Sex Differences in Incidence, Mortality, and Survival in Individuals With Stroke in Scotland, 1986 to 2005

Sex differences in the inflammatory response to stroke

Ischemic stroke is a leading cause of morbidity and mortality and disproportionally affects women, in part due to their higher longevity. Older women have poorer outcomes after stroke with high rates of cognitive deficits, depression, and reduced quality of life. Post-stroke inflammatory responses are also sexually dimorphic and drive differences in infarct size and recovery. Factors that influence sex-specific immune responses can be both intrinsic and extrinsic. Differences in gonadal hormone exposure, sex chromosome compliment, and environmental/social factors can drive changes in transcriptional and metabolic profiles. In addition, how these variables interact, changes across the lifespan. After the onset of ischemic injury, necrosis and apoptosis occur, which activate microglia and other glial cells within the central nervous system, promoting the release of cytokines and chemokines and neuroinflammation. Cells involved in innate and adaptive immune responses also have dual functions after stroke as they can enhance inflammation acutely, but also contribute to suppression of the inflammatory cascade and later repair. In this review, we provide an overview of the current literature on sex-specific inflammatory responses to ischemic stroke. Understanding these differences is critical to identifying therapeutic options for both men and women.

Gender differences in mortality of hospitalised stroke patients. Systematic review and meta-analysis

OBJECTIVE

Gender differences in mortality after stroke remains unclear in the current literature. We therefore aimed to systematically review the gender differences in mortality up to five years after ischaemic (IS) or haemorrhagic stroke (HS) to address this evidence gap.

METHODS

The literature was systematically searched using Ovid EMBASE, Ovid Medline, and Web of Science databases, from inception-November 2021. The quality of evidence was appraised using the CASP Cohort-study checklist. Unadjusted and adjusted odds and hazard ratios were meta-analysed, separately for IS and HS and a subgroup analysis of age-stratified mortality data was conducted.

RESULTS

Forty-one studies were included (n = 8,128,700; mean-age 68.5 yrs; 47.1% female). 37 studies were included in meta-analysis (n = 8, 8008, 110). Compared to men, women who had an IS had lower mortality risk in-hospital (0.94; 95%CI 0.91-0.97), at one-month (0.87; 95%CI 0.77-0.98), 12-months (0.94; 95%CI 0.91-0.98) and five-years (0.93 95%CI 0.90-0.96). The subgroup analysis showed that this gender difference in mortality was present in women ≥ 70 years up to one-month post-IS (in-hospital: 0.94; 95%CI 0.91-0.97; one-month: 0.87; 95% CI 0.77-0.98), however, in women < 70 years this difference was no longer present. Nevertheless, analysis of crude data showed women were at higher risk of mortality in-hospital, at 12-months and five-years (in-hospital: 1.05; 95%CI 1.03-1.07, 12-months: 1.10; 95%CI 1.06-1.14, five-years: 1.06; 95%CI 1.02-1.10). After HS, women had higher mortality risk in-hospital (1.03; 95%CI 1.01-1.04) however, no gender differences were found post-discharge.

CONCLUSION

The gender differences in post-stroke mortality differ by stroke type, age group and follow-up. Crude stroke mortality in women is higher than in men and this appears to be driven by pre-existing comorbidities. In adjusted models, women have a lower mortality risk following IS, independent of duration of follow-up. After HS, women had higher mortality in hospital however, no gender differences after hospital discharge were found.

Sex Differences in Short-term and Long-term Outcomes among Acute Ischemic Stroke Patients in China

Background: Sex differences in stroke outcomes are crucial to secondary prevention but previous reports showed inconsistent results. We aimed to explore the sex differences in stroke outcomes in the Third China National Stroke Registry, a prospective multi-center registry study. Methods: Among the 15166 patients enrolled between 2015 and 2018, 9038 patients with acute ischemic stroke (AIS) were included. The primary outcomes were stroke recurrence, mortality, and unfavorable functional outcome (modified Rankin Scale [mRS] > 2) at 3, 6, and 12 months. Cox regression model was used for stroke recurrence and mortality and logistic regression was used for the unfavorable functional outcome, and adjusted as follows: (1) Model 1: without adjustment; (2) Model 2: adjusted for potential risk factors, National Institutes of Health Stroke Scale (NIHSS) at admission, pre-stroke mRS, tissue plasminogen activator (TPA) treatment, TOAST classification, and onset-to-door time; (3) Model 3: adjusted for covariates from model 2 in addition to blood pressure and blood serum covariates. Multiple imputation was used for missing values, and sensitivity analyses were conducted to describe sex differences by age groups. Results: One-third (2802/9038) of the patients were women. Women were significantly older than men (64.78±10.84 vs. 61.26±11.42, p<0.001). In the fully adjusted model, female patients were more likely to have unfavorable functional outcomes at 3 months (odds ratio [OR], 1.28 [1.09, 1.50]), especially among patients aged 65 years or older (OR, 1.39 [1.14, 1.70]), but no difference was discovered in patients aged < 65 years. There were no sex differences in stroke recurrence and mortality at 3, 6, or 12 months or unfavorable functional outcomes at 6 or 12 months after adjustment. Conclusions: Compared to men, women with AIS were less likely to have favorable outcomes at three months in China, especially among those over 65 years of age. Experts should aim to tailor secondary prevention strategies for high-risk patients.

Sex- related differences in the factors associated with outcomes among patients with strokes of undetermined source: a hospital-based follow-up study

Objective: Sex-related differences are well established among stroke patients, including the incidence and prevalence of stroke being higher among men than among women. However, the sex-related factors for differences in the outcomes of strokes of undetermined source (SUSs) have not been well described, especially in the Chinese population. We assessed the sex-related differences in the factors associated with outcomes among patients with SUSs in China.Method: Between January 2011 and December 2018, we recruited 205 patients diagnosed with SUSs from Kailuan General Hospital (China). The clinical features, risk factors, and outcome data were collected for the patients at 3 and 12 months after their strokes.Results: There were higher frequencies of hyperlipidemia (27.8% vs. 26.4%), smoking (41.4% vs. 5.6%), and alcohol consumption (21.8% vs. 0%) for male patients than for female patients. However, women were more likely than men to have hypertension (63.9% vs. 46.6%), diabetes (27.8% vs. 20.3%), and atrial fibrillation (9.7% vs. 5.3%); they were also more likely to be obese (16.7% vs. 12.0%). There were no significant differences in outcome between the sexes. Among men, severe strokes were associated with higher case fatality and disability risks at 12 months after stroke onset; hyperlipidemia was a risk factor for recurrence within 3 months of the initial stroke. Among women, severe strokes also increased the risk of disability; in women, high total cholesterol (TC) and age were associated with poor outcomes.Conclusion: The factors associated with outcomes in SUS differed by sex. For male patients, more severe stroke and hyperlipidemia were associated with poor outcomes in SUS. Risk factors for poor outcomes in female patients were stroke severity, age, and TC level. These findings suggest that taking measures to manage blood lipid levels and severe stroke among patients with SUS is important for both male and female patients and is crucial for reducing the burden of stroke in China.

Sex-Specific Differences in Short-Term and Long-Term Outcomes in Acute Stroke Patients from Qatar

BACKGROUND

Sex differences may determine presentation, utility of treatment, rehabilitation, and occurrences of major adverse cardiovascular events (MACEs) in acute stroke (AS).

OBJECTIVE

The purpose of the study was to evaluate the short-term prognosis and long-term outcomes in MACEs in Qatari nationals admitted with AS.

METHODS

All AS patients admitted between January 2014 and February 2019 were included. We evaluated the preadmission modified Rankin scale (mRS) score, etiology and severity of symptoms, complications, and functional recovery at discharge and 90 days. MACEs were recorded for 5 years.

RESULTS

There were 891 admissions for AS (mean age 64.0 ± 14.2 years) (male, n = 519 [mean age ± SD 62.9 ± 14.1 years]; female, n = 372 [mean age ± SD 65.6 ± 14.2 years] p = 0.005). There were no differences in the preadmission mRS and severity of symptoms as measured on National Institute of Stroke Scale. At discharge, the outcome was better (mRS 0-2) in men (57.8 vs. 46.0%), p = 0.0001. This difference persisted at the 90-day follow-up (mRS 0-2, male 69.4% vs. female 53.2%, p = 0.0001). At the 90-day follow-up, more women died (total deaths 70; women 38 [10.2%] versus men 32 [6.2%], p = 0.03). MACEs occurred in 25.6% (133/519) males and 30.9% (115/372) females over the 5-year follow-up period (odds ratio 0.77, 95% confidence interval 0.57-1.0, p = 0.83).

CONCLUSIONS

Female patients have a poor short-term outcome following an AS when corrected for age and comorbidities. While our study cannot explain the reasons for the discrepancies, higher poststroke depression and social isolation in women may be important contributory factors, and requires further studies are required to confirm these findings.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Sex differences in stroke

Sex disparities within the field of stroke, including subarachnoid hemorrhages (SAHs), have been in focus during the last 2 decades. It is clear that stroke incidence is higher in men, and also that men have their first stroke earlier than women. On the other hand, women have more severe strokes, mainly because cardioembolic strokes are more common in women. This leads to higher case fatality and worse functional outcome in women. It has often been pointed out that women more often have nontraditional stroke symptoms, and therefore may seek medical help later. After discharge from the hospital, female stroke survivors live alone in many cases and are dependent on external care. Therefore, these women frequently rate their quality of life (QoL) lower than men do. Female spouses more often provide help to their male stroke survivors than the reverse, and they accept a heavier burden. These caregivers are at high risk for depression, low QoL, and low psychologic wellbeing. SAH is a special form of stroke, often caused by a ruptured aneurysm. It is about 20% more common in women. The case fatality is high, but does not differ between the sexes.

Incidence of dementia after age 90 in a multiracial cohort

INTRODUCTION

Little is known about dementia incidence in diverse populations of oldest-old, the age group with highest dementia incidence.

METHODS

Incident dementia diagnoses from 1/1/2010 to 9/30/2015 were abstracted from medical records for 2350 members of an integrated health care system in California (n = 1702 whites, n = 375 blacks, n = 105 Latinos, n = 168 Asians) aged ≥90 in 2010. We estimated race/ethnicity-specific age-adjusted dementia incidence rates and implemented Cox proportional hazards models and Fine and Gray competing risk of death models adjusted for demographics and comorbidities in midlife and late-life.

RESULTS

Dementia incidence rates (n = 771 cases) were lowest among Asians (89.9/1000 person-years), followed by whites (96.9/1000 person-years), Latinos (105.8/1000 person-years), and blacks (121.5/1000 person-years). Cox regression and competing risk models estimated 28% and 36% higher dementia risk for blacks versus whites adjusting for demographics and comorbidities.

DISCUSSION

Patterns of racial/ethnic disparities in dementia seen in younger older adults continue after the age of 90 years, though smaller in magnitude.

Stroke Outcome and Determinants among Patients with and without Diabetes in a Tertiary Hospital in Ghana

BACKGROUND

Diabetes mellitus, a well-established independent risk factor for stroke, has varied association with stroke outcome from previous studies. This study investigated stroke outcome and determinants among patients with and without diabetes in a tertiary hospital in Ghana.

METHODS

A prospective study conducted among stroke patients with and without diabetes admitted in a Ghanaian tertiary hospital. Baseline clinical and biochemical data were documented. Functional stroke outcome was evaluated at 1, 3, and 6 months after stroke using the modified Rankin Scale.

RESULTS

Number of participants enrolled were 326 and 105 (32.20%) had diabetes. Higher proportions of diabetes patients had poor functional stroke outcome at 1, 3, and 6 months (79%, 75.23%, 73.33%) compared with those without diabetes (70.13%, 65.16, 61.99) (p>0.05). Stroke patients with diabetes had lower survival compared with those without diabetes (p=0.0745). Mortality at 6 months was more likely among ischaemic stroke patients with diabetes compared with those without diabetes (Odds Ratio 2.037; CI: 1.058-3.923). Determinants of poor functional stroke outcome for diabetes patients were older age (Adjusted Odds Ratio (AOR)-1.07; CI-1.03-1.12), female gender (AOR-3.74; CI-1.26-12.65), and pneumonia (AOR-11.32; CI-1.93-220.05) whereas the determinants for those without diabetes were unemployment (AOR-4.19; CI-1.24-19.50), speech abnormalities (AOR-1.99; CI1.08-3.73), and pneumonia (AOR-4.05; CI-1.83-9.77). High fasting plasma glucose (HR-1.15; CI-1.07-1.23), elevated temperature (HR-1.41; CI-1.11-1.79), and pneumonia (HR-2.25; CI-1.44-3.50) were determinants of low survival among all stroke patients.

CONCLUSION

Trends towards poorer functional outcome and reduced survival were found among Ghanaian stroke patients with diabetes compared with those without diabetes. Older age, female gender, pneumonia, elevated temperature, and fasting plasma glucose were determinants of adverse outcome in stroke patients with diabetes.

Gender-Related Differences and Short-Term Outcome of Stroke: Results from a Hospital-Based Registry in Sub-Saharan Africa

BACKGROUND

Studies suggest that sex differences have an impact on patients with stroke, but existing data in Africa remain inconclusive about this inference.

OBJECTIVES

To study sex differences in terms of the clinical profile and short-term outcome of stroke in the Douala General Hospital, Cameroon.

METHODS

A hospital-based prospective cohort study was carried out in a tertiary care hospital over an 8-year period, which included all patients admitted for confirmed acute stroke. Information about the history of stroke with emphasis on clinical profile and outcome was collected. Descriptive statistics, t test, and chi square test were used for comparisons, while the Kaplan-Meier curve was used for survival rate analysis.

RESULTS

Of the 818 patients included, 455 (55.6%) were male patients. When compared to males, female patients are more likely to experience a stroke at an older age (mean age 62.3 ± 14.1 vs. 58.4 ± 12.9 years, p < 0.001), to be unmarried, to remain unemployed, and to have higher rates of cardio-embolic stroke (p = 0.049), body mass index (p = 0.031), altered levels of consciousness at presentation (p = 0.005), higher mean HDL cholesterol levels (p = 0.001), and in-hospital complications (p = 0.011), especially urinary tract infections (p = 0.018). Males were more likely to have health insurance, to smoke, to consume alcohol (p < 0.001), and to have higher rates of dysarthria (p = 0.004), higher mean uric acid (p = 0.013), and creatinine (p < 0.001) concentrations. Ischemic and hemorrhagic strokes were more prevalent in men (p = 0.003). There are no sex differences in terms of stroke severity, length-of-hospital stay, case fatality, and functional outcome on admission.

CONCLUSIONS

Sex differences exist in the clinical profile of stroke but not in the outcome. Knowledge of these differences could help influence stroke prevention, thereby improving stroke burden in Africa.

Sex differences in outcomes and risk factors among elderly patients with ischemic stroke

We aimed to investigate the sex differences in the clinical characteristics and risk factors for adverse outcomes among elderly patients with atherosclerotic stroke. We recruited 942 consecutive patients with atherosclerotic stroke aged 75 years and older between January 2008 and December 2013 from Jiamusi University First Hospital, China. Stroke subtype, severity, risk factors, and outcomes (mortality, dependency, and recurrence) at 3 and 12 months after stroke were recorded and assessed. Mortality at 3 months after stroke was higher in men than in women. Stroke severity was an independent risk factor for mortality, dependency, and recurrence at 3 and 12 months after stroke in both men and women. However, the presence of total anterior circulation infarct and obesity protected against mortality at 3 months after stroke in men, while total anterior circulation infarct was a risk factor for dependency at 3 months after stroke in women. In women, positive associations were found between fasting plasma glucose level and mortality at 3 months after stroke and between hypertension, atrial fibrillation, and recurrence at 12 months after stroke. These findings suggest that it is crucial to control the primary risk factors individually by sex, especially regarding hypertension and atrial fibrillation management, to improve secondary prevention of stroke among the elderly and reduce the burden of stroke in China.

Sex-related differences in the risk factors for in-hospital mortality and outcomes of ischemic stroke patients in rural areas of Taiwan

Background and purpose

Sex-related differences in the clinical presentation and outcomes of stroke patients are issues that have attracted increased interest from the scientific community. The present study aimed to investigate sex-related differences in the risk factors for in-hospital mortality and outcome in ischemic stroke patients.

Methods

A total of 4278 acute ischemic stroke patients admitted to a stroke unit between January 1, 2007 and December 31, 2014 were included in the study. We considered demographic characteristics, clinical characteristics, co-morbidities, and complications, among others, as factors that may affect clinical presentation and in-hospital mortality. Good and poor outcomes were defined as modified Ranking Score (mRS)≦2 and mRS>2. Neurological deterioration (ND) was defined as an increase of National Institutes of Health Stroke Score (NIHSS) ≥ 4 points. Hemorrhagic transformation (HT) was defined as signs of hemorrhage in cranial CT or MRI scans. Transtentorial herniation was defined by brain edema, as seen in cranial CT or MRI scans, associated with the onset of acute unilateral or bilateral papillary dilation, loss of reactivity to light, and decline of ≥ 2 points in the Glasgow coma scale score.

Results

Of 4278 ischemic stroke patients (women 1757, 41.1%), 269 (6.3%) received thrombolytic therapy. The in hospital mortality rate was 3.35% (139/4278) [4.45% (80/1757) for women and 2.34% (59/2521) for men, p < 0.01]. At discharge, 41.2% (1761/4278) of the patients showed good outcomes [35.4% (622/1757) for women and 45.2% (1139/2521) for men]. Six months after stroke, 56.1% (1813/3231) showed good outcomes [47.4% (629/1328) for women and 62.2% (1184/1903) for men, p < 0.01]. Atrial fibrillation (AF), diabetes mellitus, stroke history, and old age were factors contributing to poor outcomes in men and women. Hypertension was associated with poor outcomes in women but not in men in comparison with patients without hypertension. Stroke severity and increased intracranial pressure were associated with increased in-hospital mortality in men and women. AF was associated with increased in-hospital mortality in women but not in men compared with patients without AF.

Conclusion

The in-hospital mortality rate was not significantly different between women and men. Functional outcomes at discharge and six months after stroke were poorer in women than in men. Hypertension is an independent factor causing poorer outcomes in women than in men. AF is an independent factor affecting sex differences in hospital mortality in women.

Effects of ambient temperature on stroke hospital admissions: Results from a time-series analysis of 104,432 strokes in Guangzhou, China

BACKGROUND

Stroke is a main cause of death and public health burden in China. The evidence on the burden of different strokes attack attribute to ambient temperature in China is limited. This study aimed to show the characteristics of stroke attack and the attributable risk due to temperature based on hospital admission data in Guangzhou, one of the most developed cities in China.

MATERIAL AND METHODS

From January 1, 2013 to December 31, 2015, 104,432 stroke hospitalizations in Guangzhou residents from 67 hospitals for stroke sentinel surveillance were registered. Characteristics of hospital admissions by gender, age group, calendar year and stroke subtype were analyzed, and distributed lag non-linear models were applied to evaluate the effects of temperature on stroke attack admissions.

RESULTS

Stroke attack admissions increased from 31,851 to 36,755 through 2013 to 2015, increasing by 15.4%. An increasing trend in the risk of stroke attack with age was observed, irrespectively of stroke subtype and calendar year. People with hypertension were more likely to have an associated stroke than people without that. The effects of cold temperature on attack admissions for CBI and ICH strokes were significant. Overall, the percentages of CBI and ICH attack admissions attribute to cold temperature were 9.06% (95% CI: 1.84, 15.00) and 15.09% (95% CI: 5.86, 21.96), respectively. Besides, elderly people were more vulnerable to cold temperature than the young.

CONCLUSIONS

Measures should be taken to increase public awareness about the ill effects of cold temperature on stroke attack, and educate the public about self-protection.

High Burden of Stroke Risk Factors in Developing Country: the Case Study of Bosnia-Herzegovina

Introduction:

The burden of stroke has been increasing worldwide, especially in developing countries. Very few data regarding epidemiology of stroke are available in Bosnia and Herzegovina (BH).

Patients and methods:

We undertook a retrospective hospital-based study in all hospitals existing in five cantons and one district of BH. The patients were recruited between January 1^st, 2014, and December 31^st, 2014, and only first-ever-in-lifetime strokes (FES) were included for evaluation.

Results:

A FES was diagnosed in 1479 patients (age 71.83 ± 11.703 years) during the study period. FES occurred in 709 men (47.9%; age 69.64 ±12.002 years) and 770 women (52.1%; age 73.85± 11.051 years). Stroke was categorized into ischemic stroke (IS), primary intracerebral hemorrhage (PICH), subarachnoid hemorrhage (SAH) and cerebral venous thrombosis (CVT), which was diagnosed in 84%, 12,2%, 3,4% and 0,4% cases respectively. Early 28-day case-fatality was 18.5 % for all patients and both sexes combined. Short-term case-fatality was significantly greater in women (P=0.007). Among all patients with FES, 87% had hypertension, 35% diabetes mellitus, 39% hypercholesterolemia and almost 25 % atrial fibrillation.

Discussion:

This is the first study that provides us with information on epidemiology of stroke in BH. More than 90% of patients had one or more modifiable risk factors and the number would be even higher if we included smoking. The early stroke case-fatality was lower than that observed in other low- to middle-income countries.

Conclusion:

All modifiable stroke risk factors, especially high blood pressure, should be understood as a major public health problem in BH and efforts should be focused on the primary prevention of stroke. Our emphasis is on the designing of a stroke register in BH for a better health planning.

Sex Differences in the Cerebral Collateral Circulation

Premenopausal women and intact female rodents sustain smaller cerebral infarctions than males. Several sex-dependent differences have been identified as potential contributors, but many questions remain unanswered. Mice exhibit wide variation in native collateral number and diameter (collateral extent) that is dependent on differences in genetic background, aging, and other comorbidities and that contributes to their also-wide differences in infarct volume. Likewise, variation in infarct volume correlates with differences in collateral-dependent blood flow in patients with acute ischemic stroke. We examined whether extent of pial collateral arterioles and posterior communicating collateral arteries (PComAs) differ depending on sex in young, aged, obese, hypertensive, and genetically different mice. We combined new data with meta-analysis of our previously published data. Females of C57BL/6J (B6) and BALB/cByJ (BC) strains sustained smaller infarctions than males after permanent MCA occlusion. This protection was unchanged in BC mice after introgression of the B6 allele of Dce1, the major genetic determinant of variation in pial collaterals among mouse strains. Consistent with this, collateral extent in these and other strains did not differ with sex. Extent of PComAs and primary cerebral arteries also did not vary with sex. No dimorphism was evident for loss of pial collateral number and/or diameter (collateral rarefaction) caused by aging, obesity, and hypertension, nor for collateral remodeling after pMCAO. However, rarefaction was greater in females with long-standing hypertension. We conclude that smaller infarct volume in female mice is not due to greater collateral extent, greater remodeling, or less rarefaction caused by aging, obesity, or hypertension.

Changes in stroke incidence, outcome, and associated factors in Porto between 1998 and 2011

Objective

Year 2000 marked a turning point in stroke prevention and treatment in Portugal. In face of high incidence rates stroke awareness campaigns, close surveillance of vascular risk factors and implementation of hospital stroke units were advanced by the National Health Authorities. To understand the effect of such measures, we assessed changes in stroke incidence and short-term outcome using data from two community-based registers undertaken in Porto in 1998–2000 and 2009–2011.

Methods

We used standard diagnostic criteria and multiple overlapping sources of case-ascertainment for first-ever strokes. Short-term outcome was measured by the modified Rankin Scale; disabling stroke was defined whenever post-stroke mRS score>pre-stroke mRS and >1.

Results

Globally, 462 and 405 first-ever stroke cases were registered in 1998–2000 and 2009–2011, respectively. Stroke incidence decreased by 23%, from 261 to 203/100,000 after adjustment for the Portuguese population. Significant reduction was found in those aged <75 years (31%) and in women (32%). Incidence of disabling strokes was reduced by 29%. Fatal strokes decreased by 46%, while intracerebral hemorrhage decreased by 51%. Risk of disability from stroke decreased by 11% (RR = 0.89; 95%CI, 0.81–0.98) in 2009–2011, as found after adjusting for patient/stroke characteristics in a Poisson model. Moreover, when patients arrived hospital within 3 h from stroke onset, the risk of disabling stroke was 0.76 (95%CI, 0.67–0.87) in 2009–2011 vs. 1998–2000, compared to 1.03 (95%CI, 0.89–1.12) for late arrival.

Conclusion

Risk of stroke, mainly of hemorrhagic stroke, was substantially reduced over time. Timely action in acute phase was responsible for the decline in disability across periods.

Knockout of ho-1 protects the striatum from ferrous iron-induced injury in a male-specific manner in mice

Men have worse survival than premenopausal women after intracerebral hemorrhage (ICH). After ICH, overproduction of iron associated with induction of heme oxygenase-1 (HO-1) in brain was observed. Rodent ICH model using ferrous citrate (FC)-infusion into the striatum to simulate iron overload, showed a higher degree of injury severity in males than in females. However, the participation of HO-1 in sex-differences of iron-induced brain injury remains unknown. The present results showed a higher level of HO-1 expression associated with more severe injury in males compared with females after FC-infusion. Estradiol (E₂) contributed to lower levels of FC-induced HO-1 expression in females compared with males. Heterozygote ho-1 KO decreased the levels of FC-induced injury severity, histological lesions, behavioral deficits, autophagy and autophagic cell death in the striatum of males but not in females. Moreover, ho-1 deficiency enhanced the neuroprotection by E₂ only in males. These results suggested that over induction of HO-1 plays a harmful role in FC-induced brain injury in a male-specific manner. Suppression of HO-1 combined with E₂ exhibits a synergistic effect on neuroprotection against FC-induced striatal injury in males. These findings open up the prospect for male-specific neuroprotection targeting HO-1 suppression for patients suffering from striatal iron overload.

Trends in Acute Ischemic Stroke Hospitalizations in the United States

Background

Population‐based studies have revealed declining acute ischemic stroke (AIS) hospitalization rates in the United States, but no study has assessed recent temporal trends in race/ethnic‐, age‐, and sex‐specific AIS hospitalization rates.

Methods and Results

Temporal trends in hospitalization for AIS from 2000 to 2010 were assessed among adults ≥25 years using the Nationwide Inpatient Sample. Age‐, sex‐, and race/ethnic‐specific and age‐adjusted stroke hospitalization rates were calculated using the weighted number of hospitalizations and US census data. From 2000 to 2010, age‐adjusted stroke hospitalization rates decreased from 250 to 204 per 100 000 (overall rate reduction 18.4%). Age‐specific AIS hospitalization rates decreased for individuals aged 65 to 84 years (846 to 605 per 100 000) and ≥85 years (2077 to 1618 per 100 000), but increased for individuals aged 25 to 44 years (16 to 23 per 100 000) and 45 to 64 years (149 to 156 per 100 000). Blacks had the highest age‐adjusted yearly hospitalization rates, followed by Hispanics and whites (358, 170, and 155 per 100 000 in 2010). Age‐adjusted AIS hospitalization rates increased for blacks but decreased for Hispanics and whites. Age‐adjusted AIS hospitalization rates were lower in women and declined more steeply compared to men (272 to 212 per 100 000 in women versus 298 to 245 per 100 000 in men).

Conclusions

Although overall stroke hospitalizations declined in the United States, the reduction was more pronounced among older individuals, women, Hispanics, and whites. Renewed efforts at targeting risk factor control among vulnerable individuals may be warranted.

Tissue plasminogen activator deficiency preserves neurological function and protects against murine acute ischemic stroke

BACKGROUND

We tested the hypothesis that tissue plasminogen activator (tPA) deficiency protected against acute ischemic stroke (AIS)-induced brain injury.

METHODS AND RESULTS

Wild-type mice (n=54) were categorized into group 1 (sham control, n=18) and group 3 [AIS by permanent ligation of left common carotid artery (CCA) and cramping right CCA for 1h and then reperfusion followed by hypoxia (11% of oxygen supply for 2h), n=36]. Similarly, tPA knockout (tPA(-/-)) mice (n=54) were randomized into group 2 (sham control, n=18) and group 4 (AIS, n=36). By day 28 after AIS procedure, mortality rate was higher in group 3 (77.8%) than in group 4 (38.9%) and lowest in groups 1 (0%) and 2 (0%) (p<0.001). By days 3 and 28, MRI demonstrated a pattern of changes in brain-infarct volume identical to that of mortality among four groups (p<0.001). By day 28, protein expressions of inflammatory (MMP-9, TNF-α, NF-κB, iNOS, PAI-1, RANTES), oxidative (NOX-1, NOX-2, oxidized protein), apoptotic (cleaved caspase-3 & PARP, Bax), and fibrotic (Smad3, TGF-β) biomarkers and cellular expressions of inflammation (CD11, F4/80, GFAP), DNA-damage (γ-H2AX) and brain-edema (AQP4) markers exhibited an identical pattern compared to that of mortality (all p<0.001), whereas protein expressions of endothelial (eNOS, CD31), anti-fibrotic (Smad1/5, BMP-2) biomarkers, and number of small vessels displayed an opposite pattern (all p<0.001) among four groups. Expressions of protein and cellular angiogenesis markers (VEGF, SDF-1α, CXCR4) were progressively increased from groups 1 and 2 to group 4 (all p<0.0001).

CONCLUSION

tPA deficiency protected the brain from AIS injury.

Male-Specific Alleviation of Iron-Induced Striatal Injury by Inhibition of Autophagy

Men exhibit a worse survival rate than premenopausal women after intracerebral hemorrhage (ICH), however, no sex-specific management has been concerned. In a rat model involving infusion of ferrous citrate (FC) that simulates iron accumulation after hemorrhage, a higher degree of autophagy associated with higher injury severity was observed in striatum of males than in females. Since the imbalance between the levels of autophagy and energy demand may lead to cell death, we proposed that FC-induced autophagy is detrimental in a male specific manner and autophagy modulation affects injury severity in a sex-dependent manner. Rapamycin, an autophagy inducer, and conditional knockout gene of autophagy-related protein 7 (Atg7) in dopamine receptor D2 (DRD2) neurons were used to test our hypothesis using a mouse model with striatal FC infusion. The result showed that the levels of autophagic cell death and injury severity were higher in male than in female mice. Pre-treatment of FC-infused females with rapamycin increased the FC-induced behavioral deficit and DRD2 neuron death. However, DRD2 neuron-specific knockout of Atg7 decreased FC-induced injury severity and the number of TUNEL(+) DRD2 neurons in males. These results suggest that autophagy in FC-infusion males is overactive with maladaptive consequences and inhibition of autophagy decreases the severity of FC-induced striatal injury in males. These findings present prospects for male-specific therapeutic strategy that targets autophagy in patients suffering from iron overload.

Gender difference in diabetes-associated risk of first-ever and recurrent ischemic stroke

OBJECTIVE

To evaluate the effect of diabetes by gender on the peak-risk of first-ever-ischemic stroke and its recurrence.

METHODS

Administrative datasets including all hospital discharges for ischemic stroke (N = 43,332) in the diabetic (N = 207,568) and non-diabetic (N = 2,808,554) population of the Tuscany region, Italy were used to calculate Hazard ratios (HR) after Cox-regression, of first-ever and recurrent ischemic strokes, between 2005 and 2011.

RESULTS

Overall, diabetes increased the HR of first-ever ischemic stroke by about 50% in both genders. However, this risk significantly declined with age and was higher in women aged 55-74 yr than in men of the same age (HR; 95% CI: 1.392; 1.228-1.579 in age-class 55-64 yr and 1.203; 1.110-1.304 in age class 65-74 yr; p < 0.001). Diabetes also increased the adjusted risk of three-year-stroke recurrence (N = 5,998) in women, independently of age, whereas this was the case in men < 70 yr.

CONCLUSIONS

Diabetes is associated with increased risk of ischemic stroke although it declines with age though at lower rate among women than men. Moreover, diabetic women have greater risk of recurrence than in men > 70 yrs old, supporting a high-risk "time-window" in postmenopausal-elderly diabetic women.

Lower hazard ratio for death in women with cerebral hemorrhage

OBJECTIVES

The aim of the study was to clarify the hazard ratio for death within 30 days after stroke comparing women to men.

MATERIAL AND METHODS

We reviewed all stroke patients registered in the Kyoto Stroke Registry (from January 1999 to December 2009) in Japan. Hazard ratio (HR) for death and 95% confidence interval were calculated by the Cox regression in stroke and in each stroke subtype: cerebral infarction (CI), cerebral hemorrhage, (CH) and subarachnoid hemorrhage (SAH). We also evaluated HR for death in women in each consciousness level at the onset of stroke: the Japan Coma Scale (JCS) 0 (alert), JCS 1-digit code (disoriented but awake), JCS 2-digit code (arousable with stimulation), and JCS 3-digit code (unarousable).

RESULTS

A total of 13,788 patients were analyzed. HR for death comparing women to men were 1.04 (0.88-1.23, P = 0.66 in stroke as a whole), 0.91 (0.69-1.21, P = 0.51 in CI), 0.53 (0.41-0.71, P < 0.01 in CH), and 0.89 (0.60-1.30, P = 0.535 in SAH) after adjustment for age and histories of hypertension, arrhythmia, diabetes mellitus and hyperlipemia and uses of tobacco and alcohol. Stratified by JCS, HR for death in women with CH were 0.32 (0.11-0.94 in JCS0), 0.48 (0.28-0.82 in JCS1), 0.49 (0.28-0.83 in JCS2), and 0.79 (0.65-0.97 in JCS3), respectively. HR for death in women with CI in JCS3 was significantly lower than in men (0.71; 0.52-0.98).

CONCLUSION

We evaluated HR for death comparing men to women in stroke and in each stroke subtype. Women with CH had lower HR for death within 30 days after stroke than men.

Time Trends in Incidence and Case Fatality of Ischemic Stroke

Background and Purpose—

Ischemic stroke incidence has declined in industrialized countries the last decades, with possible exception for the youngest age groups. We estimated age- and sex-specific trends in incidence and case fatality of first-ever ischemic stroke between 1977 and 2010 in a Norwegian municipality.

Methods—

Age-adjusted time trends in incidence from 1977 to 2010 were estimated by fractional polynomial and Poisson regression, and case fatality by logistic regression in 36 575 participants of the population-based Tromsø Study.

Results—

There were 1214 first-ever ischemic strokes within a total follow-up time of 611 176 person-years. The overall age- and sex-adjusted incidence decreased by 24% in 1995 to 2010. In women aged 30 to 49 years, the incidence increased significantly from 1980 to 2010. In men aged 30 to 49 years, there was a nonsignificant, rising trend from 1977 to 2010. Men aged 50 to 64 years had similar incidence in 2010 compared with 1989. From the mid-1990s to 2010, the incidence declined significantly in women aged 50 to 74 years and in men aged 65 to 74 years, but remained stable in those aged ≥75 years. Case fatality decreased significantly in men aged 30 to 84 years from 1995 to 2010, whereas there was no significant change in women.

Conclusions—

Age-adjusted incidence of first-ever ischemic stroke increased in young women, declined in women aged 50 to 74 years and men aged 65 to 74 years and remained stable among the oldest. Case fatality declined in men aged 30 to 84 years, but not in women.

Implications of female sex on stroke risk factors, care, outcome and rehabilitation: an Asian perspective

BACKGROUND

Stroke affects 16.9 million people annually and the greatest burden of stroke is in low- and middle-income countries, where 69% of all strokes occur. Stroke risk factors, mortality and outcomes differ in developing countries as compared to the developed world. We performed a literature review of 28 articles pertaining to epidemiology of stroke in Asian women, stroke risk factors, gender-related differences, and stroke outcomes.

SUMMARY

Asian women differ from women worldwide due to differences in stroke awareness, risk factor profile, stroke subtypes, and social issues that impact stroke care. While Asian men have a higher incidence of stroke as compared to women overall, the long- and short-term outcomes in Asian women tend to be poorer. Both conventional and gender-specific risk factors contribute to stroke risk. Oral contraceptive use and addictions such as tobacco and alcohol are less prevalent among Asian women due to socio cultural differences. There is however, a much higher preponderance of pregnancy-related stroke and cardio-embolic stroke secondary to rheumatic heart disease and heavy use of chewing tobacco. The overall outcome is poor due to poor access to health care and lack of resources. Key Messages: Our review exposed the gaps in our knowledge about stroke risk factors and differences in stroke care provided to Asian women. While there are sociocultural barriers that impede the provision of immediate care to these stroke patients, much needs to be done by way of prevention of recurrent stroke and treatment of risk factors.

Effect of diabetes on hospitalization for ischemic stroke and related in-hospital mortality: a study in Tuscany, Italy, over years 2004-2011

BACKGROUND

Incidence of ischemic stroke and associated in-hospital mortality is decreasing in Western populations, while the prevalence of diabetes, a well-known risk factor for ischemic stroke, is progressively rising. This study was aimed at evaluating the effect of diabetes on ischemic stroke hospitalization and in-hospital mortality after ischemic stroke.

METHODS

Discharges with diagnosis of ischemic stroke were identified in a database containing all hospitalizations of resident population of Tuscany, Italy, over years 2004-2011. Cases with diabetes were identified through specific drug prescriptions, official certifications or previous hospital diagnosis. Rates of annual ischemic stroke incidence and related in-hospital mortality were separately calculated for gender and age class, in subjects with and without diabetes.

RESULTS

Sixty-five thousand one hundred sixty-five hospital discharges with ischemic stroke diagnosis were identified. Diabetes was associated with increased risk of stroke odds ratio(95% confidence interval):1.31(1.28-1.34) in men and 1.24(1.21-1.37) in women. Diabetic women, compared with men, had a higher in-hospital mortality risk after ischemic stroke (odds ratio:1.32; 1.06-1.64), whereas in non-diabetic subjects, there was no difference between genders. Incidence of ischemic stroke has declined in non-diabetic subjects, except for women aged ≤70 years; a similar reduction was observed for in-hospital mortality. Among diabetic patients, conversely, annual incidence of ischemic stroke rose by 3% in the elderly people (>70 years), and annual mortality trend remained unchanged.

CONCLUSIONS

In the last decade, the incidence of ischemic stroke and of related in-hospital mortality declined in persons without diabetes, while increasing among diabetic patients of advanced age. Women with diabetes, compared with men, had a higher in-hospital mortality risk.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sex differences in trends of incidence and mortality of first-ever stroke in rural Tianjin, China, from 1992 to 2012

BACKGROUND AND PURPOSE

Sex differences in secular trends of stroke incidence are rarely reported. We aimed to explore sex differences in incidence and mortality of stroke in rural China from 1992 to 2012.

METHODS

In 1992, 14 920 residents were recruited to participate in the Tianjin Brain Study, a population-based study on stroke surveillance. Stroke events and all deaths were annually registered.

RESULTS

We observed 908 incident strokes (366 in women) from 1992 to 2012. Women were significantly younger than men (64±12 versus 68±11 years) in 1992 to 1998 (P=0.024). The incidence of first-ever stroke per 100 000 person-years for men was 166 in 1992 to 1998, 227 in 1999 to 2005, and 376 in 2006 to 2012; for women, the rates were 86 (1992-1998), 148 (1999-2005), and 264 (2006-2012). From 1992 to 2012, the incidence grew annually by 5.8% in men and 8.0% in women. The male/female incidence ratio declined significantly: 1.9 in 1992 to 1998, 1.5 in 1999 to 2005, and 1.4 in 2006 to 2012. There were no significant sex differences in mortality. The prevalence of obesity and diabetes mellitus, the levels of total cholesterol and triglycerides, and the age of menopause and reproductive years in women concurrently increased in 2011.

CONCLUSIONS

There was a significant increase in the incidence of first-ever stroke in women annually and a declining trend in the male/female rate ratio in rural China during the past 21 years. These results suggest that stroke will become one of the major diseases affecting women in future decades in China.

Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura.

CONCLUSIONS

To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted.

Sex differences in stroke case fatality: a meta-analysis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gender differences in 1-year clinical characteristics and outcomes after stroke: results from the China National Stroke Registry

Background

Previous reports have shown inconsistent results on clinical outcomes between women and men after stroke, and little is known about gender differences on outcomes in Chinese post-stroke patients. The aim of this study was to explore whether there were gender differences on clinical characteristics and outcomes in Chinese patients after ischemic stroke by using the data from the China National Stroke Registry (CNSR).

Methods and Findings

Out of 12,415 consecutively recruited patients with acute ischemic stroke in the CNSR from 2007 to 2008, 11,560 (93.1%) patients were followed up for 12 months. Their clinical characteristics and outcomes on death, recurrence, and dependency were recorded. The multivariate logistic regression was performed to determine whether there were gender differences in these outcomes. Women were older than men at baseline (67.9 vs. 64.0 years, P<0.001). Women had a higher mortality, recurrence rate, and dependency rate at 3, 6, and 12 months than men, but after adjusting for age, history of diabetes, pre-stroke dependency, stroke severity, in-hospital complications, and other confounders, there were no statistically significant differences in gender on mortality and recurrence rate at 3, 6, and 12 months; and dependency rate at 3, and 6 months. However, the dependency rate at 12 months remained significantly higher in women (odds ratio, 1.24; 95% confidence interval, 1.06 to 1.45).

Conclusions

There are many differences in clinical characteristics between women and men after ischemic stroke in China. Compared with men, women are more dependent at 12 months after stroke. This difference still exists after controlling the potential confounders.

Gender differences in emergency stroke care and hospital outcome in acute ischemic stroke: a multicenter observational study

BACKGROUND

We aimed to investigate the effect of gender difference on the accessibility to emergency care, hospital mortality and disability in acute stroke care.

METHODS

This study was performed on a single-tiered basic emergency medical service with a comprehensive national health insurance. Demographic variables, risk factors, elapsed time intervals, performing diagnosis and treatment options, hospital mortality, and modified Rankin Scale of acute ischemic stroke during 2008 were collected. We modeled the multivariate regression analysis for gender differences on the accessibility, hospital mortality, and disability. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated adjusting for potential risk factors.

RESULTS

The total number of patients was 6635. The time from symptom onset to emergency department (ED) arrival and to computed tomography or magnetic resonance imaging scan and from ED arrival to computed tomography or magnetic resonance imaging scan was significantly longer in women. No significant difference was found in either the time to intravenous thrombolysis or in the number of patients who received intravenous thrombolysis, anti-platelet therapy, anti-coagulation, or operation. The hospital mortality rate was higher in women (3.9%) than in men (2.9%) (P = .03). The increased disability was significantly higher in women (67.8%) than in men (65.1%) (P = .02). The hospital mortality and increased disability showed a non-significant difference between the 2 genders in the adjusted model (OR, 1.10; 95% CI, 0.74-1.64) and (OR, 1.11; 95% CI, 0.96-1.28), respectively.

CONCLUSION

The adjusted model for risk factors showed no significant difference on hospital mortality and disability between the 2 genders for stroke patients.

Age- and ethnic-specific sex differences in stroke risk

BACKGROUND

In white populations, age seems to modify the effect of sex on stroke risk, and compared with men, women are protected from stroke until approximately age 75 to 85 years, after which the protection is lost or reversed. Compared with non-Hispanic whites (NHWs), Mexican Americans (MAs) are at higher risk of stroke; however, age- and sex-specific stroke incidence data are currently not available for this population.

OBJECTIVE

This study was performed to compare the age-specific sex differences in stroke risk in MAs and NHWs.

METHODS

Data were derived from the BASIC (Brain Attack Surveillance in Corpus Christi) Project, a population-based stroke surveillance study conducted in Nueces County Texas. Incident strokes (n = 2421, including ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) that occurred between January 1, 2000 and May 25, 2007 in individuals aged 45 years or older were included in the analysis. Poisson regression using the generalized additive models framework was used to analyze the relationship between sex, age (5-year intervals), and race/ethnicity (NHW or MA) and incident stroke risk.

RESULTS

Among both NHWs and MAs aged 45 to 79 years, men were at higher risk of stroke than women were. The magnitude of increased stroke risk in men compared with women diminished with age, and after age 79 years, no sex difference in stroke risk was observed.

CONCLUSIONS

Reasons for the loss of protection from stroke in aging women of all races/ethnicities are not fully understood, and further study is warranted.

The Incidence, Prevalence, and Mortality of Stroke in France, Germany, Italy, Spain, the UK, and the US: A Literature Review

Background. Although the burden of stroke in terms of mortality and disability has been well documented in previous years, data after 2000 are limited. Therefore, the aim of this paper was to identify the epidemiology of stroke in the US and EU5 nations from data published in 2000 and later. Methods. Data from literature databases and online sources were collated to identify information relating to the incidence, prevalence, and mortality of stroke from the year 2000 onwards. Results and Conclusions. Twenty-three data sources were identified. The incidence of and mortality due to stroke both increase with age and are greater in males compared to females. Stroke is a common problem and likely to worsen in the US and EU5 as their populations age. However, pre-2000 trends of decreasing stroke mortality over time have continued after 2000, reflecting a consistent improvement in the treatment and care of patients with stroke.

Predictors of poor outcome in patients with acute cerebral infarction

BACKGROUND AND PURPOSE

Plasma D-dimer levels are elevated during the acute phase of cerebral infarction (CI). We investigated whether the D-dimer level on admission and other clinical characteristics could be used to predict the poor outcome of patients with acute CI.

METHODS

The clinical characteristics and plasma D-dimer levels measured within 3 days of onset were compared according to outcome among patients with acute CI.

RESULTS

In total, 359 consecutive patients (mean age, 71.8 years) were examined, of which 174 had a poor outcome [score on the modified Rankin scale (mRS) ≥3] at 30 days after hospitalization. The mean mRS score was higher and a poor outcome was observed more frequently among women than among men (p<0.001 for each). The proportions of women, cardioembolism, atrial fibrillation, advanced age (≥75 years), prior history of CI or transient ischemic attack, and elevated D-dimer level (≥1.0 µg/mL) were significantly higher among patients with a poor outcome than among those with a good outcome. A multivariate analysis showed that elevated D-dimer level [≥1.0 µg/mL; odds ratio (OR), 2.45; 95% confidence interval (95% CI), 1.52-3.89; p<0.01], advanced age (OR, 1.93; 95% CI, 1.21-3.07; p<0.01), and female gender (OR, 1.75; 95% CI, 1.08-2.83; p=0.02) were independent predictors of a poor outcome.

CONCLUSIONS

Certain clinical characteristics (gender and advanced age) and an elevated D-dimer level upon admission can be used to predict the outcome of patients with acute CI at 30 days after hospitalization.