Sex Differences In Stroke Outcomes Research Articles

Abstract WP285: Stroke Recurrence and Poststroke Mortality: Sex Differences and Contributors in a Population-Based Study

Few population-based studies have assessed whether stroke recurrence differs by sex. Additionally, contributors, particularly social factors, to sex differences in recurrence and poststroke mortality are unclear. Methods: First-ever ischemic stroke cases (2008-2019) identified from the population-based Brain Attack Surveillance in Corpus Christi Project were included. Recurrence and all-cause mortality were ascertained through 2020. Sex differences in outcomes with and without adjustment for 21 potential contributors (Figure) were examined by Cox proportional hazard models. Contributions of each factor to sex differences were assessed by change in the β estimate for sex before and after adjustment. Final models including all identified contributors (≥ 10% contribution) were conducted. Results: Of 2,326 participants (mean age 68 years; 48% women; 57% Mexican American), 274 had a recurrence and 965 died (median follow-up 5.4 and 3.7 years, respectively). No significant sex difference in recurrence was noted before (HR 0.89, 95% CI 0.70-1.13) or after adjustment in the final model (HR 0.86, 95% CI 0.66-1.13). While women had a higher crude mortality rate than men (HR 1.23, 95% CI 1.08-1.39), after adjusting for identified contributors (Figure), women had lower mortality (HR 0.79, 95% CI 0.67-0.92). Age and marital status were the two most important contributors to the sex difference. Other contributors included social support, physician access, insurance, stroke severity, coronary artery disease, prestroke disability, and alcohol consumption (Figure). Conclusion: Crudely, women had a nonsignificantly lower recurrence rate but higher poststroke mortality rate than men. After adjustment, women had a similar recurrence rate but lower mortality rate. Findings suggest that in addition to clinical factors, social factors including physician access, private insurance, having a partner, and higher social support, impact sex differences in stroke outcomes.

Trends of Sex Differences and Associated Factors in Stroke Outcomes Among Patients With Acute Ischemic Stroke: 2007 to 2018

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. 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. 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. 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.

Sex Differences in Short-Term and Long-Term Outcomes Among Patients With Acute Ischemic Stroke in China.

Sex differences in stroke outcomes are crucial to secondary prevention, but previous reports showed inconsistent results. We aimed to explore the sex differences in stroke outcomes in the Third China National Stroke Registry, a prospective multicenter registry study. Among the 15 166 patients enrolled between 2015 and 2018, 9038 patients with acute ischemic stroke (AIS) were included. The primary outcomes were stroke recurrence, mortality, and unfavorable functional outcome (modified Rankin Scale > 2) at 3, 6, and 12 months. Cox regression model was used for stroke recurrence and mortality and logistic regression was used for the unfavorable functional outcome, and adjusted as follows: (1) Model 1: without adjustment; (2) Model 2: adjusted for potential risk factors, National Institutes of Health Stroke Scale at admission, prestroke modified Rankin Scale, tPA (tissue-type plasminogen activator) treatment, TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification, and onset-to-door time; (3) Model 3: adjusted for covariates from model 2 in addition to blood pressure and blood serum covariates. Multiple imputation was used for missing values, and sensitivity analyses were conducted to describe sex differences by age groups. One-third (2802/9038) of the patients were women. Women were significantly older than men (64.78±10.84 versus 61.26±11.42, P<0.001). In the fully adjusted model, female patients were more likely to have unfavorable functional outcomes at 3 months (odds ratio, 1.28 [1.09-1.50]), especially among patients aged 65 years or older (odds ratio, 1.39 [1.14-1.70]), but no difference was discovered in patients aged <65 years. There were no sex differences in stroke recurrence and mortality at 3, 6, or 12 months or unfavorable functional outcomes at 6 or 12 months after adjustment. Compared with men, women with AIS were less likely to have favorable outcomes at 3 months in China, especially among those over 65 years of age. Experts should aim to tailor secondary prevention strategies for high-risk patients.

Sex differences in the risk of recurrent ischemic stroke after ischemic stroke and transient ischemic attack.

Sex differences in stroke outcomes have been noted, but whether this extends to stroke recurrence is unclear. We examined sex differences in recurrent stroke using data from the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial. We assessed the risk of recurrent stroke in women compared to men using data from the POINT trial. Adults >18 years old were randomized within 12 hours of onset of minor ischemic stroke or transient ischemic attack (TIA), and followed for up to 90 days for ischemic stroke, our primary outcome. We used Cox proportional hazards model adjusted for demographics and stroke risk factors to evaluate the association between sex and stroke recurrence. We used interaction term testing and prespecified subgroup analyses to determine if the association between sex and recurrent stroke differed by age (<60 versus >60 years old), locale (US versus non-US), and index event type (stroke versus TIA). Last, we evaluated whether sex modified the effect of common stroke risk factors on stroke recurrence. Of 4,881 POINT trial participants with minor stroke or high-risk TIA, 2,195 (45%) were women. During the 90-day follow-up period, 267 ischemic strokes occurred; 121 were in women and 146 in men. The cumulative risk of recurrent ischemic stroke was not significantly different among women (5.76%; 95% CI, 4.84%-6.85%) compared to men (5.67%; 95% CI, 4.83%-6.63%). Women were not at a different risk of recurrent ischemic stroke compared to men (hazard ratio [HR], 1.02; 95% CI, 0.80-1.30) in unadjusted models or after adjusting for covariates. However, there was a significant interaction of age with sex (P=0.04). Among patients <60 years old, there was a non-significantly lower risk of recurrent stroke in women compared to men (HR 0.66; 95% CI 0.42-1.05). Last, sex did not modify the association between common stroke risk factors and recurrent stroke risk. Among patients with minor stroke or TIA, the risk of recurrent ischemic stroke and the impact of common stroke risk factors did not differ between men and women.

Abstract MP57: Sex Differences in Stroke Outcome Are Associated With Constitutive Gut Dysbiosis and Stroke-Induced Gut Permeability

Sex differences in experimental stroke are well documented, such that adult males show worse outcomes compared to adult females, including greater infarct volume, increased stroke-induced mortality and more severe sensory-motor impairment. Based on recent evidence that gut dysbiosis may be an early response to stroke, the present study tested the hypothesis that in the acute phase, stroke will result in greater gut dysbiosis and greater permeability of the gut blood barrier in males as compared to females. Male and female Sprague Dawley rats (5-7 months of age) were subject to endothelin-1-induced middle cerebral artery occlusion (MCAo). Fecal samples, blood draws and sensory motor tests were collected/conducted pre and 2d after MCAo. Fecal samples were subject to 16s sequencing. Serum samples were subject to gas chromatography for short chain fatty acid (SCFA) analysis. Gut permeability was assessed by histology, biochemical markers in serum and functional assays using oral dextran gavage. We confirmed stroke-induced sex differences, including increased mortality and more severe sensory motor deficit in males as compared to age-matched female rats. Fecal 16s sequencing showed greater bacterial diversity in females at baseline (pre stroke) while 2 days after stroke, these measures were similar between the sexes. Fecal levels of SCFAs, which are usually beneficial, were higher in males. In contrast, MCAo-induced gut permeability was much worse in males as compared to females. Male rats had a decreased villus length to crypt length ratio, higher levels of biochemical gut permeability markers in serum and higher levels of fluorescent-labeled dextrans following oral gavage in serum. Additionally, males had higher serum levels of proinflammatory cytokines IL-17A, MCP-1, IL-5 and EGF compared to females after stroke. Collectively, these results indicate that the worse stroke outcomes seen in males is associated with increased gut permeability in this group. These data suggest that therapeutics that target the gut epithelium in order to reinforce the gut-blood barrier post stroke may be an effective intervention especially in populations such as the elderly or those with co-morbid conditions who have already been shown to have more permeable barriers.

Sex differences in stroke outcome correspond to rapid and severe changes in gut permeability in adult Sprague-Dawley rats

BackgroundSex differences in experimental stroke outcomes are well documented, such that adult males have a greater infarct volume, increased stroke-induced mortality, and more severe sensory-motor impairment. Based on recent evidence that the gut is an early responder to stroke, the present study tested the hypothesis that sex differences in stroke severity will be accompanied by rapid and greater permeability of the gut-blood barrier and gut dysbiosis in males as compared to females.MethodMale and female Sprague-Dawley rats (5–7 months of age) were subject to endothelin (ET)-1-induced middle cerebral artery occlusion (MCAo). Sensory-motor tests were conducted pre- and 2 days after MCAo. Gut permeability was assessed in serum samples using biomarkers of gut permeability as well as functional assays using size-graded dextrans. Histological analysis of the gut was performed with H&E staining, periodic acid-Schiff for mucus, and immunohistochemistry for the tight junction protein, ZO-1. Fecal samples obtained pre- and post-stroke were analyzed for bacterial taxa and short-chain fatty acids (SCFAs).ResultsAfter stroke, males displayed greater mortality, worse sensory-motor deficit, and higher serum levels of proinflammatory cytokines IL-17A, MCP-1, and IL-5 as compared to females. MCAo-induced gut permeability was rapid and severe in males as indicated by dextran extravasation from the gut to the blood in the hyperacute (< 2 h) and early acute (2 days) phase of stroke. This was accompanied by dysmorphology of the gut villi and dysregulation of the tight junction protein ZO-1 in the acute phase. Fecal 16s sequencing showed no differences in bacterial diversity in the acute phase of stroke. Predictive modeling indicated that markers of gut permeability were associated with acute sensory-motor impairment and infarct volume.ConclusionsThese data show that extensive leakiness of the gut barrier is associated with severe post-stroke disability and suggest that reinforcing this barrier may improve stroke outcomes.

Sex Differences Among Participants in the Latin American Stroke Registry

BackgroundReports on sex differences in stroke outcome and risk factors are scarce in Latin America. Our objective was to analyze clinical and prognostic differences according to sex among participants in the LASE (Latin American Stroke Registry).Methods and ResultsNineteen centers across Central and South America compiled data on demographics, vascular risk factors, clinical stroke description, ancillary tests, and functional outcomes at short‐term follow‐up of patients included from January 2012 to January 2017. For the present study, all these variables were analyzed according to sex at hospital discharge. We included 4788 patients with a median in‐hospital stay of 8 days (interquartile range, 5–8); 2677 were male (median age, 66 years) and 2111 female (median age, 60 years). Ischemic stroke occurred in 4293: 3686 as cerebral infarction (77%) and 607 as transient ischemic attack cases (12.7%); 495 patients (10.3%) corresponded to intracerebral hemorrhage. Poor functional outcome (modified Rankin scale, 3–6) was present in 1662 (34.7%) patients and 38.2% of women (P<0.001). Mortality was present in 6.8% of the registry, with 7.8% in women compared with 6.0% in men (P=0.01). Death and poor functional outcome for all‐type stroke showed a higher risk in female patients (hazard ratio, 1.3, P=0.03; and hazard ratio, 1.1, P=0.001, respectively).ConclusionsA worse functional outcome and higher mortality rates occurred in women compared with men in the LASE, confirming sex differences issues at short‐term follow‐up.

Focused Update of Sex Differences in Patient Reported Outcome Measures After Stroke

Women experience worse outcomes after stroke than men1 despite their lower age-adjusted incidence of stroke.2 Previous reviews of sex differences in select stroke outcomes, including activity limitations,3–5 participation restriction,4 poststroke depression (PSD),3 and health-related quality of life (HRQoL),3,4 demonstrated that women had worse outcomes than men across many of these measures. Women’s greater age and stroke severity, as well as poorer prestroke function, seem to contribute to the sex difference in outcomes, but data on other contributing factors are limited.4 Existing reviews included studies published >5 years ago, and given the rapid increase in the number of studies addressing sex differences in stroke outcomes, an updated review is warranted. Full details of our methods are provided in the online-only Data Supplement. A previous review included studies up to 2007,3 so we reviewed studies from 2007 onwards that examined sex differences in patient reported outcome measures (PROMs) at ≤12 months after stroke, including activity limitations, HRQoL, participation restriction, impaired cognition, and mood.6 Full results tables are shown in the online-only Data Supplement. ### Activity Limitations Of 1875 articles identified, 22 studies (3 population based) that were designed to examine sex differences (Results and Table I in the online-only Data Supplement) met criteria for inclusion. The most common instrument to assess activity limitations was the modified Rankin Scale, followed by the Barthel Index. In 8 studies including ischemic and hemorrhagic strokes, unadjusted estimates showed that women had more activity limitations than men through significantly lower odds of good outcome (odds ratio [OR] range: 0.44–0.61)7–9 or greater odds of poor outcome (OR range: 1.29–1.62).10–14 In multivariable adjusted analyses, women had worse outcome than men with significantly lower odds of good outcome (OR range: 0.37–0.75) or …

Pannexin1 knockout and blockade reduces ischemic stroke injury in female, but not in male mice.

The membrane channel Pannexin 1 (Panx1) mediates apoptotic and inflammatory signaling cascades in injured neurons, responses previously shown to be sexually dimorphic under ischemic conditions. We tested the hypothesis that Panx1 plays an underlying role in mediating sex differences in stroke outcome responses. Middle-aged, 8-9 month old male and female wild type and Panx1 KO mice were subjected to permanent middle cerebral artery (MCA) occlusion, and infarct size and astrocyte and microglia activation were assessed 4 days later. The sexually dimorphic nature of Panx1 deletion was also explored by testing the effect of probenecid a known Panx1 blocker to alter stroke volume. Panx1 KO females displayed significantly smaller infarct volumes (~ 50 % reduction) compared to their wild-type counterparts, whereas no such KO effect occurred in males. This sex-specific effect of Panx1 KO was recapitulated by significant reductions in peri-infarct inflammation and astrocyte reactivity, as well as smaller infarct volumes in probenecid treated females, but not males. Finally, females showed overall, higher Panx1 protein levels than males under ischemic conditions. These findings unmask a deleterious role for Panx1 in response to permanent MCA occlusion, that is unique to females, and provide several new frameworks for understanding sex differences in stroke outcome.

Sex differences in outcomes after stroke among patients with low total cholesterol levels: a large hospital-based prospective study.

BackgroundPrevious studies have shown that total cholesterol (TC) levels are associated with stroke outcomes, but sex differences in the association between TC levels, especially a low TC level, and ischemic stroke outcomes are unknown. We aimed to assess the sex differences in stroke outcomes among patients with atherothrombotic infarctions and low TC levels in China.MethodsThis study recruited patients with atherothrombotic infarctions from Tianjin, China, between May 2005 and September 2014. Patients with low TC levels (defined as TC <4.22 mmol/L) were analyzed in this study. Sex differences in stroke subtypes, severity, risk factors, and outcomes at 3 and 12 months after stroke were compared.ResultsOverall, 1587 patients with low TC levels were recruited to this study from among 6407 patients with atherothrombotic infarctions listed in a stroke registry. Women were more likely than men to have posterior circulation infarcts, severe stroke, hypertension, and obesity but less likely to be current smokers or to consume alcohol. There were no sex differences in stroke outcomes. Older age and severe stroke were common risk factors for poor outcomes after stroke in this study. The presence of diabetes mellitus was an independent predictor of low mortality at 12 months after stroke, possibly because a drug commonly used to treat diabetes, metformin, enhances angiogenesis. Obesity was the determinant of the recurrence and dependency rates at 12 months after stroke.ConclusionsThese findings suggest that patients (both men and women) with atherothrombotic infarction who have low TC levels would not benefit from receiving statin treatment. Therefore, it is crucial to explore the impact of statin treatment on outcomes in Asian patients, especially Chinese patients with atherothrombotic and low TC levels, in order to improve outcomes after stroke and reduce the disease burden.

Sex differences in long-term outcomes among acute ischemic stroke patients with diabetes in China.

BackgroundDiabetes has been shown to be significantly associated with poor outcome after stroke. However, the sex differences in stroke outcome among patients with diabetes are unknown. Therefore, we aimed to assess the sex differences in long-term prognosis among acute ischemic stroke patients with diabetes.MethodsThe ischemic stroke patients with diabetes were recruited to this study between May 2005 and September 2014 in Tianjin, China. Sex differences in mortality, dependency (modified rank scale > 2), and recurrence at 3, 12, and 36 months after stroke were analyzed.ResultsA total of 2360 patients were recruited in this study. The age of stroke onset, National Institute of Health stroke scale (NIHSS), and modified rank scale (mRS) on admission were greater in women than in men (P < 0.05). Women were more likely to have hypertension, obesity, atrial fibrillation, and dyslipidemias. In contrast, men were more likely to have artery stenosis, current smoking, and alcohol consumption (P < 0.001). There was higher mortality in women than in men at 3 months (7.9 % vs 5.2 %), 12 months (12.2 % vs 8.2 %), and 36 months (21.9 % vs 16.1 %) after stroke; but no differences were found in dependency and recurrence. Sex differences were found in associated factors of outcomes by time-point. Trial of Org 10172 in Acute Stroke Treatment (TOAST) of large artery atherothrombosis (LAA), cardioembolism (CE), and smoking were risk factors of outcomes in women at short term and medium term; but atrial fibrillation (AF), obesity, and alcohol were risk factors of outcomes in men at medium term and long term.ConclusionsThese findings suggest that it is crucial to establish the individual scheme of therapy for every patient by different risk factors of stroke, strengthen the rehabilitation of stroke, and carry on the health education early for the secondary prevention of stroke in patients with diabetes mellitus (DM).

Sex Differences in Outcomes and Associated Risk Factors After Acute Ischemic Stroke in Elderly Patients: A Prospective Follow-up Study

Stroke has a greater effect on women. However, sex differences in outcome and factors associated with outcome among elderly patients are unknown. From January 2009 to December 2011, 810 patients with acute ischemic stroke aged 75 years or older were recruited in China. Clinical profile and risk factors were recorded. Outcomes and associated risk factors at 12 and 36 months after stroke were assessed by sex. Hypertension, diabetes mellitus, dyslipidemias, and obesity prevalence rates were higher in women than in men; opposite trends were found for smoking and alcohol consumption. The mortality rate at 12 months after stroke was significantly greater in men than in women (23.3% versus 16.6%, P = .015). Large-artery atherothrombotic and cardioembolic stroke subtypes were risk factors for mortality, recurrence, and dependency in both sexes. In men, atrial fibrillation was a risk factor of mortality at 12 months after stroke (relative ratio [RR], 2.12; 95% confidence interval [CI], 1.38-3.27), but obesity was a protective factor of mortality at 36 months after stroke (RR, .30; 95% CI, .10-.94). However, in women, atrial fibrillation was a risk factor of recurrence at 12 months (RR, 2.32; 95% CI, 1.31-4.12) and dependency at 36 months after stroke (RR, 7.68; 95% CI, 1.60-36.82). We assessed sex differences in stroke outcomes and associated risk factors at 12 and 36 months after stroke in a large hospital-based stroke registry of elderly patients from Northern China. Thus, it is crucial to emphasize risk management to elderly patients to reduce mortality, recurrence, and dependency after stroke.

Abstract 2977: Sex Differences and Hemoglobin Levels in Relation to Stroke Outcomes

Background: Women have worse outcomes after ischemic stroke compared to men. Several mechanisms are postulated, including older age and a differential effect of sex hormones. We have previously shown that hemoglobin levels are associated with increased stroke volume and infarct expansion. Since women have lower hemoglobin values, we examined whether hemoglobin levels may be associated with poorer stroke outcomes in women. Methods: We retrospectively studied 274 patients (N = 121 women, N = 153 men) enrolled in a prospective study. We explored the relationship of hemoglobin with clinical outcome at 6 months, as measured by the modified Rankin Scale. We employed ordinal logistic regression to evaluate the effect of hemoglobin on clinical outcome and to explore the influence of sex on that association. Results: Women had a lower hemoglobin level (11.7 +/- 1.8 g/dL) compared to men (13.3 +/- 1.7 g/dL; P &lt; 0.001). Low hemoglobin was correlated with worse 6-month mRS outcome in univariate analysis (P &lt; 0.001). Lower hemoglobin remained independently associated with poorer outcome after adjustment for age, sex, blood glucose, NIH stroke scale score, hypertension, smoking and diabetes mellitus. The inclusion of hemoglobin in the model eliminated the independent effect of sex on outcome. Conclusions: Sex differences in stroke outcome may be mediated in part by lower hemoglobin levels, a potentially modifiable predictor. Further examination exploring whether hemoglobin has a causative role is warranted.

Sexual Dimorphism in Ischemic Stroke: Lessons from the Laboratory

Ischemic stroke is emerging as a major health problem for elderly women. Women have lower stroke incidence than men until an advanced age, when the epidemiology of ischemic stroke shifts and incidence rises dramatically in women. Experimental models of rodent stroke have replicated this clinical epidemiology, with exacerbated injury in older compared with young female rodents. Many of the detrimental effects of aging on ischemic stroke outcome in females can be replicated by ovariectomy, suggesting that hormones such as estrogen play a neuroprotective role. However, emerging data suggest that the molecular mechanisms leading to ischemic cell death differ in the two sexes, and these effects may be independent of circulating hormone levels. This article highlights recent clinical and experimental literature on sex differences in stroke outcomes and mechanisms.

Do women benefit more from systemic thrombolysis in acute ischemic stroke? A Serbian experience with thrombolysis in ischemic stroke (SETIS) study

Objective The female sex is associated with increased stroke severity and relatively poor functional recovery. Several studies have demonstrated that women with stroke benefit more from intravenous thrombolysis compared with men, while others found the nullification of gender effect among women treated with recombinant tissue plasminogen activator (rtPA). The purpose of our study was to determine any gender differences in the efficacy and safety of systemic thrombolysis among patients with acute ischemic stroke in Serbia. Methods Data were from the Serbian experience with intravenous thrombolysis in ischemic stroke (SETIS) study, a prospective, ongoing, multicenter, open, and observational study in Serbia of all patients who have received rtPA for acute ischemic stroke. We analyzed sex differences in the baseline characteristics, functional outcome and treatment complications. Results Among 60 women and 96 men with stroke and treated with intravenous thrombolysis, we found that at day 90, no significant sex differences in excellent functional outcome (50.9% of women vs. 57.0% of men, p = 0.5), favorable functional outcome (61.4% of women vs. 68.8% of men, p = 0.38) or death (8.8% of women vs. 12.9% of men, p = 0.60). These results were constant even after adjustments for age, severity of basal neurological deficit and onset to treatment time. Conclusion There were no sex differences in functional outcome at 90 days after the stroke among patients treated with IV rtPA. This finding might confirm that thrombolytic therapy nullifies usual sex differences in stroke outcome and suggests that women with stroke may benefit more from rtPA treatment.

Understanding Stroke in Women

See related article, pages 909–914. “The pure and simple truth is rarely pure and never simple”. —Oscar Wilde Sex differences in clinical care and outcomes have been documented in multiple studies of patients with coronary artery disease, with research showing differences in presentation, disparities in diagnosis and management, and worse clinical outcomes in women compared to men.1,2 There has been concern that similar sex differences exist in the care and outcomes of patients with stroke, given the parallels in patient populations and risk factors in individuals with cardiac and cerebrovascular disease. To date, however, the research on the interaction between gender and stroke has been limited and results have been inconsistent. Thus, any new information on this topic is welcome. In this issue of Stroke , Eriksson et al3 report on an analysis of 24 633 stroke events in 2006 from the large, well-designed, population-based Swedish National Quality Register (RIKS-Stroke). They found that compared to men, women were older (mean age difference 4.8 years) and were more often unconscious on presentation. No differences were found in processes of care such as administration of thrombolysis or discharge on anticoagulants. Women were more likely to develop deep venous thromboses and fractures, whereas men …