|Year : 2018 | Volume
| Issue : 2 | Page : 51-55
Gender differences in risk factors, clinical presentation, and outcome of stroke: A secondary analysis of previous hospital-based study in Qatar
Fahmi Yousef Khan1, Abdulsalam Saif Ibrahim2
1 Department of Medicine, Hamad General Hospital, Doha, Qatar
2 Department of Medicine and Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
|Date of Web Publication||29-Jun-2018|
Dr. Fahmi Yousef Khan
Department of Medicine, Hamad General Hospital, PO Box 3050, Doha
Source of Support: None, Conflict of Interest: None
Objectives: The aim of this study was to describe gender differences in stroke risk factors, clinical presentation, and outcome in Qatar. Subjects and Methods: This is a secondary post hoc analysis of our previous prospective observational hospital-based study with new objective. Results: Among the 270 patients involved in this study, there were 198 (73%) males and 72 (27%) females. Two hundred and seventeen (80.4%) patients had ischemic strokes, whereas 53 (19.6%) patients had hemorrhagic stroke. Patients with hemorrhagic stroke showed no significant gender difference in their stroke profile. On the other hand, male patients with ischemic stroke were more likely to have had a history of hypertension (P < 0.001), smoking (P < 0.001), and daily alcohol drinking (P < 0.001), while female patients were more likely to have had a history of diabetes mellitus (P < 0.001). Moreover, dysarthria, swallowing problems, and gait imbalance were observed with high frequency in male patients, while headache was significantly associated with females (P < 0.001). Posterior circulation stroke syndrome was observed more in male patients, whereas female patients tend to have had partial anterior circulation syndrome. In-hospital mortality rate showed no sex differences in both hemorrhagic and ischemic strokes. Conclusions: No gender differences were found in patients with hemorrhagic stroke, whereas in patients with ischemic stroke there were significant gender differences in risk factors and clinical presentation except for fatality rate.
Keywords: Gender differences, man, risk factors, stroke, woman
|How to cite this article:|
Khan FY, Ibrahim AS. Gender differences in risk factors, clinical presentation, and outcome of stroke: A secondary analysis of previous hospital-based study in Qatar. Libyan J Med Sci 2018;2:51-5
|How to cite this URL:|
Khan FY, Ibrahim AS. Gender differences in risk factors, clinical presentation, and outcome of stroke: A secondary analysis of previous hospital-based study in Qatar. Libyan J Med Sci [serial online] 2018 [cited 2018 Sep 21];2:51-5. Available from: http://www.ljmsonline.com/text.asp?2018/2/2/51/235696
| Introduction|| |
Gender difference, recognized in many clinical conditions, is multifactorial and may be the results of hormonal, genetic and/or environmental factors and may not be explainable in many occasions. Cardiovascular diseases are one of these clinical conditions that show gender-related differences. Many reports have described gender differences in the risk factors of ischemic heart disease., However, gender-related differences in risk factors, clinical presentation, and outcome of stroke remains an area of interest for many investigators worldwide. Although numerous studies have documented gender differences in patients with stroke,,,,,,,,,,,,,,,,,,,,,, these studies have shown inconsistent results. Information on gender-related differences in patients with stroke may provide useful insight for risk factor controls to improve outcomes. The aim of this study was to evaluate differences between men and women with respect to risk factors, clinical presentation, and outcome of stroke.
| Subjects and Methods|| |
This article describes a secondary post hoc analysis of our previous study entitled "stroke in Qatar: a first prospective hospital-based study of acute stroke" with a secondary objective of "gender differences in risk factors, clinical presentation, and outcome of stroke in Qatar" but the same primary outcome (in-hospital mortality).
The primary study was a prospective, observational, hospital-based study that was conducted at Hamad Medical Corporation (HMC), which serves as a tertiary referral center with many hospitals, covering all medical and surgical disciplines including 6 intensive care units and one rehabilitation center for adults. The patients included in this study were locals as well as expatriates mainly from other Arab countries and Asia; who were admitted with acute stroke between September 15, 2004 and September 15, 2005. Comparison between males and females in relation to risk factors, presenting symptoms, site of lesion, and outcome was made secondarily.
The original study was approved by Medical Research Ethical Committee at HMC, Qatar.
Statistical analysis was carried out using the software Epi Info 2000 (Centres for Disease Control and Prevention, Atlanta, GA). Quantitative variables are expressed as mean ± standard deviations. Student t-test was used for continuous variables and Mann–Whitney U-test if variables were not normally distributed. Fisher exact test or Chi-square test was used when appropriate to compare between males and females in relation to risk factors, clinical presentation, and outcome. Results were considered significant if the P < 0.05.
| Results|| |
Among the 270 patients involved in this study, there were 198 (73%) male and 72 (27%) female. The mean age was 57.1 ± 13.3 years (range of 17–93 years). Females had significantly higher mean age than males (61.3 ± 14.0 versus 55.6 ± 12.7, P = 0.002). Two hundred and seventeen (80.4%) patients had ischemic strokes, whereas 53 (19.6%) patients had hemorrhagic stroke [Table 1] and [Table 2].
|Table 1: Comparison between male and female patients with hemorrhagic stroke|
Click here to view
|Table 2: Comparison between male and female patients with ischemic stroke|
Click here to view
A total of 53 patients were admitted with hemorrhagic stroke. The age was 56.9 ± 13.4 (range 26–93 years). Primary intracerebral hemorrhage was found in 88.7% (47 patients; 35 males and 12 females), and subarachnoid hemorrhage occurred in 11.3% (6 patients; 5 males and 1 female). The occurrence of hemorrhagic stroke in different age groups showed no significant differences between both sexes; moreover, there were no significant differences between males and females with respect to clinical presentation, risk factors, stroke subtypes, complications, and outcome [Table 1].
A total of 217 patients had ischemic stroke. The mean age was 57.2 ± 13.3 years (range 17–91 years). Males formed 157 (71.4%) and females formed 60 (27.6%). A significant increase was noted in the number of women between 45 and 60 years (P = 0.006), whereas the number of men was significantly increased over 60 years of age (P< 0.001) [Table 2].
Regarding risk factors, male patients were more likely to have had a history of hypertension, smoking, and daily alcohol drinking. Female patients, on the other hand, were more likely to have had a history of diabetes mellitus. There were significant differences between male and female patients with respect to presenting symptoms. Speech deficit (dysarthria), swallowing, and gait imbalance were observed with high frequency in male patients, while headache was significantly associated with females. Posterior circulation stroke syndrome (POCS) was observed more in male patients, whereas female patients tended to have had partial anterior circulation syndrome. In-hospital mortality rate showed no gender differences; on the other hand, male patients were more likely to have neurological deficit at discharge. [Table 2] summarizes the major differences between males and females with respect to risk factors, clinical presentation, stroke subtypes, complications, and outcome.
| Discussion|| |
To the best of our knowledge, this is the first report, which describes gender differences in risk factors, clinical presentation, and outcome of stroke in patients living in Qatar. In this report, we found that the population of study average age of 57.1 ± 13.3 was younger than stroke patients in other studies;,,,,,,,,,,,,, moreover, the overall prevalence of stroke in this study was higher in men than in women.,,,, Consistent with many studies ,,,,,,,,,,,,, that looked at the differences between males and females; Women with stroke had significantly older average age than males, the fact that might explain the greater presence in females of risk factors that increase with age; furthermore, the contribution of unrecognized or poorly controlled risk factors may explain this population differences. However, the relative importance of genetic and environmental factors is uncertain and needs more studies.
In contrary to many studies,,, the current study showed that in patients with hemorrhagic stroke, there were no significant differences between both sexes in risk factors, clinical presentation, distribution of stroke subtypes and outcome. Gender differences in risk factors were not statistically significant in hemorrhagic stroke though hypertension which is a contributing factor in many hemorrhagic strokes were noticed more in the male group. Subarachnoid hemorrhage is reported more in females in some studies  but showed no difference in other reports  including our study. Small sample size could be the reason for "no sex differences" that observed in patients with hemorrhagic stroke in this report.
On the other hand, patients with ischemic stroke in this study showed significance gender differences in stroke risk factors, clinical presentation, subtype, and outcome. In contrary with other reports,,,,,, men more than women had a history of hypertension; moreover, men were more likely to have had a history of smoking and alcohol consumption, which was comparable with many reports.,,,,,,, In contrast, female patients in this study were more likely to have had diabetes mellitus, which coincide with some studies,,, but differ from others.,,,,, We did not find statistically significant gender differences in atrial fibrillation (AF), hyperlipidemia, coronary artery diseases, and past medical history of stroke, although some studies have found that men were more likely to have hyperlipidemia, history of heart disease ,, and past medical history of stroke,, and that women were more likely to have AF.,,,,,
Clinical findings at presentation showed significant gender differences in numerous studies. Some of these findings coincide with our study, while the others don't. Male patients in our study were more likely to present with dysarthria, dysphagia, and gait imbalance, whereas women were found to have more headache. No differences were found for aphasia, limb weakness, and urinary incontinence. Some studies have shown that females presented more with headache, loss of consciousness,, aphasia,, dysphagia,, and urinary incontinence, whereas others found that males presented more with dysarthria and gait imbalance. Although lacunar stoke syndrome, a condition commonly seen more associated with hypertension, was seen at higher percentage in our study in both sexes (31.8% in males vs. 26.7% in females), we found that men had greater proportion of POCS than women similar to some studies, whereas  women had more partial anterior circulation syndrome (PACS) than males in agreement with other reports. Prevalence of dysarthria, dysphagia, and imbalance among men compared with women in this study can be explained by the high rate of POCS among male patients, whereas greater proportion of headache among women can be explained partly by gender differences in pain perception.
Greater disability at time of discharge due to stroke in women had been observed previously,,,,, whereas outcome measures used in our studies showed more females discharged without neurological deficit. This may indicate less severity of the initial disease, and the association of more comorbid conditions in male population. or it may be attributed to either differences in stroke pathology and/or differences in functional anatomy or plasticity of the brain between genders.,,
Higher in-hospital mortality in women has been reported ,, and recent studies showed higher in-hospital complications in women.,, In-hospital complication and mortality figures in our study showed no sex differences.
This study is limited by the small population size compared to other studies that have used larger population. The role of other potential stroke risk factors such as obesity and high-density lipoprotein cholesterol could not be assessed. In addition, the functional status score at time of admission and on discharge and the outcome at 1-year follow-up could not be assessed because of lack of data in the primary study.
| Conclusions|| |
Our study showed that in patients with hemorrhagic stroke, there were no significant gender differences in risk factors, clinical presentation, distribution of stroke subtype and outcome, whereas in ischemic stroke, women more often presented with headache and had diabetes mellitus as an important risk factor. Few females were discharged with neurological deficits. Women were more likely than men to have partial anterior circulation syndrome according to the Oxfordshire Community Stroke Project. We believe that more researches should be conducted to study gender differences in a larger population and to explore the reason for these differences.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wakabayashi I. Gender differences in cardiovascular risk factors in patients with coronary artery disease and those with type 2 diabetes. J Thorac Dis 2017;9:E503-6.
Chauhan A, Moser H, McCullough LD. Sex differences in ischaemic stroke: Potential cellular mechanisms. Clin Sci (Lond) 2017;131:533-52.
Di Carlo A, Lamassa M, Baldereschi M, Pracucci G, Basile AM, Wolfe CD, et al.
Sex differences in the clinical presentation, resource use, and 3-month outcome of acute stroke in europe: Data from a multicenter multinational hospital-based registry. Stroke 2003;34:1114-9.
Holroyd-Leduc JM, Kapral MK, Austin PC, Tu JV. Sex differences and similarities in the management and outcome of stroke patients. Stroke 2000;31:1833-7.
Glader EL, Stegmayr B, Norrving B, Terént A, Hulter-Asberg K, Wester PO, et al.
Sex differences in management and outcome after stroke: A Swedish national perspective. Stroke 2003;34:1970-5.
Kapral MK, Fang J, Hill MD, Silver F, Richards J, Jaigobin C, et al.
Sex differences in stroke care and outcomes: Results from the registry of the Canadian stroke network. Stroke 2005;36:809-14.
Gargano JW, Wehner S, Reeves M. Sex differences in acute stroke care in a statewide stroke registry. Stroke 2008;39:24-9.
Barrett KM, Brott TG, Brown RD Jr., Frankel MR, Worrall BB, Silliman SL, et al.
Sex differences in stroke severity, symptoms, and deficits after first-ever ischemic stroke. J Stroke Cerebrovasc Dis 2007;16:34-9.
Simpson CR, Wilson C, Hannaford PC, Williams D. Evidence for age and sex differences in the secondary prevention of stroke in Scottish primary care. Stroke 2005;36:1771-5.
Fang MC, Singer DE, Chang Y, Hylek EM, Henault LE, Jensvold NG, et al.
Gender differences in the risk of ischemic stroke and peripheral embolism in atrial fibrillation: The anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Circulation 2005;112:1687-91.
Lai SM, Duncan PW, Dew P, Keighley J. Sex differences in stroke recovery. Prev Chronic Dis 2005;2:A13.
Berglund A, Schenck-Gustafsson K, von Euler M. Sex differences in the presentation of stroke. Maturitas 2017;99:47-50.
Jerath NU, Reddy C, Freeman WD, Jerath AU, Brown RD. Gender differences in presenting signs and symptoms of acute ischemic stroke: A population-based study. Gend Med 2011;8:312-9.
Nagaraja N, Bhattacharya P, Mada F, Salowich-Palm L, Hinton S, Millis S, et al.
Gender based differences in acute stroke care in Michigan hospitals. J Neurol Sci 2012;314:88-91.
Hinkle JL, Smith R, Revere K. A comparison of stroke risk factors between men and women with disabilities. Rehabil Nurs 2006;31:70-7.
Förster A, Gass A, Kern R, Wolf ME, Ottomeyer C, Zohsel K, et al.
Gender differences in acute ischemic stroke: Etiology, stroke patterns and response to thrombolysis. Stroke 2009;40:2428-32.
Arboix A, Oliveres M, García-Eroles L, Maragall C, Massons J, Targa C, et al.
Acute cerebrovascular disease in women. Eur Neurol 2001;45:199-205.
Roquer J, Campello AR, Gomis M. Sex differences in first-ever acute stroke. Stroke 2003;34:1581-5.
Hochner-Celnikier D, Manor O, Garbi B, Chajek-Shaul T. Gender gap in cerebrovascular accidents: Comparison of the extent, severity, and risk factors in men and women aged 45-65. Int J Fertil Womens Med 2005;50:122-8.
Worrall BB, Johnston KC, Kongable G, Hung E, Richardson D, Gorelick PB, et al.
Stroke risk factor profiles in African American women: An interim report from the African-American antiplatelet stroke prevention study. Stroke 2002;33:913-9.
Niewada M, Kobayashi A, Sandercock PA, Kamiński B, Członkowska A; International Stroke Trial Collaborative Group, et al.
Influence of gender on baseline features and clinical outcomes among 17,370 patients with confirmed ischaemic stroke in the international stroke trial. Neuroepidemiology 2005;24:123-8.
Conway SE, Roy-O'Reilly M, Friedler B, Staff I, Fortunato G, McCullough LD, et al.
Sex differences and the role of IL-10 in ischemic stroke recovery. Biol Sex Differ 2015;6:17.
Foerch C, Ghandehari K, Xu G, Kaul S. Exploring gender distribution in patients with acute stroke: A multi-national approach. J Res Med Sci 2013;18:10-6.
Santalucia P, Pezzella FR, Sessa M, Monaco S, Torgano G, Anticoli S, et al.
Sex differences in clinical presentation, severity and outcome of stroke: Results from a hospital-based registry. Eur J Intern Med 2013;24:167-71.
Khan FY, Yasin M, Abu-Khattab M, El Hiday AH, Errayes M, Lotf AK, et al.
Stroke in Qatar: A first prospective hospital-based study of acute stroke. J Stroke Cerebrovasc Dis 2008;17:69-78.
[Table 1], [Table 2]