Sex differences in cardiovascular risk profiles of ischemic stroke patients with diabetes in the Greater Cincinnati/Northern Kentucky Stroke Study

Background The aim of the present study was to compare sex-specific associations between cardiovascular risk factors and diabetes mellitus (DM) among patients with acute ischemic stroke (AIS) in the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS). Methods The GCNKSS ascertained AIS cases in 2005 and 2010 among adult (age ≥ 20 years) residents of a biracial population of 1.3 million. Past and current stroke risk factors were compared between those with and without DM using Chi-squared tests and multiple logistic regression analysis to examine sex-specific profiles. Results There were 3515 patients with incident AIS; 1919 (55%) were female, 697 (20%) were Black, and 1146 (33%) had DM. Among both women and men with DM, significantly more were obese and had hypertension, high cholesterol, and coronary artery disease (CAD) compared with those without DM. For women with AIS, multivariable sex-specific adjusted analyses revealed that older age was associated with decreased odds of having DM (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.80–0.98). For women with CAD, the odds of DM were increased (aOR 1.76, 95% CI 1.33–2.32). Age and CAD were not significant factors in differentiating the profiles of men with and without DM. Conclusions Women with DM had strokes at a younger age, whereas no such age difference existed in men. Compared with men, women with DM were also more likely to have CAD than those without DM, suggesting a sex difference in the association between DM and vascular disease. These findings may suggest a need for more aggressive risk factor management in diabetic women

Temporal Trends in Stroke Incidence over Time by Sex and Age in the Greater Cincinnati Northern Kentucky Stroke Study

Background and Purpose- Sex differences in stroke incidence over time were previously reported from the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study). We aimed to determine whether these differences continued through 2015 and whether they were driven by particular age groups. Methods- Within the GCNKSS population of 1.3 million, incident (first ever) strokes among residents ≥20 years of age were ascertained at all local hospitals during 5 periods: July 1993 to June 1994 and calendar years 1999, 2005, 2010, and 2015. Out-of-hospital cases were sampled. Sex-specific incidence rates per 100 000 were adjusted for age and race and standardized to the 2010 US Census. Trends over time by sex were compared (overall and age stratified). Sex-specific case fatality rates were also reported. Bonferroni corrections were applied for multiple comparisons. Results- Over the 5 study periods, there were 9733 incident strokes (56.3% women). For women, there were 229 (95% CI, 215-242) per 100 000 incident strokes in 1993/1994 and 174 (95% CI, 163-185) in 2015 (P<0.05), compared with 282 (95% CI, 263-301) in 1993/1994 to 211 (95% CI, 198-225) in 2015 (P<0.05) in men. Incidence rates decreased between the first and last study periods in both sexes for IS but not for intracerebral hemorrhage or subarachnoid hemorrhage. Significant decreases in stroke incidence occurred between the first and last study periods for both sexes in the 65- to 84-year age group and men only in the ≥85-year age group; stroke incidence increased for men only in the 20- to 44-year age group. Conclusions- Overall stroke incidence decreased from the early 1990s to 2015 for both sexes. Future studies should continue close surveillance of sex differences in the 20- to 44-year and ≥85-year age groups, and future stroke prevention strategies should target strokes in the young- and middle-age groups, as well as intracerebral hemorrhage

Genetic and Genomic Epidemiology of Stroke in People of African Ancestry

Stroke is one of the leading causes of disability and death worldwide and places a significant burden on healthcare systems. There are significant racial/ethnic differences in the incidence, subtype, and prognosis of stroke, between people of European and African ancestry, of which only about 50% can be explained by traditional stroke risk facts. However, only a small number of genetic studies include individuals of African descent, leaving many gaps in our understanding of stroke genetics among this population. This review article highlights the need for and significance of including African-ancestry individuals in stroke genetic studies and points to the efforts that have been made towards this direction. Additionally, we discuss the caveats, opportunities, and next steps in African stroke genetics&mdash;a field still in its infancy but with great potential for expanding our understanding of stroke biology and for developing new therapeutic strategies

Sex differences in the evaluation and treatment of acute ischaemic stroke

With the greater availability of treatments for acute ischaemic stroke, including advances in endovascular therapy, personalised assessment of patients before treatment is more important than ever. Women have a higher lifetime risk of stroke; therefore, reducing potential sex differences in the acute stroke setting is crucial for the provision of equitable and fast treatment. Evidence indicates sex differences in prevalence and types of non-traditional stroke symptoms or signs, prevalence of stroke mimics, and door-to-imaging times, but no substantial differences in use of emergency medical services, stroke knowledge, eligibility for or access to thrombolysis or thrombectomy, or outcomes after either therapy. Women presenting with stroke mimics or non-traditional stroke symptoms can be misdiagnosed, which can lead to inappropriate triage, and acute treatment delays. It is essential for health-care providers to recognise possible sex differences in stroke symptoms, signs, and mimics. Future studies focused on confounders that affect treatment and outcomes, such as age and pre-stroke function, are also needed

Hyperglycemia, Ischemic Lesions, and Functional Outcomes After Intracerebral Hemorrhage

Background Ischemic lesions observed on diffusion‐weighted imaging (DWI) magnetic resonance imaging are associated with poor outcomes after intracerebral hemorrhage (ICH). We evaluated the association between hyperglycemia, ischemic lesions, and functional outcomes after ICH. Methods and Results This was a retrospective observational analysis of 1167 patients who received magnetic resonance imaging in the ERICH (Ethnic and Racial Variations in Intracerebral Hemorrhage) study. A machine learning strategy using the elastic net regularization and selection procedure was used to perform automated variable selection to identify final multivariable logistic regression models. Sensitivity analyses with alternative model development strategies were performed, and predictive performance was compared. After covariate adjustment, white matter hyperintensity score, leukocyte count on admission, and non‐Hispanic Black race (compared with non‐Hispanic White race) were associated with the presence of DWI lesions. History of ICH and ischemic stroke, presence of DWI lesions, deep ICH location (versus lobar), ICH volume, age, lower Glasgow Coma Score on admission, and medical history of diabetes were associated with poor 6‐month modified Rankin Scale outcome (4–6) after covariate adjustment. Inclusion of interactions between race and ethnicity and variables included in the final multivariable model for functional outcome improved model performance; a significant interaction between race and ethnicity and medical history of diabetes and serum blood glucose on admission was observed. Conclusions No measure of hyperglycemia or diabetes was associated with presence of DWI lesions. However, both medical history of diabetes and presence of DWI lesions were independently associated with poor functional outcomes after ICH

Risk factors for seizures after intracerebral hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

•Risk factors for late seizure after ICH: cortical location, younger age, large hematoma volume, and surgical evacuation.•Early seizure does not independently increase late seizure risk.•CAVE score is validated in a multi-ethnic/racial cohort.•CAVS has a similar predictive value and includes surgical evacuation, an independent risk factor. We aimed to identify risk factors for seizures after intracerebral hemorrhage, and to validate the prognostic value of the previously reported CAVE score (0–4 points: cortical involvement, age 10 mL, and early seizures within 7 days of hemorrhage). Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) was a prospective study of spontaneous intracerebral hemorrhage. We included patients who did not have a prior history of seizure and survived to discharge. Univariate analysis and multiple logistic regression modeling were used to identify risk factors for seizure. From 2010–2015, 3000 cases were recruited, and 2507 patients were included in this study. Seizures after hospital discharge developed in 77 patients 3.1 %). Patients with lobar (cortical) hemorrhage (OR 3.0, 95 % CI 1.8–5.0), larger hematoma volume (OR 1.5 per cm3, 95 % CI 1.2–2.0), and surgical evacuation of hematoma (OR 2.6, 95 % CI 1.4–4.8) had a higher risk of late seizure, and older patients had a lower risk (OR 0.88 per 5-year interval increase, 95 % CI 0.81–0.95). The CAVE score was highly associated with seizure development (OR 2.5 per unit score increase, 95 % CI 2.0–3.2, p < 0.0001). The CAVS score, substituting surgical evacuation for early seizure, increased the OR per unit score to 2.8 (95 % CI 2.2–3.5). Lobar hemorrhage, larger hematoma volume, younger age, and surgical evacuation are strongly associated with the development of seizures. We validated the CAVE score in a multi-ethnic population, and found the CAVS score to have similar predictive value while representing the current practice of AED use

EXPRESS: What is the Median Volume of Intracerebral Hemorrhage and is it Changing?

OBJECTIVES: Population-level estimates of the median intracerebral hemorrhage (ICH) volume would allow for the evaluation of clinical trial external validity and determination of temporal trends. We previously reported the median ICH volume in 1988. However, differences in risk factor management, neuroimaging and demographics may have affected ICH volumes. The goal of this study was to determine the median volume of ICH within a population-based cross-sectional study, including whether it has changed over time. METHODS: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke study was a population-based study of ICH among residents of the Greater Cincinnati/Northern Kentucky region from 2008 through 2012. The current study utilizes those data and compares with ICH cases from the same region in 1988. Initial CT images of the head were reviewed, and ICH volumes were calculated using consistent methodology. RESULTS: From 2008 through 2012, we identified 1117 cases of ICH. The median volume of ICH was 14.0 mL and was lower in black (11.6) than in white (15.5) patients. Median volumes of lobar and deep ICH were 28·8 mL and 9.8 mL, respectively. Median ICH volume changed significantly from 1988 to 2008-2012, with age-and-race adjusted volume decreasing from 18.3 mL to 13.76 mL (p=0.025). CONCLUSIONS: Median volume of ICH was 13.76 mL, and this should be considered in clinical trial design. Median ICH volume has apparently decreased from 1988 to 2008-2012

Abstract 211: Do Women Receive Less Aggressive Care Following Intracerebral Hemorrhage?

Background: Several studies have shown that women with ischemic stroke receive fewer proven therapies for secondary prevention. A small study found that women receive early DNR orders after intracerebral hemorrhage (ICH) more often than men ( Stroke 2013; 44: 3229) but national data regarding sex differences in ICH are lacking. Objective: To compare comorbidities and use of surgical treatments and palliative care between men and women with ICH. We tested the hypothesis that women receive less aggressive care after ICH. Methods: ERICH is a multi-center study of ICH risk factors and outcomes. We compared clinical variables, treatments (e.g., hematoma evacuation), and use of DNR orders in men compared with women. Chi square tests(categorical items) and t-tests (continuous items) were performed. Multivariable analyses assessed the likelihood of ICH surgery and/or palliative care after adjustment for variables that were significant (p<.05) in univariate analyses. Results: 2964 patients (1220 women) were analyzed. Mean age was higher in women (65.0 vs. 59.9, p<.0001). There was no sex difference in hypertension frequency but women had a higher proportion of previous stroke (24.1% vs. 19.3%, p=.002), dementia (6.1% vs. 3.4%, p=.0007), and anticoagulant use (12.8% vs. 10.1%, p=.02). Men had a higher proportion of cocaine use (10.1% vs. 4.7%, p<.0001) and higher initial SBP (187.5 mm vs. 183.5 mm, p=.007). A higher proportion of women reported living alone (23.1% vs. 18.0%, p=.0005) and a higher proportion of women had a lobar ICH (36.9% vs. 27.4%, p<.0001). After adjustment for age, dementia, prior stroke, anticoagulant use, and ICH location, there was no difference in surgical treatment between men and women (OR=0.92, 95%CI=0.67-1.26, p=.59). Although a higher proportion of women were made DNR/comfort care (19.4% vs. 15.3%, p=.003), this finding was no longer significant after adjustment for ICH score, prior stroke, and dementia (OR for male sex=.96, 95%CI=0.77-1.22, p=.76). Conclusions: Despite sex differences in several categories, no observable sex differences were found in use of surgical therapies or use of DNR/comfort care in an American population. Future work should focus on whether sex differences exist following ICH in patient-centered outcomes