Ericka Samantha Teleg, MD

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.

The new advances on stroke treatment, namely thrombolysis and mechanical thrombectomy, from year 2000 to 2018 allowed us to treat and improve stroke outcomes significantly in all age groups. Despite the reduction of stroke burden in many ways, this article highlights that women are expected to share a higher fraction of this burden, and, hence, it is necessary to address sex-specific characteristics in order to optimize acute ischemic stroke, namely in terms of stroke severity and administration of intravenous thrombolysis — there exists a gender specific difference in women having an increased stroke severity at onset and less uptake with IVT. Hence, the aim of this article is befitting as it analyzes 19 years of data of differences in symptom severity and disability upon admission, administration of acute ischemic treatments, in-hospital mortality and functional outcome at discharge in a large German stroke registry.

The study utilized data from the Stroke Registry Northwestern Germany. This registry was able to collect data from several hospital sites between January 1, 2000 and December 31, 2018. This brings about a heterogenous representative sample of the overall stroke population throughout a time that stroke advances were also evolving. Logistic regression models to estimate the effect of sex on the outcome were utilized. It is important that corresponding models were adjusted for covariates. The strength of the methodology is being able to delineate model adjustment for covariates through year periods, namely from year 2000 to 2009, and from year 2010 to 2018.

The results highlight the following sex differences in acute presentation: that female patients have a higher chance of being admitted, with a higher degree of disability: a Rankin score of >2 in both time periods. However, despite this, female patients were more likely to be discharged with a favorable functional outcome and experienced lower in-hospital mortality. Notably, there were no sex differences with respect to treatment with intra-venous thrombolysis (2000-2009; OR=0.99, 95% -CI 0.94-1.03; 2010-2018; OR = 1.0 [0.98-1.02]). With regard to sex differences in acute stroke treatment, when correcting for age and year of admission only, women were less likely to receive IVT from year 2000 to 2009, but more likely to receive intra-arterial therapy in the subsequent years.

The nuances of gender specific differences in acute stroke treatment allow us to tailor treatment to enable understanding of the underlying mechanisms and approach prevention and treatment despite gender differences. Thus, this could lead to “clinically actionable, novel approaches” that can tailor guidelines for the benefit of stroke prevention across all gender differences. Their analyses have allowed us to understand that women have significantly more severe strokes upon admission but more favorable outcomes at discharge compared to men when all the covariates are taken into account.