1
|
Abdalkader M, Ning S, Qureshi MM, Haussen DC, Strbian D, Nagel S, Demeestere J, Puetz V, Mohammaden MH, Olive Gadea M, Winzer S, Yamagami H, Tanaka K, Marto JP, Tomppo L, Henon H, Sheth SA, Ortega-Gutierrez S, Martinez-Majander N, Caparros F, Lemmens R, Dusart A, Bellante F, Zaidi SF, Siegler JE, Nannoni S, Kaesmacher J, Dobrocky T, Farooqui M, Salazar-Marioni S, Virtanen P, Vandewalle L, Wouters A, Jesser J, Ventura R, Castonguay AC, Uchida K, Puri AS, Masoud HE, Klein P, Mansoor Z, Bui J, Kang M, Mujanovic A, Rizzo F, Kokkonen T, Ramos JN, Strambo D, Michel P, Möhlenbruch MA, Lin E, Kaiser DPO, Yoshimura S, Sakai N, Cordonnier C, Ringleb PA, Roy D, Zaidat OO, Fischer U, Ribo M, Raymond J, Nogueira RG, Nguyen TN. Sex Differences in Outcomes of Late-Window Endovascular Stroke Therapy. Stroke 2024; 55:278-287. [PMID: 38252759 DOI: 10.1161/strokeaha.123.045015] [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: 09/02/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND The association between sex and outcome after endovascular thrombectomy of acute ischemic stroke is unclear. The aim of this study was to compare the clinical and safety outcomes between men and women treated with endovascular thrombectomy in the late 6-to-24-hour window period. METHODS This multicenter, retrospective observational cohort study included consecutive patients who underwent endovascular thrombectomy of anterior circulation stroke in the late window from 66 clinical sites in 10 countries from January 2014 to May 2022. The primary outcome was the 90-day ordinal modified Rankin Scale score. Secondary outcomes included 90-day functional independence (FI), return of Rankin (RoR) to prestroke baseline, FI or RoR, symptomatic intracranial hemorrhage, and mortality. Multivariable and inverse probability of treatment weighting methods were used. We explored the interaction of sex with baseline characteristics on the outcomes ordinal modified Rankin Scale and FI or RoR. RESULTS Of 1932 patients, 1055 were women and 877 were men. Women were older (77 versus 69 years), had higher rates of atrial fibrillation, hypertension, and greater prestroke disability, but there was no difference in baseline National Institutes of Health Stroke Scale score. Inverse probability of treatment weighting analysis showed no difference between women and men in ordinal modified Rankin Scale (odds ratio, 0.98 [95% CI, 0.79-1.21]), FI or RoR (odds ratio, 0.98 [95% CI, 0.78-1.22]), severe disability or mortality (odds ratio, 0.99 [95% CI, 0.80-1.23]). The multivariable analysis of the above end points was concordant. There were no interactions between baseline characteristics and sex on the outcomes of ordinal modified Rankin Scale and FI or RoR. CONCLUSIONS In late presenting patients with anterior circulation stroke treated with endovascular thrombectomy in the 6 to 24-hour window, there was no difference in clinical or safety outcomes between men and women.
Collapse
Affiliation(s)
- Mohamad Abdalkader
- Departments of Radiology (M.A., S. Ning, M.M.Q., P.K., Z.M., J.B., M.K., T.N.N.), Boston Medical Center
| | - Shen Ning
- Departments of Radiology (M.A., S. Ning, M.M.Q., P.K., Z.M., J.B., M.K., T.N.N.), Boston Medical Center
| | - Muhammad M Qureshi
- Departments of Radiology (M.A., S. Ning, M.M.Q., P.K., Z.M., J.B., M.K., T.N.N.), Boston Medical Center
- Radiation Oncology (M.M.Q.), Boston Medical Center
| | - Diogo C Haussen
- Departments of Neurology, Grady Memorial Hospital (D.C.H., M.H.M., R.G.N.)
| | - Daniel Strbian
- Departments of Neurology (D. Strbian, L.T., N.M.-M.), Helsinki University Hospital, Finland
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Germany (S. Nagel)
- Departments of Neurology (S. Nagel, P.A.R.). Heidelberg University Hospital, Germany
| | - Jelle Demeestere
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., R.L., L.V., A.W.)
- Department of Neurology, UZ Leuven, Belgium (J.D., R.L., L.V., A.W.)
| | - Volker Puetz
- Department of Neurology (V.P., S.W.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center, Germany (V.P., S.W., D.P.O.K.)
| | | | - Marta Olive Gadea
- Department of Neurology, Hospital Vall d'Hebron, Spain (M.O.G., F.R., M.R.)
| | - Simon Winzer
- Department of Neurology (V.P., S.W.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center, Germany (V.P., S.W., D.P.O.K.)
| | - Hiroshi Yamagami
- Department of Stroke Neurology, NHO Osaka National Hospital, Japan (H.Y.)
| | - Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K.T.)
| | - João Pedro Marto
- Departments of Radiology (M.A., S. Ning, M.M.Q., P.K., Z.M., J.B., M.K., T.N.N.), Boston Medical Center
| | - Liisa Tomppo
- Departments of Neurology (D. Strbian, L.T., N.M.-M.), Helsinki University Hospital, Finland
| | - Hilde Henon
- Department of Neurology, University of Lille, CHU Lille, Inserm, France (H.H., F.C., C.C.)
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston (S.A.S., S.S.-M.)
| | | | | | - Francois Caparros
- Department of Neurology, University of Lille, CHU Lille, Inserm, France (H.H., F.C., C.C.)
| | - Robin Lemmens
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., R.L., L.V., A.W.)
- Department of Neurology, UZ Leuven, Belgium (J.D., R.L., L.V., A.W.)
| | - Anne Dusart
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium (A.D., F.B.)
| | - Flavio Bellante
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium (A.D., F.B.)
| | - Syed F Zaidi
- Department of Neurology, University of Toledo, Toledo (S.F.Z., A.C.C.)
| | | | - Stefania Nannoni
- Clinical Neurosciences, University of Cambridge, United Kingdom (S. Nannoni)
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Switzerland (J.K., T.D., A.M.)
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Switzerland (J.K., T.D., A.M.)
| | | | | | - Pekka Virtanen
- Radiology (P.V., T.K.), Helsinki University Hospital, Finland
| | - Lieselotte Vandewalle
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., R.L., L.V., A.W.)
- Department of Neurology, UZ Leuven, Belgium (J.D., R.L., L.V., A.W.)
| | - Anke Wouters
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., R.L., L.V., A.W.)
- Department of Neurology, UZ Leuven, Belgium (J.D., R.L., L.V., A.W.)
| | - Jessica Jesser
- Radiology (J.J., M.A.M.). Heidelberg University Hospital, Germany
| | - Rita Ventura
- Departments of Neurology (J.P.M., R.V.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Portugal
| | | | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Japan (K.U., S.Y.)
| | - Ajit S Puri
- Interventional Neuroradiology, University of Massachusetts Memorial Medical Center (A.S.P.)
| | - Hesham E Masoud
- Department of Neurology, State University of New York (H.E.M.)
| | - Piers Klein
- Departments of Radiology (M.A., S. Ning, M.M.Q., P.K., Z.M., J.B., M.K., T.N.N.), Boston Medical Center
| | - Zain Mansoor
- Departments of Radiology (M.A., S. Ning, M.M.Q., P.K., Z.M., J.B., M.K., T.N.N.), Boston Medical Center
| | - Jenny Bui
- Departments of Radiology (M.A., S. Ning, M.M.Q., P.K., Z.M., J.B., M.K., T.N.N.), Boston Medical Center
| | - Matthew Kang
- Departments of Radiology (M.A., S. Ning, M.M.Q., P.K., Z.M., J.B., M.K., T.N.N.), Boston Medical Center
| | - Adnan Mujanovic
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Switzerland (J.K., T.D., A.M.)
| | - Federica Rizzo
- Department of Neurology, Hospital Vall d'Hebron, Spain (M.O.G., F.R., M.R.)
| | - Tatu Kokkonen
- Radiology (P.V., T.K.), Helsinki University Hospital, Finland
| | - João Nuno Ramos
- Radiology (J.N.R.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Portugal
| | - Davide Strambo
- Department of Neurology, Lausanne University Hospital, Switzerland (D. Strambo, P.M.)
| | - Patrik Michel
- Department of Neurology, Lausanne University Hospital, Switzerland (D. Strambo, P.M.)
| | | | - Eugene Lin
- Neuroscience and Stroke Program, Mercy Health St. Vincent Hospital, Toledo (E.L., O.O.Z.)
| | - Daniel P O Kaiser
- Institute of Neuroradiology (D.P.O.K.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center, Germany (V.P., S.W., D.P.O.K.)
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Japan (K.U., S.Y.)
| | - Nobuyuki Sakai
- Neurovascular Research, Kobe City Medical Center General Hospital, Japan (N.S.)
| | - Charlotte Cordonnier
- Department of Neurology, University of Lille, CHU Lille, Inserm, France (H.H., F.C., C.C.)
| | - Peter A Ringleb
- Departments of Neurology (S. Nagel, P.A.R.). Heidelberg University Hospital, Germany
| | - Daniel Roy
- Interventional Neuroradiology, CHU Montreal, Canada (D.R., J.R.)
| | - Osama O Zaidat
- Neuroscience and Stroke Program, Mercy Health St. Vincent Hospital, Toledo (E.L., O.O.Z.)
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, Switzerland (U.F.)
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Spain (M.O.G., F.R., M.R.)
| | - Jean Raymond
- Interventional Neuroradiology, CHU Montreal, Canada (D.R., J.R.)
| | - Raul G Nogueira
- Departments of Neurology, Grady Memorial Hospital (D.C.H., M.H.M., R.G.N.)
- Department of Neurology, University of Pittsburgh Medical Center (R.G.N.)
| | - Thanh N Nguyen
- Departments of Radiology (M.A., S. Ning, M.M.Q., P.K., Z.M., J.B., M.K., T.N.N.), Boston Medical Center
- Neurology (T.N.N.), Boston Medical Center
| |
Collapse
|
2
|
Sevilis T, Avila A, McDonald M, Fowler M, Chalfin R, Amir M, Heath G, Zaman M, Avino L, Boyd C, Gao L, Devlin T. Sex differences in acute telestroke care: more to the story. Front Neurol 2023; 14:1203502. [PMID: 37426435 PMCID: PMC10325705 DOI: 10.3389/fneur.2023.1203502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023] Open
Abstract
Background Previous studies have shown sex differences in stroke care. Female patients have both lower thrombolytic treatment rates with OR reported as low as 0.57 and worse outcomes. With updated standards of care and improved access to care through telestroke, there is potential to reduce or alleviate these disparities. Methods Acute stroke consultations seen by TeleSpecialists, LLC physicians in the emergency department in 203 facilities (23 states) from January 1, 2021 to April 30, 2021 were extracted from the Telecare by TeleSpecialists™ database. The encounters were reviewed for demographics, stroke time metrics, thrombolytics candidate, premorbid modified Rankin Score, NIHSS score, stroke risk factors, antithrombotic use, admitting diagnosis of suspected stroke, and reason not treated with thrombolytic. The treatment rates, door to needle (DTN) times, stroke metric times, and variables of treatment were compared for females and males. Results There were 18,783 (10,073 female and 8,710 male) total patients included. Of the total, 6.9% of females received thrombolytics compared to 7.9% of males (OR 0.86, 95% CI 0.75-0.97, p = 0.006). Median DTN times were shorter for males than females (38 vs. 41 min, p < 0.001). Male patients were more likely to have an admitting diagnosis of suspected stroke, p < 0.001. Analysis by age showed the only decade with significant difference in thrombolytics treatment rate was 50-59 with increased treatment of males, p = 0.047. When multivariant logistic regression analysis was performed with stroke risk factors, NIHSS score, age, and admitting diagnosis of suspected stroke, the adjusted odds ratio for females was 0.9 (95% CI 0.8, 1.01), p = 0.064. Conclusion While treatment differences between sexes existed in the data and were apparent in univariate analysis, no significant difference was seen in multivariate analysis once stroke risk factors, age, NIHSS score and admitting diagnosis were taken into consideration in the telestroke setting. Differences in rates of thrombolysis between sexes may therefore be reflective of differences in risk factors and symptomatology rather than a healthcare disparity.
Collapse
Affiliation(s)
| | - Amanda Avila
- TeleSpecialists, LLC, Fort Myers, FL, United States
| | | | | | | | - Murtaza Amir
- TeleSpecialists, LLC, Fort Myers, FL, United States
| | - Gregory Heath
- Public Health, University of Tennessee at Chattanooga, Chattanooga, TN, United States
| | | | | | - Caitlyn Boyd
- TeleSpecialists, LLC, Fort Myers, FL, United States
| | - Lan Gao
- Mathematics, University of Tennessee at Chattanooga, Chattanooga, TN, United States
| | - Thomas Devlin
- TeleSpecialists, LLC, Fort Myers, FL, United States
- Neurology Department, University of Tennessee Health Science Center, Memphis, TN, United States
| |
Collapse
|
4
|
Grundtvig J, Ovesen C, Steiner T, Carcel C, Gaist D, Christensen L, Marstrand J, Meden P, Rosenbaum S, Iversen HK, Kruuse C, Christensen T, Ægidius K, Havsteen I, Christensen H. Sex-Differences in Oral Anticoagulant-Related Intracerebral Hemorrhage. Front Neurol 2022; 13:832903. [PMID: 35309585 PMCID: PMC8927802 DOI: 10.3389/fneur.2022.832903] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/31/2022] [Indexed: 12/21/2022] Open
Abstract
Introduction and Aim Data remain limited on sex-differences in patients with oral anticoagulant (OAC)-related intracerebral hemorrhage (ICH). We aim to explore similarities and differences in risk factors, acute presentation, treatments, and outcome in men and women admitted with OAC-related ICH. Method This study was a retrospective observational study based on 401 consecutive patients with OAC-related ICH admitted within 24 h of symptom onset. The study was registered on osf.io. We performed logarithmic regression and cox-regression adjusting for age, hematoma volume, Charlson Comorbidity Index (CCI), and pre-stroke modified Ranking Scale (mRS). Gender and age were excluded from CHA2DS2-VASc and CCI was not adjusted for age. Results A total of 226 men and 175 women were identified. More men were pre-treated with vitamin K-antagonists (73.5% men vs. 60.6% women) and more women with non-vitamin K-antagonist oral anticoagulants (26.5% men vs. 39.4% women), p = 0.009. Women were older (mean age 81.9 vs. 76.9 years, p < 0.001). CHA2DS2-VASc and CCI were similar in men and women. Hematoma volumes (22.1 ml in men and 19.1 ml in women) and National Institute of Health Stroke Scale (NIHSS) scores (13 vs. 13) were not statistically different, while median Glasgow Coma Scale (GCS) was lower in women, (14 [8;15] vs. 14 [10;15] p = 0.003). Women's probability of receiving reversal agents was significantly lower (adjusted odds ratio [aOR] = 0.52, p = 0.007) but not for surgical clot removal (aOR = 0.56, p = 0.25). Women had higher odds of receiving do-not-resuscitate (DNR) orders within a week (aOR = 1.67, p = 0.04). There were no sex-differences in neurological deterioration (aOR = 1.48, p = 0.10), ability to walk at 3 months (aOR = 0.69, p = 0.21) or 1-year mortality (adjusted hazard ratio = 1.18, p = 0.27). Conclusion Significant sex-differences were observed in age, risk factors, access to treatment, and DNRs while no significant differences were observed in comorbidity burden, stroke severity, or hematoma volume. Outcomes, such as adjusted mortality, ability to walk, and neurological deterioration, were comparable. This study supports the presence of sex-differences in risk factors and care but not in presentation and outcomes.
Collapse
Affiliation(s)
- Josefine Grundtvig
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Josefine Grundtvig
| | - Christian Ovesen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Thorsten Steiner
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Louisa Christensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Marstrand
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Per Meden
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Helle K. Iversen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Herlev Hospital, Copenhagen, Denmark
| | | | - Karen Ægidius
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Inger Havsteen
- Department of Radiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Hanne Christensen
| |
Collapse
|