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Otite FO, Morris N. Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke. Crit Care Clin 2024; 40:709-740. [PMID: 39218482 DOI: 10.1016/j.ccc.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.
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Affiliation(s)
- Fadar Oliver Otite
- Cerebrovascular Division, Upstate Neurological Institute, Syracuse, NY, USA.
| | - Nicholas Morris
- Neurocritical Care Division, Department of Neurology, University of Maryland, Baltimore, MD, USA
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Marko M, Miksova D, Haidegger M, Schneider J, Ebner J, Lang MB, Serles W, Kiechl S, Knoflach M, Sykora M, Ferrari J, Gattringer T, Greisenegger S. Trends in sex differences of functional outcome after intravenous thrombolysis in patients with acute ischemic stroke. Int J Stroke 2024:17474930241273696. [PMID: 39086256 DOI: 10.1177/17474930241273696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) is an approved treatment for patients with acute ischemic stroke irrespective of sex. However, the current literature on sex differences in functional outcomes following IVT is inconsistent. So far, a number of studies-including a previous analysis based on data from the Austrian Stroke Unit Registry (ASUR)-detected significant sex-related differences in functional outcome, while others did not report any differences between women and men. In addition, currently there is a lack of data on how sex-related differences evolve over time. AIMS To assess time trends of sex-related differences in functional outcome of ischemic stroke in a large nationwide cohort and to investigate associations of patient characteristics with functional outcome post thrombolysis in women and men. These data will offer crucial insights into whether sex differences in functional outcome persist despite the large advances in acute stroke treatment. METHODS We analyzed retrospective data of consecutive patients with acute ischemic stroke treated with IVT in 39 stroke centers contributing to the ASUR between 2006 and 2021. We included patients over 18 years of age diagnosed with an acute ischemic stroke who received IVT and with available data on functional outcome at 3 months after treatment. The primary outcome parameter was favorable functional outcome (modified Rankin Scale (mRS) of 0-2) at 3 months. Multivariable logistic regression analysis was performed in the overall population and stratified by sex to assess associations of baseline characteristics with functional outcome. RESULTS Among 11,840 patients receiving IVT, 2489 of 5503 (45.4%) women achieved favorable functional outcome compared to 3787 of 6337 (59.8%) men. Overall, female sex was a statistically significant predictor of functional outcome after thrombolysis, but additional predictors of outcome differed between women and men. Female sex was independently associated with decreased chances of achieving functional independency (adjusted odds ratio (adjOR) = 0.87, 95% confidence interval (CI) = 0.79-0.96, p = 0.005) and we detected a statistically significant improvement in functional outcome over time only in men (year of treatment, adjOR (per year) = 1.04, 95% CI = 1.02-1.06, p < 0.001) but not in women (adjOR (per year) = 1.01, 95% CI = 0.99-1.03, p = 0.280). Hypertension, smoking, and longer or unknown onset-to-door times were statistically significant predictors of outcome only in male patients, whereas atrial fibrillation, prior myocardial infarction, and longer door-to-needle times were significantly associated with outcome only in women. CONCLUSIONS Sex differences in functional outcome after IVT for acute ischemic stroke are persisting over the past years. Results of our analysis can increase awareness and a resulting focus on sex differences in predictors of outcome could be helpful in mitigating these differences in the future by supporting a more individualized patient care in clinical routine. Follow-up analyses are needed to assess this potential impact and its effect in the future. DATA ACCESS STATEMENT Data from the Austrian Stroke Unit Registry can only be accessed by the employed statistician (D.M.), access inquiries have to be addressed to the registry's academic review board.
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Affiliation(s)
- Martha Marko
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | | | | | - Jakob Schneider
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Johanna Ebner
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Marie B Lang
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Wolfgang Serles
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage-Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage-Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
| | - Marek Sykora
- Department of Neurology, Krankenhaus Barmherzige Brüder Wien, Wien, Austria
| | - Julia Ferrari
- Department of Neurology, Krankenhaus Barmherzige Brüder Wien, Wien, Austria
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Reyes-Esteves S, George DK, Cucchiara B. Sex differences in treatment effect in neuroprotectant trials for acute ischemic stroke: A systematic review. J Neurol Sci 2024; 460:122992. [PMID: 38579414 DOI: 10.1016/j.jns.2024.122992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/11/2024] [Accepted: 03/31/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Pre-clinical data suggest sex differences in mechanisms of cerebral ischemic injury. This might result in differential outcomes of putative neuroprotectants by sex, though little systematic data is available to assess this. METHODS We performed a systematic review of multicenter randomized controlled trials published from January 1980-June 2022 enrolling >100 subjects and testing neuroprotectants in acute ischemic stroke (AIS). For each trial, reported treatment effect by sex was extracted. When published results by sex were not available, we contacted individual authors to attempt to retrieve these data. RESULTS We identified 59 publications reporting 64 trials that met inclusion criteria. Of these, data on treatment effect by sex were published for 14/64 trials. Unpublished data for an additional 5 trials were obtained from trial investigators (19/64, or 29.7%). Two trials (one testing uric acid and one dexborneol) reported treatment benefit in women but not men. Pooled analysis of six trials of tirilazad reported worse treatment outcomes in women and no effect in men. No clear difference was apparent in the other trials. CONCLUSIONS Most trials did not report treatment effect by sex. Of those that did, there was little evidence of systematic sex differences in treatment response.
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Aziz YN, Sucharew H, Stanton RJ, Alwell K, Ferioli S, Khatri P, Adeoye O, Flaherty ML, Mackey J, De Los Rios La Rosa F, Martini SR, Mistry EA, Coleman E, Jasne AS, Slavin SJ, Walsh K, Star M, Ridha M, Ades LMC, Haverbusch M, Demel SL, Woo D, Kissela BM, Kleindorfer DO. Racial Disparities in Blood Pressure at Time of Acute Ischemic Stroke Presentation: A Population Study. J Am Heart Assoc 2024; 13:e032645. [PMID: 38700029 PMCID: PMC11179936 DOI: 10.1161/jaha.123.032645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 04/10/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Hypertension is a stroke risk factor with known disparities in prevalence and management between Black and White patients. We sought to identify if racial differences in presenting blood pressure (BP) during acute ischemic stroke exist. METHODS AND RESULTS Adults with acute ischemic stroke presenting to an emergency department within 24 hours of last known normal during study epochs 2005, 2010, and 2015 within the Greater Cincinnati/Northern Kentucky Stroke Study were included. Demographics, histories, arrival BP, National Institutes of Health Stroke Scale score, and time from last known normal were collected. Multivariable linear regression was used to determine differences in mean BP between Black and White patients, adjusting for age, sex, National Institutes of Health Stroke Scale score, history of hypertension, hyperlipidemia, smoking, stroke, body mass index, and study epoch. Of 4048 patients, 853 Black and 3195 White patients were included. In adjusted analysis, Black patients had higher presenting systolic BP (161 mm Hg [95% CI, 159-164] versus 158 mm Hg [95% CI, 157-159], P<0.01), diastolic BP (86 mm Hg [95% CI, 85-88] versus 83 mm Hg [95% CI, 82-84], P<0.01), and mean arterial pressure (111 mm Hg [95% CI, 110-113] versus 108 mm Hg [95% CI, 107-109], P<0.01) compared with White patients. In adjusted subanalysis of patients <4.5 hours from last known normal, diastolic BP (88 mm Hg [95% CI, 86-90] versus 83 mm Hg [95% CI, 82-84], P<0.01) and mean arterial pressure (112 mm Hg [95% CI, 110-114] versus 108 mm Hg [95% CI, 107-109], P<0.01) were also higher in Black patients. CONCLUSIONS This population-based study suggests differences in presenting BP between Black and White patients during acute ischemic stroke. Further study is needed to determine whether these differences influence clinical decision-making, outcome, or clinical trial eligibility.
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Affiliation(s)
- Yasmin N. Aziz
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | - Heidi Sucharew
- Department of Emergency MedicineUniversity of CincinnatiCincinnatiOH
| | - Robert J. Stanton
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | - Kathleen Alwell
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | - Simona Ferioli
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | - Pooja Khatri
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | - Opeolu Adeoye
- Department of Emergency MedicineWashington UniversitySt LouisMO
| | - Matthew L. Flaherty
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | - Jason Mackey
- Department of NeurologyIndiana UniversityIndianapolisIN
| | | | - Sharyl R. Martini
- Department of NeurologyMichael E. DeBakey VA Medical CenterHoustonTX
| | - Eva A. Mistry
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | | | | | | | - Kyle Walsh
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | | | - Mohamed Ridha
- Department of NeurologyThe Ohio State UniversityColumbusOH
| | - Laura M. C. Ades
- Department of NeurologyNYU Grossman School of MedicineBrooklynNY
| | - Mary Haverbusch
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | - Stacie L. Demel
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | - Daniel Woo
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
| | - Brett M. Kissela
- Department of Neurology and Rehabilitation MedicineUniversity of CincinnatiCincinnatiOH
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Sex Differences in Functional Outcomes Following Endovascular Treatment for Acute Ischemic Stroke. Can J Neurol Sci 2023; 50:174-181. [PMID: 35220985 DOI: 10.1017/cjn.2022.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Sex disparities have been reported across many aspects of acute ischemic stroke (AIS) care; however, there is a relative paucity of research examining sex differences in outcomes following endovascular treatment (EVT). Some studies report worse functional independence for females following EVT. Few, if any of these studies account for differences in age, baseline function, and comorbidity burden. This retrospective cohort study aimed to assess for sex differences in functional outcomes following EVT by comparing 90-day modified Rankin Scale (mRS) of males and females while controlling for baseline function and comorbidity burden. METHODS Baseline demographic and clinical data, and stroke severity were compared for 230 consecutive patients undergoing EVT for AIS between October 2014 and July 2019 at a tertiary stroke centre in Toronto, Canada. Effect of sex on likelihood of functional independence post-EVT was assessed using regression analysis with and without correction for age, baseline mRS, and Charlson Comorbidity Index (CCI). RESULTS Females undergoing EVT for AIS were older (75 ± 13 vs. 66 ± 15, p < 0.0001), with worse clinical and functional baselines. Unadjusted, males were more functionally independent (90-day mRS < 3) [OR = 1.831, 95%CI 1.082-3.098]. After controlling for age, baseline mRS and CCI, there was no difference between groups [OR 1.21, 95%CI 0.61-2.37]. CONCLUSIONS This study provides evidence that prior findings of sex disparities in function after EVT may be accounted for by differences in age, baseline clinical status and functional independence between males and females when a comprehensive measure of comorbidity burden is utilized.
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Perrier J, Renard M, Pariente A, Bezin J. Systematic review on sex differences for drug use after stroke. Therapie 2023; 78:213-224. [PMID: 36517302 DOI: 10.1016/j.therap.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/08/2022] [Accepted: 11/25/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Systematic reviews and meta-analyses have synthetized the existing knowledge on sex-differences for the risk of stroke, the most recent ones highlighting an increased risk of stroke for women. However, whether there are sex differences in post stroke treatment in real world setting is not known. We therefore conducted a systematic review on this subject. MATERIAL AND METHODS All observational studies on sex-differences in poststroke drug use published until 20/04/2021 were identified from PubMed and Scopus. Articles were selected and assessed by two independent readers; a third resolved disagreements. Data extraction was performed using a standardized form; articles quality was assessed using the STROBE guidelines. The study is registered on PROSPERO: CRD42021250256. RESULTS Of the 604 identified articles, 33 were included. Most were published before 2015 and presented methodological limitations. These limitations differentially affected studies with statistically significant and non-significant results, questioning the reliability of conflicting results. The exploration of sex-differences in drug use varied between therapeutic classes (articles focusing on thrombolytics: 25; antithrombotics: 23; on antihypertensive: 13; lipid-lowering drugs: 9). After stroke, women were found less likely to be prescribed antithrombotics in 48% of the articles investigating this class, and lipid-lowering drugs in 56%. Thirty-one percent of the studies concerning antihypertensive drugs reported the opposite. DISCUSSION/CONCLUSION In women, a lack of use of antithrombotics and lipid-lowering drugs after stroke seem to emerge from this review. Conflicting results regarding sex-differences might relate to methodological limitations in studies with no statistical differences, and advocate for the conduct of newer and more comprehensive research.
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Affiliation(s)
- Julia Perrier
- Université de Bordeaux, INSERM, BPH, équipe AHeaD, U1219, 33000 Bordeaux, France.
| | - Mathilde Renard
- Université de Bordeaux, INSERM, BPH, équipe AHeaD, U1219, 33000 Bordeaux, France
| | - Antoine Pariente
- Université de Bordeaux, INSERM, BPH, équipe AHeaD, U1219, 33000 Bordeaux, France; CHU de Bordeaux, service de pharmacologie médicale,INSERM, U1219, 33000 Bordeaux, France
| | - Julien Bezin
- Université de Bordeaux, INSERM, BPH, équipe AHeaD, U1219, 33000 Bordeaux, France; CHU de Bordeaux, service de pharmacologie médicale,INSERM, U1219, 33000 Bordeaux, France
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7
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Okon M, Blum B, Nathaniel TI. Risk factors and ambulatory outcome in ischemic stroke patients with pre-stroke depression. JOURNAL OF VASCULAR NURSING 2021; 39:91-99. [PMID: 34865727 DOI: 10.1016/j.jvn.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 04/25/2021] [Accepted: 07/19/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE It is well known that post-stroke depression might be a negative factor for stroke recovery, however there is limited evidence to establish the link between pre-stroke depression and stroke outcome such motor recovery. The objective is to determine clinical risk factors in ischemic stroke patients with pre-stroke depression that are associated functional ambulatory outcome. METHODS Data from acute ischemic patients from a regional stroke registry were collected for consecutive recombinant tissue plasminogen activator(rtPA)-treated acute ischemic stroke patients between January 2010 and June 2016. Logistic regression model was used to predict risk factors that served as predictive variables, while the increase or reduce odds of improvement in ambulatory outcome was considered as the primary outcome. Multicollinearity and possible interactions among the independent variables were analyzed using the variance inflation factor. RESULTS A total of 1446 patients were eligible for recombinant tissue plasminogen activator (rtPA) and 596 of these patients received rtPA. Of the 596 ischemic stroke patients, 286 patients presented with recent pre-stroke depression, 310 had no pre-stroke depression. Carotid artery stenosis (OR = 11.577, 95% CI, 1.281-104.636, P = 0.029) and peripheral vascular disease (OR = 18.040, 95% CI, 2.956-110.086, P = 0.002) were more likely to be associated with increase odds of improvement in ambulation in patients with no pre-stroke depression treated with rtPA, while antihypertensive medications (OR = 0.192, 95% CI, 0.035-1.067, P = 0.050),previous TIA (OR = 0.177, 95% CI, 0.038-0.818, P = 0.027), and congestive heart failure (OR = 0. 0.160, 95% CI, 0.030-0.846, P = 0.031) were associated with reduced odds of improvement in ambulation. In addition, carotid artery stenosis (OR = 0.078, 95% CI, 0.10-0.614, P = 0.015, congestive heart failure (OR = 0.217, 95% CI, 0.318-0.402, P = 0.030), previous TIA (OR = 0.444, 95% CI, 0.517-0.971, P = 0.012), higher NIHSS scores ((OR = 0.887, 95% CI, 0.830-0.948, P < 0.001), and antihypertensive medications (OR = 0.810, 95% CI, 0.401-0.529, P = 0.019) were associated with the reduced odd of improvement in ambulation in an ischemic stroke population with pre-stroke depression treated with rtPA. CONCLUSION Our findings indicate that more risk factors were associated with the decreased odds of an improvement in ambulation following thrombolytic therapy in an ischemic stroke population with pre-stroke depression when compared with those without pre-stroke depression. This finding maybe helpful in the development of management strategies to increase the use of thrombolytic therapy for pre-stroke depressed ischemic stroke to increased their eligibility for rtPA.
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Affiliation(s)
- Marvin Okon
- Department of Public Health, Clemson University, Clemson, SC 29631
| | - Brice Blum
- University of South Carolina School of Medicine, School of Medicine-Greenville, Greenville, SC 29605, USA
| | - Thomas I Nathaniel
- University of South Carolina School of Medicine, School of Medicine-Greenville, Greenville, SC 29605, USA.
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Mizuma A, Yenari MA. Clinical perspectives on ischemic stroke. Exp Neurol 2021; 338:113599. [PMID: 33440204 PMCID: PMC7904589 DOI: 10.1016/j.expneurol.2021.113599] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 12/13/2020] [Accepted: 01/07/2021] [Indexed: 01/01/2023]
Abstract
Treatments for acute stroke have improved over the past years, but have largely been limited to revascularization strategies. The topic of neuroprotection, or strategies to limit brain tissue damage or even reverse it, has remained elusive. Thus, the clinical mainstays for stroke management have focused on prevention. The lack of clinical translation of neuroprotective therapies which have shown promise in the laboratory may, in part, be due to a historic inattention to comorbidities suffered by a majority of stroke patients. With the advent of more stroke models that include one or more relevant comorbidities, it may be possible to identify effective treatments that may translate into new treatments at the clinical level. In the meantime, we review comorbidities in stroke patients, modification of stroke risk factors and available acute stroke treatments in the clinic.
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Affiliation(s)
- Atsushi Mizuma
- Department of Neurology, University of California, San Francisco and the San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA; Department of Neurology, Tokai University School of Medicine, Isehara, Japan
| | - Midori A Yenari
- Department of Neurology, University of California, San Francisco and the San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
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Wang X, Carcel C, Wang R, Li J, Bae HJ, Wang Y, Wang A, Wang Y, Toyoda K, Sui Y, Lee TH, Navarro JC, Sun MC, Anderson CS, Sharma V, Sandset EC, Woodward M. Worse prognosis in women, compared with men, after thrombolysis: An individual patient data pooling study of Asian acute stroke registries. Int J Stroke 2020; 16:784-791. [PMID: 32638639 DOI: 10.1177/1747493020938307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE To examine sex differences in disease profiles and short-term outcomes after acute ischemic stroke treated with recombinant tissue plasminogen activator. METHODS Eight national and regional stroke registries contributed individual participant data from mainland China, Japan, Philippines, Singapore, South Korea and Taiwan in 2005-2018. The primary outcome was ordinal-modified Rankin scale at 90 days. Key safety outcome was symptomatic intracerebral hemorrhage (sICH). RESULTS Of 4453 patients included in the analyses, 1692 (36.3%) were women who were older, more likely to have a more severe neurological deficit, history of hypertension and atrial fibrillation, and a cardioembolic stroke compared to men. Women were more likely than men to have unfavorable shift of modified Rankin scale (fully adjusted odds ratio) (women vs. men) 1.14, 95% confidence interval 1.02-1.28). There was no significant sex difference for death 1.05 (0.84-1.31) or sICH (1.17, 0.89-1.54). Women were more likely to have unfavorable functional outcome with increasing age (P = 0.022 for interaction). In the age groups 70-80 and ≥80 years, women had a worse functional outcome compared to men (1.22, 1.02-1.47 and 1.43, and 1.06-1.92, respectively). CONCLUSION In this pooled data from Asian acute stroke registries, women had poorer prognosis than men after receiving recombinant tissue plasminogen activator for acute ischemic stroke, which worsened with age. Women older than 70 appear to have a worse outcome than men which could be explained by greater stroke severity, more AF, and cardioembolic stroke.
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, University of New South Wales, NSW, Australia
| | - Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, NSW, Australia.,Sydney School of Public Health, University of Sydney, NSW, Australia
| | - Ruigang Wang
- North China University of Science and Technology Affiliated Hospital, HeBei Province, Tangshan, China
| | - Jingwei Li
- Department of Cardiology, People's Liberation Army General Hospital, Beijing, China.,Department of Cardiology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University, Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Yi Sui
- Shenyang First People's Hospital, Shenyang Medical College Affiliated Shenyang Brain Hospital, Shenyang Brain Institute, Shenyang Clinical Research Center for Neurological Disorders, Shenyang, China
| | - Tsong-Hai Lee
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan
| | - Jose C Navarro
- Stroke Services, Department of Neurology, Jose R. Reyes Memorial Medical Center, Manila, Philippines
| | - Mu-Chien Sun
- Department of Neurology, Changhua Christian Hospital, Changhua
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, NSW, Australia.,The George Institute China at Peking University Health Science Center, Beijing, PR China.,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia.,Health Heart Research Center, Beijing, China
| | - Vijay Sharma
- Division of Neurology, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, NSW, Australia.,The George Institute for Global Health, University of Oxford, Oxford, UK.,Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
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10
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Strong B, Lisabeth LD, Reeves M. Sex differences in IV thrombolysis treatment for acute ischemic stroke. Neurology 2020; 95:e11-e22. [DOI: 10.1212/wnl.0000000000009733] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 12/05/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveA prior meta-analysis of reports published between 2000 and 2008 found that women were 30% less likely to receive IV recombinant tissue plasminogen activator (rtPA) treatment for stroke than men; we updated this meta-analysis to determine if this sex difference persisted.MethodsWe identified studies that reported sex-specific IV rtPA treatment rates for acute ischemic stroke published between 2008 and 2018. Eligible studies included representative populations of patients with ischemic stroke from hospital-based, registry-based, or administrative data. Random effects odds ratios (ORs) were generated to quantify sex differences.ResultsTwenty-four eligible studies were identified during this 10-year period. The summary unadjusted OR based on 17 studies with data on all ischemic stroke patients was 0.87 (95% confidence interval [CI], 0.82–0.93), indicating that women had 13% lower odds of receiving IV rtPA treatment than men. However, substantial between-study variability existed. Lower treatment odds in women were also observed in 7 studies that provided data on the subgroup of patients eligible for IV rtPA treatment, although the summary OR of 0.95 (95% CI, 0.88–1.02) was not statistically significant. Examination of time trends across 33 studies published between 2000 and 2018 found evidence that the sex difference had narrowed in more recent years.ConclusionsAlthough there is considerable variability in the findings of individual studies, pooled data from recent studies show that women with acute stroke are less likely to be treated with IV thrombolysis compared with men. However, the size of this difference has narrowed compared to studies published before 2008.
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11
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Kim T, Chelluboina B, Chokkalla AK, Vemuganti R. Age and sex differences in the pathophysiology of acute CNS injury. Neurochem Int 2019; 127:22-28. [PMID: 30654116 PMCID: PMC6579702 DOI: 10.1016/j.neuint.2019.01.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/11/2019] [Indexed: 12/21/2022]
Abstract
Despite the immeasurable burden on patients and families, no effective therapies to protect the CNS after an acute injury are available yet. Furthermore, the underlying mechanisms that promote neuronal death and functional deficits after injury remain to be poorly understood. The prevalence, age of onset, pathophysiology, and symptomatology of many CNS insults differ significantly between males and females. In the case of stroke, younger males tend to show a higher risk than younger females, while this trend reverses with age. Accumulating evidence from preclinical studies have shown that sex hormones play a crucial role in providing neuroprotection following ischemic stroke and other acute CNS injuries. Estrogen, in particular, exerts a neuroprotective effect by modulating the immune responses after injury. In addition, there exists a sexual dimorphism in cell death pathways between males and females that are independent of hormones. Meanwhile, recent studies suggest that microRNAs are critically involved in the sex-specific mechanisms of cell death. This review discusses the current knowledge on the contribution of sex and age to outcome after stroke. Implication of the interplay between these two factors on other CNS injuries (spinal cord injury and traumatic brain injury) from the experimental evidence were also discussed.
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Affiliation(s)
- TaeHee Kim
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Bharath Chelluboina
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Anil K Chokkalla
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA; Cellular and Molecular Pathology Program, University of Wisconsin, Madison, WI, USA
| | - Raghu Vemuganti
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA; Cellular and Molecular Pathology Program, University of Wisconsin, Madison, WI, USA; William S. Middleton Veterans Administration Hospital, Madison, WI, USA.
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12
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Bushnell C, Howard VJ, Lisabeth L, Caso V, Gall S, Kleindorfer D, Chaturvedi S, Madsen TE, Demel SL, Lee SJ, Reeves M. Sex differences in the evaluation and treatment of acute ischaemic stroke. Lancet Neurol 2019; 17:641-650. [PMID: 29914709 DOI: 10.1016/s1474-4422(18)30201-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 05/02/2018] [Accepted: 05/14/2018] [Indexed: 10/14/2022]
Abstract
With the greater availability of treatments for acute ischaemic stroke, including advances in endovascular therapy, personalised assessment of patients before treatment is more important than ever. Women have a higher lifetime risk of stroke; therefore, reducing potential sex differences in the acute stroke setting is crucial for the provision of equitable and fast treatment. Evidence indicates sex differences in prevalence and types of non-traditional stroke symptoms or signs, prevalence of stroke mimics, and door-to-imaging times, but no substantial differences in use of emergency medical services, stroke knowledge, eligibility for or access to thrombolysis or thrombectomy, or outcomes after either therapy. Women presenting with stroke mimics or non-traditional stroke symptoms can be misdiagnosed, which can lead to inappropriate triage, and acute treatment delays. It is essential for health-care providers to recognise possible sex differences in stroke symptoms, signs, and mimics. Future studies focused on confounders that affect treatment and outcomes, such as age and pre-stroke function, are also needed.
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Affiliation(s)
- Cheryl Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA.
| | - Virginia J Howard
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lynda Lisabeth
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Valeria Caso
- Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Stacie L Demel
- Department of Neurology & Ophthalmology and Pharmacology & Toxicology, Michigan State University, East Lansing, MI, USA
| | - Seung-Jae Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Mathew Reeves
- Department of Epidemiology, Michigan State University, East Lansing, MI, USA
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13
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Spiliopoulos S, Festas G, Reppas L, Brountzos E. Intra-arterial administration of cell-based biological agents for ischemic stroke therapy. Expert Opin Biol Ther 2019; 19:249-259. [PMID: 30615496 DOI: 10.1080/14712598.2019.1566454] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Ischemic stroke is becoming a primary cause of disability and death worldwide. To date, therapeutic options remain limited focusing on mechanical thrombolysis or administration of thrombolytic agents. However, these therapies do not promote neuroprotection and neuro-restoration of the ischemic area of the brain. AREAS COVERED This review highlights the option of minimal invasive, intra-arterial, administration of biological agents for stroke therapy. The authors provide an update of all available studies, discuss issues that influence outcomes and describe future perspectives which aim to improve clinical outcomes. New therapeutic options based on cellular and molecular interactions following an ischemic brain event, will be highlighted. EXPERT OPINION Intra-arterial administration of biological agents during trans-catheter thrombolysis or thrombectomy could limit neuronal cell death and facilitate regeneration or neurogenesis following ischemic brain injury. Despite the initial progress, further meticulous studies are needed in order to establish the clinical use of stem cell-induced neuroprotection and neuroregeneration.
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Affiliation(s)
- Stavros Spiliopoulos
- a 2nd Department of Radiology, Division of Interventional Radiology, School of Medicine , National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
| | - Georgios Festas
- a 2nd Department of Radiology, Division of Interventional Radiology, School of Medicine , National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
| | - Lazaros Reppas
- a 2nd Department of Radiology, Division of Interventional Radiology, School of Medicine , National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
| | - Elias Brountzos
- a 2nd Department of Radiology, Division of Interventional Radiology, School of Medicine , National and Kapodistrian University of Athens, Attikon University Hospital , Athens , Greece
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14
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Bushnell CD, Chaturvedi S, Gage KR, Herson PS, Hurn PD, Jiménez MC, Kittner SJ, Madsen TE, McCullough LD, McDermott M, Reeves MJ, Rundek T. Sex differences in stroke: Challenges and opportunities. J Cereb Blood Flow Metab 2018; 38:2179-2191. [PMID: 30114967 PMCID: PMC6282222 DOI: 10.1177/0271678x18793324] [Citation(s) in RCA: 195] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/25/2018] [Accepted: 06/19/2018] [Indexed: 12/19/2022]
Abstract
Biologic sex influences many variables that are important to brain health in general, and to stroke or cerebral ischemia in particular, such as general health status, cerebrovascular anatomy and function, unique risk factors such as pregnancy and preeclampsia, symptomatology, and therapeutic response. A more complete understanding of the scale and depth of sexual dimorphism in the brain and the role of more general sex-based factors is crucial to reducing the burden of stroke in women and men. This focused review highlights recent findings in stroke, including sex differences in epidemiology, risk factor reduction, comparative use of stroke therapeutics in both sexes, the importance of frailty in women, and the biologic basis for sex differences in stroke. Such findings show tremendous promise for the future of personalized medicine in stroke prevention and treatment.
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Affiliation(s)
| | - Seemant Chaturvedi
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kathy R Gage
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Paco S Herson
- Department of Anesthesiology, University of Colorado, Denver, CO, USA
| | - Patricia D Hurn
- School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Monik C Jiménez
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Steven J Kittner
- Baltimore Veterans Administration Medical Center and Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, Lansing, MI, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
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15
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Brown DL, Li C, Sánchez BN, Dunietz GL, Chervin RD, Case E, Garcia NM, Lisabeth LD. Lack of Worsening of Sleep-Disordered Breathing After Recurrent Stroke in the BASIC Project. J Clin Sleep Med 2018; 14:835-839. [PMID: 29734992 DOI: 10.5664/jcsm.7118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/13/2018] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To investigate the difference in sleep-disordered breathing (SDB) prevalence and severity after an index and recurrent stroke. METHODS In a sample of 40 subjects, home sleep apnea tests were performed a median of 10 days after an index ischemic stroke and 14 days after a recurrent ischemic stroke. A respiratory event index (REI) of ≥ 10 events/h (apneas plus hypopneas per hour of recording) was used to define clinically significant SDB. The relative difference in REI or relative SDB prevalence was used to compare the post-recurrent stroke measurement with that made after the index stroke, and was expressed as a rate ratio (RR) or prevalence ratio (PR). Adjusted regression models (negative binomial for REI and log binomial for SDB) included change in body mass index and time between the events. RESULTS The median time from index to recurrent stroke was 330.5 days (interquartile range [IQR]: 103.5, 766.5). The median REI was 17.5 (IQR: 9.0, 32.0) after the index stroke and 18.0 (IQR: 11.0, 25.5) after the recurrent stroke. The within-subject median difference was zero (IQR: -9, 7.5). The relative difference in REI was not significant in unadjusted or adjusted (RR: 0.97 [95% confidence interval: 0.76, 1.24]) models. The prevalence of SDB was not different after the recurrent stroke compared with the index stroke, in unadjusted or adjusted (PR: 1.10 [95% confidence interval: 0.91, 1.32]) models. CONCLUSIONS In this within-subject, longitudinal study, neither severity nor prevalence of SDB worsened after recurrent stroke.
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Affiliation(s)
- Devin L Brown
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan
| | - Chengwei Li
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Brisa N Sánchez
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Galit Levi Dunietz
- Sleep Disorders Center and Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ronald D Chervin
- Sleep Disorders Center and Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Erin Case
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Nelda M Garcia
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Lynda D Lisabeth
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
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16
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Gainey J, Brechtel L, Konklin S, Madeline L, Lowther E, Blum B, Nathaniel TI. In a stroke cohort with incident hypertension; are more women than men likely to be excluded from recombinant tissue-type Plasminogen Activator (rtPA)? J Neurol Sci 2018; 387:139-146. [PMID: 29571851 DOI: 10.1016/j.jns.2018.02.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 01/10/2018] [Accepted: 02/04/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND The treatment outcomes in the use of rt-PA have been reported. Some studies reported worse outcome in women than men, while others presented opposing data. Using data from a hospital-based stroke registry, we investigated evidence of gender difference and determined exclusion criteria in a stroke population with incidence of hypertension. METHOD In a stroke population of women and men with incident of hypertension from a stroke registry, demographics and clinical factors were compared. Univariate analysis was used to determine gender differences, while multivariable models adjusted for demographic and clinical variables. RESULTS Among the 669 stroke patients with incident of hypertension that were excluded from rt-PA treatment, 362 were female and 307 were male. Female patients with increasing age (OR = 0.956-0.984, P < 0.001), diabetes mellitus (OR = 0.095-0.559, P = 0.001), higher NIH stroke scale score (OR = 1.019-1.090, P = 0.002), previous stroke (OR = 0.337-0.850, P = 0.008), diabetes medication (OR = 1.200-7.724, P = 0.019), and INR (OR = 0.033-0.597, P = 0.008) are more likely to be excluded. Male patients with a history of a previous stroke (OR = 0.265-0.704, P = 0.001), risk of mortality (OR = 0.803-0.950, P = 0.002), higher NIH stroke scale score(OR = 1.101-1.276, P < 0.001), cholesterol reducing medication (OR = 1.191-2.910, P = 0.006), weakness at presentation(OR = 1.207-4.421, P = 0.011), and INR (OR = 0.016-0.243, P < 0.001) are more likely to be excluded. CONCLUSION Women have a worse outcome than men in an untreated acute ischemic stroke population, but when treated, women have a better treatment outcome compared to men. In a hypertensive stroke population, the clinical variables for the exclusion criteria for women and men are significantly different, even after adjustment for confounding variables.
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Affiliation(s)
- Jordan Gainey
- University of South Carolina School of Medicine, SC, USA
| | | | - Sarah Konklin
- North Greenville University, USA; University of South Carolina School of Medicine, SC, USA
| | | | | | - Brice Blum
- University of South Carolina School of Medicine, SC, USA
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17
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Choleris E, Galea LAM, Sohrabji F, Frick KM. Sex differences in the brain: Implications for behavioral and biomedical research. Neurosci Biobehav Rev 2018; 85:126-145. [PMID: 29287628 PMCID: PMC5751942 DOI: 10.1016/j.neubiorev.2017.07.005] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 07/16/2017] [Indexed: 01/11/2023]
Abstract
Biological differences between males and females are found at multiple levels. However, females have too often been under-represented in behavioral neuroscience research, which has stymied the study of potential sex differences in neurobiology and behavior. This review focuses on the study of sex differences in the neurobiology of social behavior, memory, emotions, and recovery from brain injury, with particular emphasis on the role of estrogens in regulating forebrain function. This work, presented by the authors at the 2016 meeting of the International Behavioral Neuroscience Society, emphasizes varying approaches from several mammalian species in which sex differences have not only been documented, but also become the focus of efforts to understand the mechanistic basis underlying them. This information may provide readers with useful experimental tools to successfully address recently introduced regulations by granting agencies that either require (e.g. the National Institutes of Health in the United States and the Canadian Institutes of Health Research in Canada) or recommend (e.g. Horizon 2020 in Europe) the inclusion of both sexes in biomedical research.
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Affiliation(s)
- Elena Choleris
- Department of Psychology and Neuroscience Program, University of Guelph, MacKinnon Bldg. Room 4020, Guelph, ON N1G 2W1, Canada.
| | - Liisa A M Galea
- Department of Psychology, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC V6T1Z3, Canada
| | - Farida Sohrabji
- Women's Health in Neuroscience Program, Department of Neuroscience and Experimental Therapeutics, Texas A&M HSC College of Medicine, Bryan, TX 77807, United States
| | - Karyn M Frick
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI 53211, United States
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18
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Chang BP, Wira C, Miller J, Akhter M, Barth BE, Willey J, Nentwich L, Madsen T. Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department. Acad Emerg Med 2018; 25:54-64. [PMID: 28646558 PMCID: PMC6415947 DOI: 10.1111/acem.13243] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/09/2017] [Accepted: 06/19/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting. METHODS A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors. RESULTS Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals. CONCLUSION Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.
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Affiliation(s)
- Bernard P. Chang
- Department of Emergency Medicine, Columbia University Medical Center
| | - Charles Wira
- Department of Emergency Medicine, Yale-New Haven Medical Center
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Medical Center
| | - Murtaza Akhter
- Department of Emergency Medicine, University of Arizona College of Medicine–Phoenix, Maricopa Integrated Health System, Phoenix, AZ
| | - Bradley E. Barth
- Department of Emergency Medicine, University of Kansas Medical Center
| | - Joshua Willey
- Department of Neurology, Stroke Service, Columbia University Medical Center
| | | | - Tracy Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
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19
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Sohrabji F, Park MJ, Mahnke AH. Sex differences in stroke therapies. J Neurosci Res 2017; 95:681-691. [PMID: 27870437 PMCID: PMC5125551 DOI: 10.1002/jnr.23855] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/20/2016] [Accepted: 07/06/2016] [Indexed: 02/03/2023]
Abstract
Stroke is the fifth leading cause of death and acquired disability in aged populations. Women are disproportionally affected by stroke, having a higher incidence and worse outcomes than men. Numerous preclinical studies have discovered novel therapies for the treatment of stroke, but almost all of these have been shown to be unsuccessful in clinical trials. Despite known sex differences in occurrence and severity of stroke, few preclinical or clinical therapeutics take into account possible sex differences in treatment. Reanalysis of data from studies of tissue plasminogen activator (tPA), the only currently FDA-approved stroke therapy, has shown that tPA improves stroke outcomes for both sexes and also shows sexual dimorphism by more robust improvement in stroke outcome in females. Experimental evidence supports the inclusion of sex as a variable in the study of a number of novel stroke drugs and therapies, including preclinical studies of anti-inflammatory drugs (minocycline), stimulators of cell survival (insulin-like growth factor-1), and inhibitors of cell death pathways (pharmacological inhibition of poly[ADP-ribose] polymerase-1, nitric oxide production, and caspase activation) as well as in current clinical trials of stem cell therapy and cortical stimulation. Overall, study design and analysis in clinical trials as well as in preclinical studies must include both sexes equally, consider possible sex differences in the analyses, and report the differences/similarities in more systematic/structured ways to allow promising therapies for both sexes and increase stroke recovery. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Farida Sohrabji
- Women’s Health in Neuroscience Program, Department of Neuroscience and Experimental Therapeutics, Texas A&M University Health Science Center, Bryan, TX 77807, USA
| | - Min Jung Park
- Women’s Health in Neuroscience Program, Department of Neuroscience and Experimental Therapeutics, Texas A&M University Health Science Center, Bryan, TX 77807, USA
| | - Amanda H Mahnke
- Women’s Health in Neuroscience Program, Department of Neuroscience and Experimental Therapeutics, Texas A&M University Health Science Center, Bryan, TX 77807, USA
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20
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Fredwall M, Sternberg S, Blackhurst D, Lee A, Leacock R, Nathaniel TI. Gender Differences in Exclusion Criteria for Recombinant Tissue-Type Plasminogen Activator. J Stroke Cerebrovasc Dis 2016; 25:2569-2574. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 04/06/2016] [Accepted: 06/07/2016] [Indexed: 10/21/2022] Open
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21
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Harada S, Tokuyama S. [Involvement of communication system between brain and peripheral tissues on the development of post-ischemic glucose intolerance induced by cerebral neuronal damage]. Nihon Yakurigaku Zasshi 2016; 148:34-38. [PMID: 27430677 DOI: 10.1254/fpj.148.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Craig AJ, Housley GD. Evaluation of Gene Therapy as an Intervention Strategy to Treat Brain Injury from Stroke. Front Mol Neurosci 2016; 9:34. [PMID: 27252622 PMCID: PMC4877374 DOI: 10.3389/fnmol.2016.00034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 05/06/2016] [Indexed: 01/01/2023] Open
Abstract
Stroke is a leading cause of death and disability, with a lack of treatments available to prevent cell death, regenerate damaged cells and pathways, or promote neurogenesis. The extended period of hours to weeks over which tissue damage continues to occur makes this disorder a candidate for gene therapy. This review highlights the development of gene therapy in the area of stroke, with the evolution of viral administration, in experimental stroke models, from pre-injury to clinically relevant timeframes of hours to days post-stroke. The putative therapeutic proteins being examined include anti-apoptotic, pro-survival, anti-inflammatory, and guidance proteins, targeting multiple pathways within the complex pathology, with promising results. The balance of findings from animal models suggests that gene therapy provides a viable translational platform for treatment of ischemic brain injury arising from stroke.
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Affiliation(s)
- Amanda J Craig
- Translational Neuroscience Facility & Department of Physiology, School of Medical Sciences, University of New South Wales, Sydney NSW, Australia
| | - Gary D Housley
- Translational Neuroscience Facility & Department of Physiology, School of Medical Sciences, University of New South Wales, Sydney NSW, Australia
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24
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Munich SA, Mokin M, Snyder KV, Siddiqui AH, Hopkins LN, Levy EI. Guest Editorial: An Update on Stroke Intervention. Neurosurgery 2016; 77:313-20. [PMID: 26080070 DOI: 10.1227/neu.0000000000000828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Endovascular treatment for acute ischemic stroke has changed remarkably over the past decade. Beginning with IA thrombolytic administration, endovascular strategies have evolved to include aspiration, self-expanding intracranial stents, and now retrievable stents. With the recent publication of 5 randomized, controlled studies (MR CLEAN, EXTEND-IA, ESCAPE, SWIFT PRIME, and REVASCAT), mechanical thrombectomy, when used in combination with IV tPA, has demonstrated a significant radiographic and clinical benefit over traditional strategies with IV tPA alone. These results have placed endovascular therapy at the forefront of stroke treatment, redefining the standard of care.
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Affiliation(s)
- Stephan A Munich
- *Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York; ‡Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York; §Departments of Neurology and Neurosurgery, University of South Florida College of Medicine, Tampa, Florida; ¶Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York; ‖Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York; #Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York; **Jacobs Institute, Buffalo, New York
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25
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Gender and Time to Arrival among Ischemic Stroke Patients in the Greater Cincinnati/Northern Kentucky Stroke Study. J Stroke Cerebrovasc Dis 2015; 25:504-10. [PMID: 26617327 DOI: 10.1016/j.jstrokecerebrovasdis.2015.10.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/09/2015] [Accepted: 10/27/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Some studies of stroke patients report longer prehospital delays in women, but others conflict; studies vary in their inclusion of factors including age and stroke severity. We aimed to investigate the relationship between gender and time to emergency department (ED) arrival and the influence of age and stroke severity on this relationship. METHODS Ischemic stroke patients 20 years old or older who presented to 15 hospitals within a 5-county region of Greater Cincinnati/Northern Kentucky during 2010 were included. Time from symptom onset to ED arrival and covariates were abstracted by study nurses and reviewed by study physicians. Data were analyzed using logistic regression with time to arrival dichotomized at 3 hours or less in the overall sample and then stratified by National Institutes of Health Stroke Scale (NIHSS) and age. RESULTS 1991 strokes (55% women) were included. Time to arrival was slightly longer in women (geometric mean 337 minutes [95% confidence interval {CI} 307-369] versus 297 [95% CI 268-329], P = .05), and 24% of women versus 27% of men arrived within 3 hours (P = .15). After adjusting for age, race, NIHSS, living situation, and other covariates, gender was not associated with delayed time to arrival (OR = 1.00, 95% CI .78-1.28). This did not change across age or NIHSS categories. CONCLUSIONS After adjusting for factors including age, NIHSS score, and living alone, women and men with ischemic stroke had similar times to arrival. Arrival time is not likely a major contributor to differences in outcome between men and women.
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Madsen TE, Baird KA, Silver B, Gjelsvik A. Analysis of Gender Differences in Knowledge of Stroke Warning Signs. J Stroke Cerebrovasc Dis 2015; 24:1540-7. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/20/2015] [Accepted: 03/14/2015] [Indexed: 11/26/2022] Open
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Morgenstern LB, Adelman EE, Hughes R, Wing JJ, Lisabeth LD. The Women Independently Living Alone with a Medical Alert Device (WILMA) trial. Transl Stroke Res 2015; 6:355-60. [PMID: 26031786 DOI: 10.1007/s12975-015-0411-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 05/22/2015] [Accepted: 05/25/2015] [Indexed: 11/29/2022]
Abstract
Women are more likely to live alone compared with men, and therefore have more difficulty activating emergency medical systems for stroke. The goal of this study was to examine the benefit of wearing medical alert devices to activate emergency medical systems for elderly women living alone. This was a randomized, controlled pilot trial. Women over 60 with at least 1 stroke risk factor were recruited from Southeast Michigan. Subjects received either a medical alert device or control. The primary outcome was change in health-related quality of life (HRQOL) from baseline to 90 days of wearing the device or control. A planned sample size of 320 could not be reached, and the trial was stopped at 265 women randomized prior to data examination. On average, the treatment group was older, reported lower prevalence of high cholesterol, and was less likely to complete follow-up. There was a nonsignificant smaller loss of healthy days in the past month in the intervention group (0.46) compared with the control group (2.23) (p = 0.213). Similarly, the secondary outcomes of changes in anxiety, depression, and changes in perceived isolation did not differ by treatment and control groups. This study did not establish improvement in HRQOL among women who wore the device compared with those that did not, nor the feasibility of a trial to study the efficacy of medical alert devices in elderly women. Newer devices that use cellular technology may be more accepted than the landline-based system used in this study.
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