The paradox for women emerges in the imaging of ischemic stroke

LOS ANGELES – Although women seem to have more favorable vascular and hemodynamic measures after an ischemic stroke than men, on the whole, they present worse functional results, they demonstrate new evidence. The results suggest that other factors could drive this inconsistency.

Women “had smaller penumbra, better collaterals, and slower lesion growth, but still, paradoxically, had worse outcomes than men” at 90 days, Steven Warach, MD, PhD, said here at the International Stroke Conference (ISC) 2020.

“This was true even among those who have achieved satisfactory recanalization,” he added.

The findings were also published online in the February 2020 issue of Stroke.

Blow Blow Differently

Sexual differences in ischemic stroke are well known, said Warach, a professor of neurology at the University of Texas at Austin Dell Medical School. “In general, women have more severe strokes with worse clinical outcomes.”

In addition, women were more likely to experience a large vessel occlusion and penumbral discrepancy in the first 24 hours after stroke onset than men in previous evaluation work by the National Institute for Neurological Disorders and the database of stroke injuries.

There may also be differences in how women and men respond to thrombolytic and endovascular treatment, he said. “But the published data have been inconsistent.”

In search of a more definitive answer, Warach, lead author Adrienne Dula, PhD and colleagues performed a sub-analysis of the endovascular therapy study after assessing ischemic stroke imaging (DEFUSE 3). They wanted to determine whether baseline sexual differences in core and penumbra imaging measures predict outcome or differential response to endovascular therapy.

They rated 182 adults – 92 women and 90 men. At baseline, participants in DEFUSE 3 had a National Institutes of Health Stroke Scale (NIHSS) score of 6 or greater and a modified Rankin Scale (mRS) score of 2 or less.

Overall, women had a lower median mean volume than men at baseline, 8.0 ml versus 12.6 ml. The difference was not significant (P = .087).

The women also had a median perfusion deficit lower than baseline, 89 ml, compared to 134 ml among men, defined by a delay threshold Tmax of 6 seconds. This difference was statistically significant (P <.001).

Another favorable outcome for women was better collateral function, reflected by a lower median hypoperfusion intensity ratio, 0.31, compared to 0.39 in men (P = .006).

Key findings

At 24 hours from the onset of stroke, women had significantly lower ischemic nucleus growth, a median of 22 ml, compared to 42 ml in men (P <.001).

In contrast, reperfusion volumes did not differ significantly by gender (P = .407).

The researchers also assessed the results between the sexes if they received medical or endovascular treatment.

“In the medical treatment arm, the results were very similar to the overall sample,” he said, including women with a smaller ischemic core and men who experience greater injury growth in 24 hours.

Investigators found no difference between sexes undergoing medical treatment regarding MRS scores or 90-day functional independence. Furthermore, the results did not differ based on the randomization time.

More noticeable differences emerged, however, between women and men undergoing endovascular therapy plus medical care.

“The women had a modified Rankin Scale score worse at 90 days,” Warach said. The mean mRS scores at this point were 3.5 in women compared to 2 for men, despite similar NIHSS scores and mRS results at discharge.

In addition, fewer women undergoing endovascular therapy and successful recanalization achieved functional independence at 90 days, 36%, compared to 67% of men (P = .016).

The randomization and recanalization time also differed in this group, which “was about 90 minutes longer in women than men.”

Warach has repeatedly stressed that endovascular therapy was associated with an overall benefit regardless of gender. “Both men and women showed a benefit for thrombectomy over control, but in the thrombectomy group, however, women had a worse clinical outcome than men.”

The limitations of the study include its post hoc design, which means that there may have been unexplained factors that could help explain the paradox for women.

Going forward, Warach said, “with the support of the lone star stroke research consortium, we initiated a prospective observational study of basic multimodal imaging to determine whether sexual differences in vascularization and hemodynamics predict differences in outcomes.”

“Women should do better”

“We have known for some time that men and women treat stroke differently,” session moderator Justin F. Fraser, MD, director of cerebrovascular surgery in the Department of Neurological Surgery at the UK’s HealthCare at the University from Kentucky to Lexington Medscape medical news. “There has been growing interest in really trying to dig into this.”

For example, although previous studies evaluating uric acid for neuroprotection after stroke appeared to be unsuccessful, “when you delved into the data, it worked for one sex but not the other,” he added.

More work is needed to assess the differences in treatment outcomes by gender. “You have seen that today with the paradox – according to prediction models, women should do better but they are getting worse.”

The study was funded by the National Institute of Neurological Disorders and Stroke (NINDS) and support for Dula from the Lone Star Stroke Research Consortium. Warach has reported support from NINDS StrokeNet and advice for Genentech. Fraser did not disclose relevant financial reports.

International Stroke Conference (ISC) 2020. Abstract 56. Presented February 19, 2020.

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The best foods that reduce stroke risk

One of the largest studies, conducted on 418,000 people in nine European countries, suggested that different foods can contribute separately to ischemic stroke and hemorrhagic stroke.

Two types of stroke are more common: ischemic stroke that occurs when a blood clot blocks an artery that supplies blood to the brain and a hemorrhagic stroke that occurs when blood supply to the brain is stopped when a vessel blood bursts and bleeds (bleeding) in your brain. When there is bleeding in the brain, it damages nearby cells.

Researchers, including those from the University of Oxford in the UK, said that higher intake of fruit, vegetables, fiber, milk, cheese or yogurt could be linked to a lower risk of ischemic stroke, but there was no association significant with a lower risk of hemorrhagic stroke. Eating more eggs may be linked to an increased risk of suffering from a hemorrhagic stroke, but not an ischemic stroke.

“The most important finding is that increased consumption of dietary fiber and fruit and vegetables was strongly associated with lower risk of ischemic stroke, which supports current European guidelines,” said Tammy Tong, first author of the Oxford University study. .

“The public should be recommended to increase their consumption of fiber and fruit and vegetables if they are not already following these guidelines,” said Tong.

According to the study, published in the European Heart Journal, the total amount of fiber that people ate was associated with the maximum potential reduction in the risk of ischemic stroke.

He observed that every 10 grams (g) an increase in fiber intake per day was associated with a 23% lower risk of ischemic stroke, which, according to the researchers, equates to approximately two fewer cases per 1000 of the population in the span of ten years.

They said that fruits and vegetables alone were associated with a 13% lower risk for every 200 g consumed per day.

The researchers also said that for every 20g more eggs consumed per day there was a 25% greater risk of hemorrhagic stroke.

Tong and his team suspect that the associations they found between different foods and ischemic and hemorrhagic strokes could be explained in part by the effects on blood pressure and cholesterol.

They analyzed data from 418,329 men and women in nine European countries including Denmark, Germany and Greece, who completed questionnaires asking for information on diet, lifestyle, medical history and socio-demographic factors and were followed up for an average of 12.7 years.

During this period, the study observed that there were 4281 cases of ischemic stroke and 1430 cases of hemorrhagic stroke.

According to the researchers, one of the main strengths of the study was that it included a large number of people studied in different countries over a long follow-up period.

However, the researchers noted that the study is observational and does not show that the foods studied cause an increase or decrease in the risk of ischemic or hemorrhagic stroke.

(With inputs from PTI)

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Skipping clot formers and using only mechanical clot removal can be sufficient treatment for running

Skipping tingling IV and using mechanical clot removal alone for strokes can be as good as the combination of both treatments, with less risk of brain bleeding, according to the late science presented today at the American Stroke’s International Stroke Conference 2020 Association. conference, February 19-21 in Los Angeles, is a worldwide meeting for researchers and clinicians dedicated to the science of stroke and brain health.

The use of both therapies has previously been reported to improve outcomes in acute stroke patients with large vessel occlusion. However, blood clots could cause bleeding in the brain, and no studies have examined mechanical removal of the clot alone without alteplase, the most commonly administered IV clot destruction drug, within 4.5 hours.

In a Japanese, multicenter, prospective, randomized study, approximately 200 stroke patients (mean age 74; 62% men) were assigned to remove the mechanical clot alone or to combine a bust IV clot and mechanical clot removal. At 90 days, the favorable results, based on the level of disability, were similar: 59% for those who received only the removal of the clot and 57% for those who received the combined approach. There was no difference in the mortality rates between the two groups. However, brain hemorrhage rates within 36 hours were significantly lower for the mechanical clot removal group than for the combination treatment group (34% vs. 50%, respectively).

We believe that it is not necessary to administer alteplase to dissolve the clots and that mechanical removal of the clot can be performed immediately. If we skip alteplase, we can perform mechanical thrombectomy with low risk of bleeding. “

Kentaro Suzuki, M.D., Ph.D., professor in the neurology department at Nippon Medical School Hospital in Japan

Suzuki noted that five ongoing studies, including this study, are investigating the optimal approach for stroke patients.

“The current recommendations of the American Heart Association / American Stroke Association recommend using intravenous therapy within the 4.5 hour window and then dealing with mechanical removal of the clot, if appropriate,” said Mitchell SV Elkind, MD, MS, FAHA, FAAN, president-elect of the American Heart Association, former president of the American Stroke Association advisory board – a division of the American Heart Association and professor of neurology and epidemiology at Columbia University in New York and attending neurologist at the Columbia University Medical Center of New York- Presbyterian Hospital.

“The best strategy is usually to deal [alteplase] . . . and then if the patient is eligible, the patient also undergoes endovascular therapy, “said Elkind.” But [we] do not skip this initial step because endovascular therapy is sometimes delayed or does not occur for some reason. “

Source:

American Heart Association

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