDirect, SciELO, and Dialnet. Articles were selected according to the inclusion and exclusion criteria, including those dealing with post-stroke depression in adults whose psychological status had changed. Studies that only assessed the psychological state of caregivers were excluded. (3) Results: In total, 609 articles were identified, of which 11 randomized controlled trials were finally included in the review. The results indicate that post-stroke depression influences the recovery of functionality and quality of life. In addition, the need to detect the mood of the adult population after the stroke and to provide individualized treatment according to the characteristics of the person is highlighted. (4) Conclusions: This systematic review shows how early detection of post-stroke depressive symptoms can improve the degree of disability and quality of life of the person, especially in women.

Sex Differences in Stroke Risk Factors, Clinical Profiles, and In-Hospital Outcomes Among Stroke Patients Admitted to the Medical Ward of Dessie Comprehensive Specialized Hospital, Northeast Ethiopia

BACKGROUND

A stroke is a vascular accident that affects both men and women. The threat of stroke and outcome status differ between the sexes. Such data are lacking in Ethiopia. Therefore, this study assessed sex differences in stroke risk factors, clinical profiles, and outcomes in the medical ward of Dessie comprehensive specialized hospital.

METHODS

A retrospective cross-sectional study was employed among stroke patients. Medical records with complete information and a confirmed diagnosis of stroke using imaging techniques were included in the study. Using simple random sampling, 344 medical records were selected, 312 of which fulfilled the inclusion criteria. Bivariate and multivariate logistic regression analyses and a chi-square test were employed. The frequency, percentage, and mean and standard deviation of the variables were described using descriptive statistics. Findings with a P-value <0.05 were considered statistically significant.

RESULTS

Most of the patients were above or equal to 45 years old in both sexes. A significantly higher number of male than female patients were aged less than 45 years (p-value-0.001). Younger age (AOR: 2.998, p = 0.000), cigarette smoking (AOR: 2.911, p = 0.009), and Khat chewing (AOR: 3.650, p = 0.001) were risk factors for stroke in males. A higher number of males presented with hemiplegia/hemiparesis 89 (28.5%), aphasia 45 (14.4%), and facial palsy 19 (6.1%). However, more females were unconscious (15.1%). Significant differences were not seen in the stroke outcomes. Furthermore, there were no apparent differences in risk factors for stroke-related mortality.

CONCLUSION

Males developed stroke at a younger age. Women were older at the time of stroke onset and presented unconscious. More males experienced hemiplegia/hemiparesis, aphasia, and facial palsy. Smoking, drinking, and khat chewing were risk factors for stroke in men. There were no gender differences in the stroke death rate. Therefore, educating the public about stroke risk factors, lifestyle modification, and conducting prospective research is required.

Strategies for Maintaining Brain Health: The Role of Stroke Risk Factors Unique to Elderly Women

Stroke risk and prevalence increase with advanced age and women tend to be older than men at the time of their first stroke. Advanced age in women confers unique stroke risks that are beyond reproductive factors. Previous reviews and guidelines have largely focused on risk factors specific to women, with a predominant focus on reproductive factors and, therefore, younger to middle-aged women. This review aims to specifically describe stroke risk factors in elderly women, the population of women where the majority of strokes occur, with a focus on atrial fibrillation, hormone therapy, psychosocial risk factors, and cognitive impairment. Our review suggests that prevention and management of stroke risks that are unique or more prevalent in elderly women needs a coordinated system of care from general physicians, general neurologists, vascular and cognitive neurologists, psychologists, cardiologists, patients, and their caretakers. Early identification and management of the elderly woman-specific and traditional stroke risk factors is key for decreasing stroke burden in elderly women. Increased education among elderly women regarding stroke risk factors and their identification should be considered, and an update to the guidelines for prevention of stroke in women is strongly encouraged.

Trends in Mortality from Hemorrhagic Stroke in Korea from 2012 to 2020

Purpose

To analyze trends in mortality rates from hemorrhagic stroke (HS) according to HS subtypes, using nationwide data from January 2012 to December 2020.

Materials and Methods

We used data from the National Health Claims Database provided by the National Health Insurance Service for 2012–2020 using the International Classification of Disease. The age-adjusted mortality rates of HS, which included subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH), were calculated, and additional analyses were conducted according to age and sex.

Results

The age-adjusted mortality rates for HS, SAH, and ICH decreased substantially in both sexes between 2012 and 2020. During the study period, mortality rates for HS decreased from 8.87 deaths per 100,000 inhabitants to 6.27 deaths per 100,000 inhabitants. Regarding SAH, mortality rates decreased from 3.72 deaths per 100,000 inhabitants to 2.57 deaths per 100,000 inhabitants. Concerning ICH, mortality rates decreased from 6.91 deaths per 100,000 inhabitants to 4.75 deaths per 100,000 inhabitants. The average annual percentage change for HS, SAH, and ICH was –0.04, –0.04, and –0.05, respectively. Mortality rates from HS, SAH, and ICH in both sexes decreased from 2012 to 2020 in all age groups.

Conclusion

In Korea, the age-adjusted mortality rate of HS, SAH, and ICH demonstrated a declining trend in both sexes and across all age groups. These results may aid in the design and improvement of preventive strategies.

Sex differences in outcome after thrombectomy for acute ischemic stroke. A propensity score-matched study

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.

Gut dysbiosis and age-related neurological diseases in females

Historically, females have been underrepresented in biological research. With increased interest in the gut microbiome and the gut-brain axis, it is important for researchers to pursue studies that consider sex as a biological variable. The composition of the gut microbiome is influenced by environmental factors, disease, diet, and varies with age and by sex. Detrimental changes in the gut microbiome, referred to as dysbiosis, is believed to influence the development and progression of age-related neurodegenerative disorders such as Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, and stroke. Many are investigating the changes in microbial populations in order or to better understand the role of the gut immunity and the microbiome in neurodegenerative diseases, many of which the exact etiology remains elusive, and no cures exist. Others are working to find diagnostic markers for earlier detection, or to therapeutically modulate microbial populations using probiotics. However, while all these diseases present in reproductively senescent females, most studies only use male animals for their experimental design. Reproductively senescent females have been shown to have differences in disease progression, inflammatory responses, and microbiota composition, therefore, for research to be translational to affected populations it is necessary for appropriate models to be used. This review discusses factors that influence the gut microbiome and the gut brain axis in females, and highlights studies that have investigated the role of dysbiosis in age-related neurodegenerative disorders that have included females in their study design.

Sex differences in cardiovascular risk may be related to sex differences in diet patterns: a narrative review

CONTEXT

Cardiovascular disease (CVD) is the leading cause of death in the United States and globally. The social and biological differences in diet patterns among men and women may play a role in their differential cardiovascular risk.

OBJECTIVE

To describe the dietary patterns associated with CVD risk and investigate the differences in diet patterns between men and women, if these differences affect cardiovascular risk, and to explore potential mechanisms of action.

METHODS

Diet patterns associated with CVD risk were described based on epidemiological and experimental trials. Observational and experimental studies together with systematic and non-systematic reviews were synthesised to examine sex differences in diet and cardiovascular risk factors.

RESULTS

Differences in vasculature and body composition between sexes may be mediated by dissimilarities in adherence to diet patterns and nutrient metabolism. Salt sensitivity and breakdown and storage of lipids may account for some differences in CVD risk between men and women. Sex differences in social norms, cognitive processing, and odour perception may be affected by biological differences and contribute to differences in cardiovascular risk and dietary patterns.

CONCLUSION

The relation between diet patterns and cardiovascular risk is well-established and sex differences in diet patterns likely differentially affect CVD risk between men and women.

|Therapeutic and preventive effects of apigenin in cerebral ischemia: a review

APG can exert various protective effects against cerebral ischemia. Moreover, APG has shown a highly promising ability to prevent cerebral ischemia in terms of regulating blood glucose, blood pressure, lipids and gut microbes.

Epoxyeicosatrienoic acids and soluble epoxide hydrolase in physiology and diseases of the central nervous system

Epoxyeicosatrienoic acids (EETs) are fatty acid signaling molecules synthesized by cytochrome P450 epoxygenases from arachidonic acid. The biological activity of EETs is terminated when being metabolized by soluble epoxide hydrolase (sEH), a process that serves as a key regulator of tissue EETs levels. EETs act through several signaling pathways to mediate various beneficial effects, including anti-inflammation, anti-apoptosis, and anti-oxidation with relieve of endoplasmic reticulum stress, thereby sEH has become a potential therapeutic target in cardiovascular disease and cancer therapy. Enzymes for EET biosynthesis and metabolism are both widely detected in both neuron and glial cells in the central nervous system (CNS). Recent studies discovered that astrocyte-derived EETs not only mediate neurovascular coupling and neuronal excitability by maintaining glutamate homeostasis but also glia-dependent neuroprotection. Genetic ablation as well as pharmacologic inhibition of sEH has greatly helped to elucidate the physiologic actions of EETs, and maintaining or elevating brain EETs level has been demonstrated beneficial effects in CNS disease models. Here, we review the literature regarding the studies on the bioactivity of EETs and their metabolic enzyme sEH with special attention paid to their action mechanisms in the CNS, including their modulation of neuronal activity, attenuation of neuroinflammation, regulation of cerebral blood flow, and improvement of neuronal and glial cells survival. We further reviewed the recent advance on the potential application of sEH inhibition for treating cerebrovascular disease, epilepsy, and pain disorder.

Women With Cerebral Infarction Feature Worse Clinical Profiles at Admission but Comparable Success to Men During Long-Term Inpatient Neurorehabilitation

Objective: Little is known about possible sex and gender differences in post-stroke neurorehabilitation outcomes. We aimed to analyze if functional performance, prevalence and impact of comorbidities at admission, and success of inpatient stroke-neurorehabilitation differ between men and women.

Methods: Retrospective cohort analysis of 1,437 men and 907 women with prior cerebral infarction treated at a neurorehabilitation clinic between 2012 and 2017; multiple linear regression was used to examine the influence of sex/gender as well as multiple confounders on health and functional outcomes. The main outcome measures were Barthel index (BI) at admission and its change during 4 weeks inpatient neurorehabilitation.

Results: Men had been diagnosed with osteoporosis less frequently than women but more often with type 2 diabetes mellitus, coronary artery or chronic kidney disease (p ≤ 0.01). Although twice as many women presented with pre-stroke depression compared to men, the risk of post-stroke depression detected during rehabilitation was comparable. Men were more likely to have less than 30 days between diagnosis and neurorehabilitation start than women (p < 0.03). At admission, women exhibited less autonomy, a lower BI, a higher pain score and worse 2-min walk test (2′WT) compared to men (p < 0.001). Among males osteoporosis and peripheral artery disease independently predicted BI at admission, in women it was pre-stroke depression, dementia, and arterial fibrillation. During neurorehabilitation, both sexes improved regarding BI, pain and walk tests (p < 0.001). Despite comparable rehabilitation effectiveness, women still had worse functional outcomes than males at discharge. Time after stroke to start of neurorehabilitation and length of the stay but, most strongly, the simple 2′WT at admission, and in women, pain intensity independently predicted post-stroke functional status and recovery.

Conclusion: Women presented with worse functional status at admission to neurorehabilitation. Although men and women showed similar rehabilitation effectiveness, women still displayed worse clinical outcome measures and higher levels of pain at discharge. Early access and gender-sensitive, personalized post-stroke care with more focus on different comorbidities and psychosocial factors like pain levels and management, could further improve neurorehabilitation outcomes.

Predictors of the functional outcome after thrombolysis in an Egyptian patients’ sample

Background

About 6.2 million individuals worldwide and approximately 200 Egyptians/100,000 citizens have cerebrovascular stroke annually, and only less than 1% of stroke patients received intravenous (IV) thrombolysis in 2014. Outcome of the ischemic stroke after IV thrombolysis varies, and there is lack of data about the predicting factors that contributes to the outcome of ischemic strokes after IV thrombolysis in Egypt.

Objective

The aim of this work is to study the predictors of the functional outcome of ischemic cerebrovascular stroke after IV thrombolysis in Egyptian patients.

Patients and methods

This is a prospective study that includes acute ischemic stroke patients who received IV thrombolysis at the Alexandria University Hospital during the year from February 2017 to February 2018, and they were evaluated initially by Rapid Arterial Occlusion Evaluation (RACE) scale and followed-up serially for 6 months after thrombolysis using the National Institutes of Health Stroke Scale (NIHSS) and modified ranking score (mRS).

Results

Forty-five patients are included; 56% had favorable functional outcome (mRS 0–2) after 6 months, 68% had ≥ 4 points improvement in NIHSS after 6 months, and 13% had hemorrhagic conversion with 18% mortality rate. High initial RACE scale and long hospital stay are associated with poor functional outcome 6 months after thrombolysis.

Conclusion

Stroke severity demonstrated by high initial RACE and the duration of hospital stay are the two most significant predictors with an impact on the functional outcome of ischemic cerebrovascular stroke after thrombolysis.

Temporal trend and attributable risk factors of stroke burden in China, 1990–2019: an analysis for the Global Burden of Disease Study 2019

Background

Understanding the temporal trend of the disease burden of stroke and its attributable risk factors in China, especially at provincial levels, is important for effective prevention strategies and improvement. The aim of this analysis from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is to investigate the disease burden of stroke and its risk factors at national and provincial levels in China from 1990 to 2019.

Methods

Following the methodology in the GBD 2019, the incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) of stroke cases in the Chinese population were estimated by sex, age, year, stroke subtypes (ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage), and across 33 provincial administrative units in China from 1990 to 2019. Attributable mortality and DALYs of underlying risk factors were calculated by a comparative risk assessment.

Findings

In 2019, there were 3·94 million (95% uncertainty interval 3·43–4·58) new stroke cases in China. The incidence rate of stroke increased by 86·0% (73·2–99·0) from 1990, reaching 276·7 (241·3–322·0) per 100 000 population in 2019. The age-standardised incidence rate declined by 9·3% (3·3–15·5) from 1990 to 2019. Among 28·76 million (25·60–32·21) prevalent cases of stroke in 2019, 24·18 million (20·80–27·87) were ischaemic stroke, 4·36 million (3·69–5·05) were intracerebral haemorrhage, and 1·58 million (1·32–1·91) were subarachnoid haemorrhage. The prevalence rate increased by 106·0% (93·7–118·8) and age-standardised prevalence rate increased by 13·2% (7·7–19·1) from 1990 to 2019. In 2019, there were 2·19 million (1·89–2·51) deaths and 45·9 million (39·8–52·3) DALYs due to stroke. The mortality rate increased by 32·3% (8·6–59·0) from 1990 to 2019. Over the same period, the age-standardised mortality rate decreased by 39·8% (28·6–50·7) and the DALY rate decreased by 41·6% (30·7–50·9). High systolic blood pressure, ambient particulate matter pollution exposure, smoking, and diet high in sodium were four major risk factors for stroke burden in 2019. Moreover, we found marked differences of stroke burden and attributable risk factors across provinces in China from 1990 to 2019.

Interpretation

The disease burden of stroke is still severe in China, although the age-standardised incidence and mortality rates have decreased since 1990. The stroke burden in China might be reduced through blood pressure management, lifestyle interventions, and air pollution control. Moreover, because substantial heterogeneity of stroke burden existed in different provinces, improved health care is needed in provinces with heavy stroke burden.

Funding

National Key Research and Development Program of China and Taikang Yicai Public Health and Epidemic Control Fund.

Sex Differences in Risk Profile, Stroke Cause and Outcome in Ischemic Stroke Patients With and Without Migraine

Background: An increased risk of stroke in patients with migraine has been primarily found for women. The sex-dependent mechanisms underlying the migraine–stroke association, however, remain unknown. This study aims to explore these sex differences to improve our understanding of pathophysiological mechanisms behind the migraine–stroke association.

Methods: We included 2,492 patients with ischemic stroke from the prospective multicenter Dutch Parelsnoer Institute Initiative study, 425 (17%) of whom had a history of migraine. Cardiovascular risk profile, stroke cause (TOAST classification), and outcome [modified Rankin scale (mRS) at 3 months] were compared with both sexes between patients with and without migraine.

Results: A history of migraine was not associated with sex differences in the prevalence of conventional cardiovascular risk factors. Women with migraine had an increased risk of stroke at young age (onset < 50 years) compared with women without migraine (RR: 1.7; 95% CI: 1.3–2.3). Men with migraine tended to have more often stroke in the TOAST category other determined etiology (RR: 1.7; 95% CI: 1.0–2.7) in comparison with men without migraine, whereas this increase was not found in women with migraine. Stroke outcome was similar for women with or without migraine (mRS ≥ 3 RR 1.1; 95% CI 0.7–1.5), whereas men seemed to have a higher risk of poor outcome compared with their counterparts without migraine (mRS ≥ 3 RR: 1.5; 95% CI: 1.0–2.1).

Conclusion: Our results indicate possible sex differences in the pathophysiology underlying the migraine–stroke association, which are unrelated to conventional cardiovascular risk factors. Further research in larger cohorts is needed to validate these findings.

Morphological Subtypes of Intracranial Internal Carotid Artery Arteriosclerosis and the Risk of Stroke

BACKGROUND AND PURPOSE

Accumulating evidence highlights the existence of distinct morphological subtypes of intracranial carotid arteriosclerosis. So far, little is known on the prevalence of these subtypes and subsequent stroke risk in the general population. We determined the prevalence of morphological subtypes of intracranial arteriosclerosis and assessed the risk of stroke associated with these subtypes.

METHODS

Between 2003 and 2006, 2391 stroke-free participants (mean age 69.6, 51.7% women) from the population-based Rotterdam Study underwent noncontrast computed tomography to visualize calcification in the intracranial carotid arteries as a proxy for intracranial arteriosclerosis. Calcification morphology was evaluated according to a validated grading scale and categorized into intimal, internal elastic lamina (IEL), or mixed subtype. Follow-up for stroke was complete until January 1, 2016. We used multivariable Cox regression to assess associations of each subtype with incident stroke.

RESULTS

The prevalence of calcification was 82% of which 39% had the intimal subtype, 48% IEL subtype, and 13% a mixed subtype. During a median follow-up of 10.4 years, 155 participants had a stroke. All 3 subtypes were associated with a higher risk of stroke (adjusted hazard ratio [95% CI] for intimal: 2.11 [1.07-4.13], IEL: 2.66 [1.39-5.11], and mixed subtype 2.57 [1.18-5.61]). The association of the IEL subtype with stroke was strongest among older participants. The association of the intimal subtype with stroke was noticeably stronger in women than in men.

CONCLUSIONS

Calcification of the IEL was the most prevalent subtype of intracranial arteriosclerosis. All 3 subtypes were associated with an increased risk of stroke, with noticeable age and sex-specific differences.

A sex specific approach of ophthalmic and middle cerebral arteries Doppler in smokers

Vascular dysfunctions can progress and lead to stroke and cardiovascular disease, especially in smokers. The presence of particular vascular changes according to sex has been described and they can be identified by the Doppler method. This study evaluated Doppler velocimetry parameters of the Ophthalmic Artery (OA) and the Middle Cerebral Artery (MCA) according to sex in smokers regarding a non-smoker group. This cross-sectional observational study included 178 subjects: 93 women and 85 men. Doppler parameters were assessed in OA and MCA. Student's t-test was used, with p < 0.05. There were no significant differences in OA and MCA Doppler velocimetry data between male non-smokers and smokers. However, female smokers presented several differences compared with non-smokers: lower pulsatility index (PI) and higher peak ratio in OA, and higher PI and resistance index and lower end diastolic velocity in MCA. There were different brain vascular waveforms in the group of female smokers compared with non-smokers. Cigarette smoking also led to opposite arterial patterns in OA and MCA in the female group, with signs of falling impedance in OA and increased impedance in MCA. An individualized approach regarding arterial changes according to sex is desirable.

Sex-Specific Causal Relations between Steroid Hormones and Obesity-A Mendelian Randomization Study

Steroid hormones act as important regulators of physiological processes including gene expression. They provide possible mechanistic explanations of observed sex-dimorphisms in obesity and coronary artery disease (CAD). Here, we aim to unravel causal relationships between steroid hormones, obesity, and CAD in a sex-specific manner. In genome-wide meta-analyses of four steroid hormone levels and one hormone ratio, we identified 17 genome-wide significant loci of which 11 were novel. Among loci, seven were female-specific, four male-specific, and one was sex-related (stronger effects in females). As one of the loci was the human leukocyte antigen (HLA) region, we analyzed HLA allele counts and found four HLA subtypes linked to 17-OH-progesterone (17-OHP), including HLA-B*14*02. Using Mendelian randomization approaches with four additional hormones as exposure, we detected causal effects of dehydroepiandrosterone sulfate (DHEA-S) and 17-OHP on body mass index (BMI) and waist-to-hip ratio (WHR). The DHEA-S effect was stronger in males. Additionally, we observed the causal effects of testosterone, estradiol, and their ratio on WHR. By mediation analysis, we found a direct sex-unspecific effect of 17-OHP on CAD while the other four hormone effects on CAD were mediated by BMI or WHR. In conclusion, we identified the sex-specific causal networks of steroid hormones, obesity-related traits, and CAD.

Developmental mechanisms of sex differences: from cells to organisms

Male-female differences in many developmental mechanisms lead to the formation of two morphologically and physiologically distinct sexes. Although this is expected for traits with prominent differences between the sexes, such as the gonads, sex-specific processes also contribute to traits without obvious male-female differences, such as the intestine. Here, we review sex differences in developmental mechanisms that operate at several levels of biological complexity - molecular, cellular, organ and organismal - and discuss how these differences influence organ formation, function and whole-body physiology. Together, the examples we highlight show that one simple way to gain a more accurate and comprehensive understanding of animal development is to include both sexes.

Sex differences in vascular risk factors, in-hospital management, and outcomes of patients with acute ischemic stroke in China

BACKGROUND

Previous assessments of sex differences for patients with acute ischemic stroke were limited in a specific region or population, narrow scope, or small sample size.

METHODS

Patients with acute ischemic stroke hospitalized in the China Stroke Center Alliance hospitals were analyzed. Absolute standardized differences (ASDs) were used to assess sex differences in vascular risk factors, guideline-recommended in-hospital management measures and outcomes, including stroke severity (National Institutes of Health Stroke Scale≥16), death/discharge against medical advice, major adverse cardiovascular events, pneumonia, and disability (modified Rankin Scale≥3).

RESULTS

Of 838,229 patients analyzed, 524351 (62.6%) were men and 313,878 (37.4%) were women. Compared with men, women were older (68.6 vs. 64.7 years), had higher prevalence of hypertension (67.7% vs. 62.4%), diabetes (24.7% vs. 19.5%), and atrial fibrillation (7.1% vs. 4.3%), but lower prevalence of smoking (4.5% vs. 56.6%) and drinking (2.6% vs 35.8%) (ASDs >10%). No sex differences were seen in guideline-directed management measures, indicated by risk-adjusted individual measures and the all-or-null summary measure (34.5% vs 34.9%, ASD = 1.0%). Compared to men, women tended to have strokes that were more severe at presentation (6.5% vs. 4.5%, ASD = 8.8%) and more disabilities at discharge (34.9% vs 30.5%, ASD =9.4%). However, all sex-related differences in outcomes were attenuated to null after risk adjustments (ASDs<2%).

CONCLUSIONS

Compared to male patients, female patients had more vascular risk factors and received similar in-hospital care. They had strokes that were more severe at presentation and more disabilities at discharge, both of which may be explained by worse vascular risk profiles.

Finger Exoskeleton in Simple Motor Rehabilitation Therapy on Arm and Hand Muscle Ability of Post-Stroke Sufferers

Post-stroke sufferers will generally experience weakness on one side of the body, balance, vision, sensory, motor, and cognitive. In West Kalimantan, the estimated stroke sufferer in 2013 was 25,195 people. Based on data from the Public Hospital of  Dr. Soedarso Pontianak shows a significant increase from January 2018 to December 2018 totaling 722 people. The research objective was to assess the effectiveness of the finger exoskeleton tool in simple motor therapy on the ability of the client's arm and hand muscles after a stroke. This study used a quantitative approach with a quasi-experimental design. Pre-test and Post-test Nonequivalent Control Group with two groups, which were the control group of 12 people and the intervention group of 12 people with finger exoskeleton tools. The statistical test used was the independent t test and paired t test. Measurement of muscle ability with the Action Research Arm Test. Analysis of the difference in total scores between before and after treatment in the intervention group using Paired T-Test obtained a p-value of 0.000 (p value <0.05) and in the control group using the Wilcoxon test a p-value of  0.016 (p value <0.05). It shows that there is a significant difference in the total score between before and after finger exoskeleton therapy and range of motion. Intervention of finger exoskeleton assistive devices in simple motor rehabilitation therapy is effective in increasing the ability of the client's arm and hand muscles after stroke. It is recommended to make another finger rehabilitation tool with a more optimal design according to the parameters, which are the severity of the client after stroke, subject kinematics, control of movement torque and adaptation between the subject and the robotic device used.

Influence of cardiovascular risk-factors on morphological changes of cerebral arteries in healthy adults across the life span

Cerebral artery morphological alterations have been associated with several cerebrovascular and neurological diseases, whereas these structures are known to be highly variable among healthy individuals. To date, the knowledge about the influence of cardiovascular risk factors on the morphology of cerebral arteries is rather limited. The aim of this work was to investigate the impact of cardiovascular risk factors on the regional cerebroarterial radius and density. Time-of-Flight magnetic resonance angiography from 1722 healthy adults (21-82 years) were used to extract region-specific measurements describing the main cerebral artery morphology. Multivariate statistical analysis was conducted to quantify the impact of cardiovascular risk factors, including clinical and life behavioural factors, on each region-specific artery measurement. Increased age, blood pressure, and markers of obesity were significantly associated with decreased artery radius and density in most regions, with aging having the greatest impact. Additionally, females showed significantly higher artery density while males showed higher artery radius. Smoking and alcohol consumption did not show any significant association with the artery morphology. The results of this study improve the understanding of the impact of aging, clinical factors, and life behavioural factors on cerebrovascular morphology and can help to identify potential risk factors for cerebrovascular and neurological diseases.

Characteristics and Risk Factors Associated with Stroke Subtypes among Adult Patients Admitted to the Stroke Unit of Jimma University Medical Center: A Retrospective Cross-sectional Study

BACKGROUND

Almost 80% of deaths due to non-communicable diseases occur in lowand middle-income countries. Stroke is a great public health problem in Ethiopia. Stroke mortality was estimated to be 14.7% in Ethiopia. Despite this, researches done in Ethiopia on factors associated with stroke sub-types were inadequate.

OBJECTIVE

To assess the characteristics and risk factors associated with stroke subtypes among patients admitted to Jimma University Medical Center.

MATERIALS AND METHODS

A retrospective cross-sectional study was conducted from May 2017 to May 2018 in the stroke unit of the Jimma University Medical Center. A total of 106 medical charts of patients diagnosed with stroke were reviewed. A checklist comprising relevant variables was used to collect data. SPSS version 21 was employed for data entry and analysis. Pearson chi-square test was used to check the association of different parameters with stroke subtypes. A P-value <0.05 was used as a cutoff point to declare statistical significance. Data were presented using text, tables, and figures.

RESULTS

From a total of 106 patients, 67 (63.2%) were men. The mean ± SD of age was 52.67±12.46 Year's, and the difference was not significant among stroke subtypes. Among all patients, 59 (55.6%) had ischemic strokes and 47 (44.4%) had hemorrhagic strokes. The most prevalent risk factors significantly associated with stroke subtypes were being male 67 (63.2%) followed by dyslipidemia 43 (40.5%) and cigarette smoking 38 (35.8%).

CONCLUSION

The ischemic stroke was reported to be higher than hemorrhagic in this study. The overall mean (±SD) age of the patient was 52.67±(12.46) years. The mean age of hemorrhagic stroke patients was 55.98 (±13.77) years; while in ischemic stroke was 50.03 (±10.70) years. Being male, a history of cigarette smoking, and dyslipidemia were significantly associated with stroke subtypes.

Decoding the Transcriptional Response to Ischemic Stroke in Young and Aged Mouse Brain

Ischemic stroke is a well-recognized disease of aging, yet it is unclear how the age-dependent vulnerability occurs and what are the underlying mechanisms. To address these issues, we perform a comprehensive RNA-seq analysis of aging, ischemic stroke, and their interaction in 3- and 18-month-old mice. We assess differential gene expression across injury status and age, estimate cell type proportion changes, assay the results against a range of transcriptional signatures from the literature, and perform unsupervised co-expression analysis, identifying modules of genes with varying response to injury. We uncover downregulation of axonal and synaptic maintenance genetic program, and increased activation of type I interferon (IFN-I) signaling following stroke in aged mice. Together, these results paint a picture of ischemic stroke as a complex age-related disease and provide insights into interaction of aging and stroke on cellular and molecular level.

Sex Differences in Outcomes After Spontaneous Intracerebral Hemorrhage Among Patients With Low Total Cholesterol Levels

BACKGROUND

Low total cholesterol (TC) levels were shown to be an independent predictor of intracerebral hemorrhagic stroke in previous studies. However, the role of sex in risk and outcome of patients with ICH and low TC levels is unclear. Therefore, the objective of our study was to assess the sex differences in the risk factors and outcomes after spontaneous intracerebral hemorrhage (ICH) in patients with low TC levels in China.

METHODS

This study recruited consecutive patients diagnosed with ICH who were admitted to the Stroke Registry System in Tianjin between May 2005 and May 2018. Patients with low TC levels (defined as TC<200mg/dl) were analyzed in this study. Sex differences in clinical features, risk factors, and outcomes at hospital discharge, 3 months, and 12 months after ICH were evaluated.

RESULTS

Of the 824 patients with low TC levels, 610 men (74%) and 214 women (26%). The mean age at ICH onset was younger in men than in women (60.93±12.54 vs. 64.5±12.28, P<0.001), and men were more likely to have higher educational levels than women. There were higher prevalence rates of hypertension, current smoking status, and alcohol consumption in men. Urinary tract infections were more prevalent in women, and hepatic/renal dysfunctions were more prevalent in men. Women had significantly higher neurological function deficits. With lower Barthel indices (BIs) and higher modified Rankin scale (mRS) scores at admission; but there was no significant difference between men and women in National Institutes of Health Stroke Scale (NIHSS) scores. The study showed that there was no significant difference in mortality and dependency rates at hospital discharge, 3 months, and 12 months after ICH.

CONCLUSIONS

Our study showed that there were no sex differences in clinical outcomes of patients with ICH and low TC levels, which suggests that the effect of low cholesterol as a risk factor for cerebral hemorrhage is the same on patients of different sexs. The possible mechanisms need larger, prospective, multicenter studies to further research.

Meta-analysis of variation suggests that embracing variability improves both replicability and generalizability in preclinical research

The replicability of research results has been a cause of increasing concern to the scientific community. The long-held belief that experimental standardization begets replicability has also been recently challenged, with the observation that the reduction of variability within studies can lead to idiosyncratic, lab-specific results that cannot be replicated. An alternative approach is to, instead, deliberately introduce heterogeneity, known as "heterogenization" of experimental design. Here, we explore a novel perspective in the heterogenization program in a meta-analysis of variability in observed phenotypic outcomes in both control and experimental animal models of ischemic stroke. First, by quantifying interindividual variability across control groups, we illustrate that the amount of heterogeneity in disease state (infarct volume) differs according to methodological approach, for example, in disease induction methods and disease models. We argue that such methods may improve replicability by creating diverse and representative distribution of baseline disease state in the reference group, against which treatment efficacy is assessed. Second, we illustrate how meta-analysis can be used to simultaneously assess efficacy and stability (i.e., mean effect and among-individual variability). We identify treatments that have efficacy and are generalizable to the population level (i.e., low interindividual variability), as well as those where there is high interindividual variability in response; for these, latter treatments translation to a clinical setting may require nuance. We argue that by embracing rather than seeking to minimize variability in phenotypic outcomes, we can motivate the shift toward heterogenization and improve both the replicability and generalizability of preclinical research.

Post-traumatic stress disorder and its association with stroke and stroke risk factors: A literature review

Stroke is a major cause of mortality and disability globally that has multiple risk factors. A risk factor that has recently gained more attention is post-traumatic stress disorder (PTSD). Literature searches were carried out for updated PTSD information and for the relationship between PTSD and stroke. The review was divided into two sections, one exploring PTSD as an independent risk factor for stroke, with a second concentrating on PTSD's influence on stroke risk factors. The study presents accumulating evidence that shows traumatic stress predicts stroke and is also linked to many major stroke risk factors. The review contributes knowledge to stroke aetiology and acts as a reference for understanding the relationship between PTSD and stroke. The information presented indicates that screening and identification of traumatic experience would be beneficial for directing stroke patients to appropriate psychological and lifestyle interventions. In doing so, the burden of stroke may be reduced worldwide.

Effect of menopause on cerebral artery blood flow velocity and cerebrovascular reactivity: Systematic review and meta-analysis

BACKGROUND

Menopause and its associated decline in oestrogen is linked to chronic conditions like cardiovascular disease and osteoporosis, which may be difficult to disentangle from the effects of ageing. Further, post-menopausal women are at increased risk of cerebrovascular disease, linked to declines in cerebral blood flow (CBF) and cerebrovascular reactivity (CVR), yet the direct understanding of the impact of the menopause on cerebrovascular function is unclear. The aim of this systematic review and meta-analysis was to examine the literature investigating CBF and CVR in pre- compared with post-menopausal women METHODS: Five databases were searched for studies assessing CBF or CVR in pre- and post-menopausal women. Meta-analysis examined the effect of menopausal status on middle cerebral artery velocity (MCAv), and GRADE-assessed evidence certainty RESULTS: Nine studies (n=504) included cerebrovascular outcomes. Six studies (n=239) reported negligible differences in MCAv between pre- and post-menopausal women [2.11cm/s (95% CI: -8.94 to 4.73, p=0.54)], but with a "low" certainty of evidence. MCAv was lower in post-menopausal women in two studies, when MCAv was adjusted for blood pressure. CVR was lower in post- compared with pre-menopausal women in two of three studies, but high-quality evidence is lacking. Across outcomes, study methodology and reporting criteria for menopause were inconsistent CONCLUSIONS: MCAv was similar in post- compared with pre-menopausal women. Methodological differences in characterising menopause and inconsistent reporting of cerebrovascular outcomes make comparisons difficult. Comprehensive assessments of cerebrovascular function of the intra- and extracranial arteries to determine the physiological implications of menopause on CBF with healthy ageing is warranted.

Heterogeneity among women with stroke: health, demographic and healthcare utilization differentials

BACKGROUND

Although age specific stroke rates are higher in men, women have a higher lifetime risk and are more likely to die from a stroke. Despite this increased severity, most studies focus on male/female differences in stroke onset, patterns of care and stroke-related outcomes. Given that stroke presents differently in men and women, mixed sex studies fail to fully capture heterogeneity among women with stroke and the subsequent impact on their outcomes. This study examined the sociodemographic characteristics, factors related to stroke incidence and post-stroke functional status between young (< 60) and old (≥ 60) women with stroke.

METHODS

Using 5 years of data from the National Health Interview Survey (NHIS), a nationally representative sample of US adults, cohorts of young and old women with stroke were identified. A set of demographic/lifestyle, health services utilization and health status characteristics were used evaluate within gender heterogeneity in three ways. First, disparities in population characteristics were assessed using Chi-Square and t tests. Second, young and old women with stroke were matched with women without stroke in their respective cohorts to determine differences in factors related to stroke incidence. Finally, the determinants of post-stroke functional limitation for the two cohorts were determined.

RESULTS

Young women with stroke were more likely to be Black, smoke regularly and frequently consume alcohol than older women. Young women were also less likely to engage with their health provider regularly or receive preventative health screenings. Diabetes, high blood pressure, high cholesterol and high BMI were correlated with an increased relative likelihood of stroke among older women. In contrast, family size, smoking frequency, alcohol consumption and sleep were correlated with an increased prevalence of stroke among young women. Although factors correlated with stroke varied between young and old women, health status and receipt of healthcare were the most significant determinants of post-stroke functional status for both cohorts.

CONCLUSIONS

Health related characteristics were the primary correlates of stroke in older women, whereas post-stroke lifestyle and behaviors are the most significant correlates for younger stroke survivors. These findings suggest that while receipt of health services is essential for preventing stroke in both young and old women, providers should stress the importance of post-stoke lifestyle and behaviors to younger women at risk of stroke using approaches that may be different from older stroke women.

Method of intra-arterial drug administration in a rat: Sex based optimization of infusion rate

BACKGROUND

Endovascular thrombectomy is the process of removing a blood clot and re-establishing blood flow in patients with emergent large vessel occlusion. The technique provides an opportunity to deliver therapeutics directly to the site of injury. The intra-arterial (IA) route of drug administration in the mouse was developed to bridge the gap between animal stroke treatments and clinical stroke therapy. Here, we adapted the IA method for use in rats, by investigating various flow rates to optimize the IA injection through the internal carotid artery (ICA).

METHODS

Male and female Sprague-Dawley rats (∼4 months of age) were subjected to placement of micro-angio tubing at the bifurcation of the common carotid artery for injection into the ICA. We evaluated a range of infusion rates of carbon black ink and its vascular distribution within the brain.

RESULTS

Optimal injection rates in males was 4-6 μl/min and 2-4 μl/min in females. The IA injection using these sex-specific rates resulted in appropriate limited dye delivery to only the ipsilateral region of the brain, without inducing a subarachnoid hemorrhage.

CONCLUSION

Upon adapting the IA administration model to rats, it was determined that the rate of infusion varied between males and females. This variability is an important consideration for studies utilizing both sexes, such as in ischemic stroke studies.