1
|
Liu H, Jin A, Pan Y, Jing J, Meng X, Li H, Li Z, Wang Y. Trends of Sex Differences and Associated Factors in Stroke Outcomes Among Patients With Acute Ischemic Stroke: 2007 to 2018. Neurology 2024; 102:e207818. [PMID: 38165366 PMCID: PMC10834133 DOI: 10.1212/wnl.0000000000207818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/27/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Female patients have been shown to experience worse clinical outcomes after acute ischemic stroke (AIS) compared with male patients. We aimed to estimate the temporal trends in the sex differences in stroke outcomes and identify risk factors contributing to the sex differences spanning 10 years in China. METHODS This cohort study was conducted based on data from the China National Stroke Registries (CNSRs, comprising 3 phases, I-III, from 2007 to 2018). Patients with ischemic stroke within 7 days of symptom onset were included. The primary outcome was a 12-month poor functional outcome. Other outcomes included mortality and disability-adjusted life-year (DALY) lost. The sex differences in outcomes and associated factors were estimated using multivariable logistic regression. The sex differences between CNSRs were tested by the interaction of sex and time. RESULTS Among 42,564 patients included, 35.4% were female. The age-adjusted event rate of 12-month poor functional outcome and mortality decreased both in male and female patients after stroke onset (CNSRs I, II, and III, all p varies over time <0.001). There was a decrease in DALY lost for both sexes over the decade (male patients: from 10.1 to 9.3 DALYs; female patients: from 10.9 to 9.6 DALYs). Female patients showed worse 12-month poor functional outcome in CNSRs I and II (odds ratio [OR] with 95% CI: 1.24 [1.10-1.39] and 1.12 [1.01-1.25], respectively) compared with male patients, but the sex difference attenuated in CNSR III (OR with 95% CI: 1.02 [0.89-1.16]), with the temporal trend (p varies over time = 0.004). The sex difference and the temporal trend of the sex difference in mortality from 2007 to 2018 were not found (p varies over time = 0.45). The most important factors attenuating the sex difference in poor functional outcome in CNSRs I and III were education level, socioeconomic deprivation, baseline stroke severity, and current smoking. DISCUSSION This study demonstrated that the sex disparity in poor functional outcome at 12 months was substantially narrowed covering 10 years and completely attenuated in 2015-2018. The findings suggested that female patients have experienced larger improvements in stroke outcomes than male patients over the past decade.
Collapse
Affiliation(s)
- Huihui Liu
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Aoming Jin
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Yuesong Pan
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Jing Jing
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Xia Meng
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Hao Li
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Zixiao Li
- From the Department of Neurology, Beijing Tiantan Hospital, China
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital, China
| |
Collapse
|
2
|
Abstract
INTRODUCTION Telerehabilitation (TR) may be useful for rehabilitation therapy after stroke. However, stroke is a heterogeneous condition, and not all patients can be expected to derive the same benefit from TR, underscoring the need to identify predictors of response to TR. METHODS A prior trial provided patients with 6 weeks of intensive rehabilitation therapy targeting arm movement, randomly assigned to be provided in the home via TR (current focus) or in clinic. Eligible patients had moderate arm motor deficits and were in the subacute-chronic stage post stroke. Behavioral gains were measured as change in the arm motor Fugl-Meyer score from baseline to 30 days post therapy. To delineate predictors of TR response, multivariable linear regression was performed, advancing the most significant predictor from each of eight categories: patient demographics, stroke characteristics, medical history, rehabilitation therapy outside of study procedures, motivation, sensorimotor impairment, cognitive/affective deficits, and functional status. RESULTS The primary focus was on patients starting TR >90 days post stroke onset (n = 44), among whom female sex, less spasticity, and less visual field defects predicted greater motor gains. This model explained 39.3% of the variance in treatment-related gains. In secondary analysis that also included TR patients enrolled ≤90 days post stroke (total n = 59), only female sex was a predictor of treatment gains. A separate secondary analysis examined patients >90 days post stroke (n = 34) randomized to in-clinic therapy, among whom starting therapy earlier post stroke and less ataxia predicted greater motor gains. DISCUSSION Response to TR varies across patients, emphasizing the need to identify characteristics that predict treatment-related behavioral gain. The current study highlights factors that might be important to patient selection for home-based TR after stroke.
Collapse
Affiliation(s)
- Sang Min Paik
- Ewha Woman's University College of Medicine, Republic of Korea
| | - Steven C Cramer
- Department of Neurology, University of California Los Angeles, USA
- California Rehabilitation Institute, USA
| |
Collapse
|
3
|
Hart M, Blackwell AA, Whishaw IQ, Wallace DG, Cheatwood JL. Impairments and Compensation in String-pulling After Middle Cerebral Artery Occlusion in the Rat. Behav Brain Res 2023; 450:114469. [PMID: 37146723 DOI: 10.1016/j.bbr.2023.114469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 03/12/2023] [Accepted: 03/20/2023] [Indexed: 05/07/2023]
Abstract
Stroke is a leading cause of long-term disability in humans, and it is frequently associated with impairments in the skilled use of the arms and hands. Many human upper limb impairments and compensatory changes have been successfully modeled in rodent studies of neocortical stroke, especially those that evaluate single limb use in tasks, such as reaching for food. Humans also use their hands for bilaterally coordinated movements, dependent upon interhemispheric cortical projections, which are also compromised by unilateral stroke. This study describes middle cerebral artery occlusion (MCAO) dependent changes in the bilaterally dependent hand use behavior of string-pulling in the rat. The task involves making hand-over-hand movements to pull down a string that contains a food reward attached to its end. MCAO rats missed the string more often with both hands than Sham rats. When the string was missed on the contralateral to MCAO body side, rats continued to cycle through subcomponents of string-pulling behavior as if the string were grasped in the hand. Rats also failed to make a grasping motion with the contralateral to MCAO hand when the string was missed and instead, demonstrated an open-handed raking-like motions. Nevertheless, with repeated attempts, rats performed components of string-pulling well enough to obtain a reward on the end of the string. Thus, string-pulling behavior is sensitive to bilateral impairments but is achieved with compensatory adjustments following MCAO. These aspects of MCAO string-pulling provide a foundation for studies that investigate the efficacy of therapeutic intervention which might enhance neuroplasticity and recovery. DATA AVAILABILITY: The datasets generated during the current study are available upon request.
Collapse
Affiliation(s)
- Muriel Hart
- Department of Anatomy, Southern Illinois University School of Medicine, Carbondale, Illinois, USA
| | - Ashley A Blackwell
- Department of Psychology, Northern Illinois University, De Kalb, Illinois, 60115 USA.
| | - Ian Q Whishaw
- Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Douglas G Wallace
- Department of Psychology, Northern Illinois University, De Kalb, Illinois, 60115 USA
| | - Joseph L Cheatwood
- Department of Anatomy, Southern Illinois University School of Medicine, Carbondale, Illinois, USA
| |
Collapse
|
4
|
Wouters A, Scheldeman L, Liessens H, Dupont P, Boutitie F, Cheng B, Ebinger M, Endres M, Fiebach JB, Gerloff C, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Thijs V, Thomalla G, Lemmens R. Sex differences in imaging and clinical characteristics of patients from the WAKE-UP trial. Eur J Neurol 2023; 30:641-647. [PMID: 36349887 PMCID: PMC10099623 DOI: 10.1111/ene.15629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND PURPOSE Sex-based differences in acute ischemic stroke are a well-known phenomenon. We aimed to explore these differences between women and men in the Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke (WAKE-UP) trial. METHODS We compared baseline demographic and imaging characteristics (visual fluid-attenuated inversion recovery [FLAIR] positivity, relative FLAIR signal intensity, collateral status) between women and men in all screened patients. In randomized patients (i.e., those with diffusion-weighted imaging (DWI)-FLAIR mismatch), we evaluated a modifying role of sex on the treatment effect of alteplase in multivariable logistic regression, with treatment adjusted for National Institute of Health Stroke Scale (NIHSS) score and age. Dependent variables were modified Rankin Scale (mRS) score of 0-1 at 90 days and distribution of mRS scores at 90 days. RESULTS Of 1362 screened patients, 529 (38.8%) were women. Women were older than men, had higher baseline NIHSS scores and smoked less frequently. FLAIR positivity of the DWI lesion was equally present in women (174/529, 33.1%) and men (273/833, 33.3%; p = 1.00) and other imaging variables also did not differ between the sexes. In a total of 503 randomized patients, of whom 178 were women (35.4%), sex did not modify the treatment effect of alteplase on mRS score 0-1 or on the total distribution of mRS scores. CONCLUSION As in many other stroke trials, more men than women were included in the WAKE-UP trial, but the presence of a visual DWI-FLAIR mismatch and the relative FLAIR signal intensity did not differ between the sexes. The treatment effect of alteplase was not modified by sex.
Collapse
Affiliation(s)
- Anke Wouters
- Neurology, Amsterdam University Medical Centers location AMC, Amsterdam, the Netherlands
- Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium
- Center for Brain & Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium
| | - Lauranne Scheldeman
- Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium
- Center for Brain & Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | - Patrick Dupont
- Department of Neurosciences, Laboratory for Cognitive Neurology, KU Leuven - University of Leuven, Leuven, Belgium
- Leuven Brain Institute, Leuven, Belgium
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Université Lyon, Lyon, France
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité- Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
- ExcellenceCluster NeuroCure, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1; Hospices Civils de Lyon, Lyon, France
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomedica de Girona (IDIBGI), Parc Hospitalari Marti i Julia de Salt - Edifici M2, Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Vincent Thijs
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium
- Center for Brain & Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
5
|
Tang T, Hu L, Liu Y, Fu X, Li J, Yan F, Cao S, Chen G. Sex-Associated Differences in Neurovascular Dysfunction During Ischemic Stroke. Front Mol Neurosci 2022; 15:860959. [PMID: 35431804 PMCID: PMC9012443 DOI: 10.3389/fnmol.2022.860959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/28/2022] [Indexed: 12/28/2022] Open
Abstract
Neurovascular units (NVUs) are basic functional units in the central nervous system and include neurons, astrocytes and vascular compartments. Ischemic stroke triggers not only neuronal damage, but also dissonance of intercellular crosstalk within the NVU. Stroke is sexually dimorphic, but the sex-associated differences involved in stroke-induced neurovascular dysfunction are studied in a limited extend. Preclinical studies have found that in rodent models of stroke, females have less neuronal loss, stronger repairing potential of astrocytes and more stable vascular conjunction; these properties are highly related to the cerebroprotective effects of female hormones. However, in humans, these research findings may be applicable only to premenopausal stroke patients. Women who have had a stroke usually have poorer outcomes compared to men, and because stoke is age-related, hormone replacement therapy for postmenopausal women may exacerbate stroke symptoms, which contradicts the findings of most preclinical studies. This stark contrast between clinical and laboratory findings suggests that understanding of neurovascular differences between the sexes is limited. Actually, apart from gonadal hormones, differences in neuroinflammation as well as genetics and epigenetics promote the sexual dimorphism of NVU functions. In this review, we summarize the confirmed sex-associated differences in NVUs during ischemic stroke and the possible contributing mechanisms. We also describe the gap between clinical and preclinical studies in terms of sexual dimorphism.
Collapse
Affiliation(s)
- Tianchi Tang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Libin Hu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yang Liu
- Department of Ultrasonography, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiongjie Fu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianru Li
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Feng Yan
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shenglong Cao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Shenglong Cao,
| | - Gao Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Gao Chen,
| |
Collapse
|
6
|
Stroke Disparities. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00015-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
7
|
Bonkhoff AK, Karch A, Weber R, Wellmann J, Berger K. Female Stroke: Sex Differences in Acute Treatment and Early Outcomes of Acute Ischemic Stroke. Stroke 2021; 52:406-415. [PMID: 33493053 DOI: 10.1161/strokeaha.120.032850] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Men and women are differently affected by acute ischemic stroke (AIS) in many aspects. Prior studies on sex disparities were limited by moderate sample sizes, varying years of data acquisition, and inconsistent inclusions of covariates leading to controversial findings. We aimed to analyze sex differences in AIS severity, treatments, and early outcome and to systematically evaluate the effect of important covariates in a large German stroke registry. METHODS Analyses were based on the Stroke Registry of Northwestern Germany from 2000 to 2018. We focused on admission-stroke severity and disability, acute recanalization treatment, and early stroke outcomes. Potential sex divergences were investigated via odds ratio (OR) using logistic regression models. Covariates were introduced in 3 steps: (1) base models (age and admission year), (2) partially adjusted models (additionally corrected for acute stroke severity and recanalization treatment), (3) fully adjusted models (additionally adjusted for onset-to-admission time interval, prestroke functional status, comorbidities, and stroke cause). Models were separately fitted for the periods 2000 to 2009 and 2010 to 2018. RESULTS Data from 761 106 patients with AIS were included. In fully adjusted models, there were no sex differences with respect to treatment with intravenous thrombolysis (2000-2009: OR, 0.99 [95% CI, 0.94-1.03]; 2010-2018: OR, 1.0 [0.98-1.02]), but women were more likely to receive intraarterial therapy (2010-2018: OR, 1.12 [1.08-1.15]). Despite higher disability on admission (2000-2009: OR, 1.10 [1.07-1.13]; 2010-2018: OR, 1.09 [1.07-1.10]), female patients were more likely to be discharged with a favorable functional outcome (2003-2009: OR, 1.05 [1.02-1.09]; 2010-2018: OR, 1.05 [1.04-1.07]) and experienced lower in-hospital mortality (2000-2009: OR, 0.92 [0.86-0.97]; 2010-2018: OR, 0.91 [0.88-0.93]). CONCLUSIONS Female patients with AIS have a higher chance of receiving intraarterial treatment that cannot be explained by clinical characteristics, such as age, premorbid disability, stroke severity, or cause. Women have a more favorable in-hospital recovery than men because their higher disability upon admission was followed by a lower in-hospital mortality and a higher likelihood of favorable functional outcome at discharge after adjustment for covariates.
Collapse
Affiliation(s)
- Anna K Bonkhoff
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (A.K.B.).,Institute of Epidemiology and Social Medicine, University of Muenster, Germany (A.K.B., A.K., J.W., K.B.)
| | - André Karch
- Institute of Epidemiology and Social Medicine, University of Muenster, Germany (A.K.B., A.K., J.W., K.B.)
| | - Ralph Weber
- Department of Neurology, Alfried Krupp Hospital Essen and Ruhr University Bochum, Germany (R.W.)
| | - Jürgen Wellmann
- Institute of Epidemiology and Social Medicine, University of Muenster, Germany (A.K.B., A.K., J.W., K.B.)
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine, University of Muenster, Germany (A.K.B., A.K., J.W., K.B.)
| |
Collapse
|
8
|
Egenrieder L, Mitricheva E, Spanagel R, Noori HR. No basal or drug‐induced sex differences in striatal dopaminergic levels: a cluster and meta‐analysis of rat microdialysis studies. J Neurochem 2019; 152:482-492. [DOI: 10.1111/jnc.14911] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/29/2019] [Accepted: 11/05/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Lisamon Egenrieder
- Institute of Psychopharmacology Central Institute of Mental Health Medical Faculty Mannheim University of Heidelberg Mannheim Germany
| | | | - Rainer Spanagel
- Institute of Psychopharmacology Central Institute of Mental Health Medical Faculty Mannheim University of Heidelberg Mannheim Germany
| | - Hamid R. Noori
- Institute of Psychopharmacology Central Institute of Mental Health Medical Faculty Mannheim University of Heidelberg Mannheim Germany
- Max Planck Institute for Biological Cybernetics Tübingen Germany
| |
Collapse
|