Sex-specific differences in ischemic stroke outcomes are prevalent. We sought to investigate sex differences in the determinants of reperfusion and functional outcomes after endovascular thrombectomy (EVT) for emergent large vessel occlusion ischemic stroke (ELVO).
Patients presenting to a single referral center with an anterior circulation ELVO that underwent EVT from 2011 to 2019 were included in this retrospective analysis. Sex differences in history, presentation, adequate reperfusion (TICI 2b-3), and 90-day good outcome [delta modified Rankin Scale (mRS) ≤ 2 from pre-stroke] were examined. Multivariable logistic regression analyses were performed to assess sex-specific associations with outcomes.
Three hundred and eighty-one consecutive ELVO patients were identified. Women (N = 193) were older (75 vs 64 years, p < 0.0001), had more pre-stroke disability (17% vs 9%, p = 0.032), more atrial fibrillation (41% vs 30%, p = 0.033), but less carotid atherosclerosis (8% vs 16%, p = 0.027). Rates of TICI 2b-3 and good outcome were similar between sexes. Carotid atherosclerosis (OR 0.315, 95% CI 0.130, 0.762) and dissection (OR 0.124, 95% CI 0.027, 0.569) independently decreased the odds of TICI 2b-3 among men but not women. Older age, more severe stroke, and not achieving TICI 2b-3 independently decreased the odds of good outcome among both sexes, while prior stroke (OR 0.258, 95% CI 0.083, 0.797) and hemorrhagic transformation (OR 0.111, 0.021, 0.592) were determinants exclusive to men.
In a real-world analysis of ELVO stroke patients treated with EVT, we found that despite advanced age and more pre-stroke disability, women have comparable reperfusion rates and functional outcomes compared to men. Sex-specific determinants of reperfusion and functional outcome were identified that require further study.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
The data that support the findings of this study will be made available from the corresponding author upon reasonable request and pending approval of local institutional review board.
Albers GW, Marks MP, Kemp S et al (2018) Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 378:708–718. https://doi.org/10.1056/NEJMoa1713973
Regenhardt RW, Young MJ, Leslie-Mazwi TM (2021) Is the COVID-19 pandemic magnifying disparities in stroke treatment? J Neurointerv Surg 13:299–300. https://doi.org/10.1136/neurintsurg-2021-017292
Regenhardt RW, Biseko MR, Shayo AF et al (2019) Opportunities for intervention: stroke treatments, disability and mortality in urban Tanzania. Int J Qual Heal Care 31:385–392. https://doi.org/10.1093/intqhc/mzy188
Blonde L, Khunti K, Harris SB et al (2018) Interpretation and impact of real-world clinical data for the practicing clinician. Adv Ther 35:1763–1774. https://doi.org/10.1007/s12325-018-0805-y
Dehlendorff C, Andersen KK, Olsen TS (2015) Sex disparities in stroke: women have more severe strokes but better survival than men. J Am Heart Assoc 4:e001967. https://doi.org/10.1161/JAHA.115.001967
Mozaffarian D, Benjamin EJ, Go AS et al (2016) Heart disease and stroke statistics-2016 update a report from the American Heart Association. Circulation 133:e38-48. https://doi.org/10.1161/CIR.0000000000000350
Lisabeth LD, Reeves MJ, Baek J et al (2015) Factors influencing sex differences in poststroke functional outcome. Stroke 46:860–863. https://doi.org/10.1161/STROKEAHA.114.007985
Weber R, Krogias C, Eyding J et al (2019) Age and sex differences in ischemic stroke treatment in a nationwide analysis of 1.11 million hospitalized cases. Stroke 50:3494–3502. https://doi.org/10.1161/STROKEAHA.119.026723
Liu M, Li G, Tang J et al (2018) The influence of sex in stroke thrombolysis: a systematic review and meta-analysis. J Clin Neurol 14:141–152. https://doi.org/10.3988/jcn.2018.14.2.141
Sheth SA, Lee S, Warach SJ et al (2019) Sex differences in outcome after endovascular stroke therapy for acute ischemic stroke. Stroke 50:2420–2427. https://doi.org/10.1161/STROKEAHA.118.023867
Chalos V, De Ridder IR, Lingsma HF et al (2019) Does sex modify the effect of endovascular treatment for ischemic stroke? a subgroup analysis of 7 randomized trials. Stroke 50:2413–2419. https://doi.org/10.1161/STROKEAHA.118.023743
Uchida K, Yoshimura S, Sakai N et al (2019) Sex differences in management and outcomes of acute ischemic stroke with large vessel occlusion. Stroke 50:1915–1918. https://doi.org/10.1161/STROKEAHA.119.025344
Yu AT, Regenhardt RW, Whitney C et al (2021) CTA protocols in a telestroke network improve efficiency for both spoke and hub hospitals. Am J Neuroradiol 42:435–440. https://doi.org/10.3174/ajnr.A6950
Regenhardt RW, Etherton MR, Das AS et al (2021) White matter acute infarct volume after thrombectomy for anterior circulation large vessel occlusion stroke is associated with long term outcomes. J Stroke Cerebrovasc Dis 30:105567. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105567
Boulouis G, Siddiqui K-A, Lauer A et al (2017) Immediate vascular imaging needed for efficient triage of patients with acute ischemic stroke initially admitted to nonthrombectomy centers. Stroke 48:2297–2300. https://doi.org/10.1161/STROKEAHA.117.017607
Zachrison KS, Leslie-Mazwi TM, Boulouis G et al (2019) Frequency of early rapid improvement in stroke severity during interfacility transfer. Neurol Clin Pract 9:373–380. https://doi.org/10.1212/CPJ.0000000000000667
Barnett HJM, Taylor DW, Collaborators NASCET et al (1991) Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:445–453. https://doi.org/10.1056/NEJM199108153250701
Nolan NM, Regenhardt RW, Koch MJ et al (2021) Treatment approaches and outcomes for acute anterior circulation stroke patients with tandem lesions. J Stroke Cerebrovasc Dis 30:105478. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105478
Powers WJ, Rabinstein AA, Ackerson T et al (2019) Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke. Stroke 50:e344-418. https://doi.org/10.1161/STR.0000000000000211
Regenhardt RW, Etherton MR, Das AS et al (2020) Infarct growth despite endovascular thrombectomy recanalization in large vessel occlusive stroke. J Neuroimaging 31:155–164. https://doi.org/10.1111/jon.12796
Hacke W, Kaste M, Fieschi C et al (1995) Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 274:1017–1025. https://doi.org/10.1001/jama.1995.03530130023023
Young MJ, Regenhardt RW, Leslie-Mazwi TM et al (2020) Disabling stroke in persons already with a disability: ethical dimensions and directives. Neurology 94:306–310. https://doi.org/10.1212/WNL.0000000000008964
Regenhardt RW, Young MJ, Etherton MR et al (2020) Toward a more inclusive paradigm: thrombectomy for stroke patients with pre-existing disabilities. J Neurointerv Surg. https://doi.org/10.1136/neurintsurg-2020-016783
Salwi S, Cutting S, Salgado AD et al (2020) Mechanical thrombectomy in patients with ischemic stroke with prestroke disability. Stroke 51:1539–1545. https://doi.org/10.1161/STROKEAHA.119.028246
Gory B, Piotin M, Haussen DC et al (2017) Thrombectomy in acute stroke with tandem occlusions from dissection versus atherosclerotic cause. Stroke 48:3145–3148. https://doi.org/10.1161/STROKEAHA.117.018264
Flottmann F, Broocks G, Faizy TD et al (2020) Factors associated with failure of reperfusion in endovascular therapy for acute ischemic stroke: a multicenter analysis. Clin Neuroradiol 31:197–205. https://doi.org/10.1007/s00062-020-00880-8
Kaesmacher J, Gralla J, Mosimann PJ et al (2018) Reasons for reperfusion failures in stent-retriever-based thrombectomy: registry analysis and proposal of a classification system. Am J Neuroradiol 39:1848–1853. https://doi.org/10.3174/ajnr.A5759
Leischner H, Flottmann F, Hanning U et al (2019) Reasons for failed endovascular recanalization attempts in stroke patients. J Neurointerv Surg 11:439–442. https://doi.org/10.1136/neurintsurg-2018-014060
Regenhardt RW, Takase H, Lo EH et al (2020) Translating concepts of neural repair after stroke: Structural and functional targets for recovery. Restor Neurol Neurosci 38:67–92. https://doi.org/10.3233/rnn-190978
Takase H, Regenhardt R (2021) Motor tract reorganization after acute central nervous system injury: a translational perspective. Neural Regen Res 16:1144–1149. https://doi.org/10.4103/1673-5374.300330
Rizvi A, Seyedsaadat SM, Murad MH et al (2019) Redefining success’: a systematic review and meta-analysis comparing outcomes between incomplete and complete revascularization. J Neurointerv Surg 11:9–13. https://doi.org/10.1136/neurintsurg-2018-013950
Adams HP, Davis PH, Leira EC et al (1999) Baseline NIH Stroke Scale score strongly predicts outcome after stroke: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 53:126–131. https://doi.org/10.1212/wnl.53.1.126
Luo G, Mo D, Tong X et al (2018) Factors associated with 90-day outcomes of patients with acute posterior circulation stroke treated by mechanical thrombectomy. World Neurosurg 109:e318–e328. https://doi.org/10.1016/j.wneu.2017.09.171
Danière F, Lobotesis K, Machi P et al (2015) Patient selection for stroke endovascular therapy-DWI-ASPECTS thresholds should vary among age groups: insights from the RECOST study. Am J Neuroradiol 36:32–39. https://doi.org/10.3174/ajnr.A4104
Madsen TE, Decroce-Movson E, Hemendinger M et al (2019) Sex differences in 90-day outcomes after mechanical thrombectomy for acute ischemic stroke. J Neurointerv Surg 11:221–225. https://doi.org/10.1136/neurintsurg-2018-014050
Reeves MJ, Bushnell CD, Howard G et al (2008) Sex differences in stroke: epidemiology, clinical presentation, medical care, and outcomes. Lancet Neurol 7:915–926. https://doi.org/10.1016/S1474-4422(08)70193-5
de Ridder IR, Fransen PSS, Beumer D et al (2016) Is intra-arterial treatment for acute ischemic stroke less effective in women than in men. Interv Neurol 5:174–178. https://doi.org/10.1159/000447331
Desai SM, Haussen DC, Aghaebrahim A et al (2018) Thrombectomy 24 hours after stroke: beyond DAWN. J Neurointerv Surg 10:1039–1042. https://doi.org/10.1136/neurintsurg-2018-013923
We would like to thank Joyce A. McIntyre for her work maintaining the prospective Massachusetts General Hospital stroke database. This work was supported by the National Institute of Neurological Disorders and Stroke [Grant Number R25 NS065743].
This work was supported by the National Institute of Neurological Disorders and Stroke [Grant Number R25 NS065743].
Conflict of interest
The ethics committee of Massachusetts General Hospital approved this study.
Waived based on minimal patient risk and practical inability to perform the study without the waiver.
About this article
Cite this article
Regenhardt, R.W., Turner, A.C., Hirsch, J.A. et al. Sex-specific differences in presentations and determinants of outcomes after endovascular thrombectomy for large vessel occlusion stroke. J Neurol 269, 307–315 (2022). https://doi.org/10.1007/s00415-021-10628-0