Acute ischemic stroke (AIS) is one of the leading causes of morbidity and mortality worldwide. Gender has emerged as a significant factor influencing stroke incidence, etiology, severity, and outcomes. Numerous studies in different countries have examined the impact of gender on the occurrence and outcomes of ischemic strokes, with varying conclusions. In particular, differences in stroke etiology between men and women have been noted, as well as variations in stroke severity, treatment response, and functional recovery. In Armenia, the Comprehensive Stroke Center at the Erebouni Medical Center (ECSC) serves as a critical facility for managing acute ischemic strokes in the frames of the National Stroke Program [1].
Stroke is the second leading cause of death globally and a major cause of long-term disability. The incidence of stroke increases with age, and while both men and women are affected, gender-related differences in stroke outcomes are evident. It is well established that ischemic stroke in women tends to occur at an older age than in men, likely due to hormonal and aging-related factors. Furthermore, the causes of ischemic stroke can differ between genders, with women more likely to experience cardioembolic strokes, while men often present with atherosclerotic subtypes [2]. The National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) are standard measures used to assess stroke severity and functional outcomes, respectively [3,4]. Reperfusion therapies, including thrombolysis and thrombectomy, have significantly improved outcomes for ischemic stroke patients, although disparities in treatment access and outcomes between genders have been observed [5].
The Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification is a widely used system to categorize the etiology of ischemic stroke [3]. It divides strokes into five subtypes. This classification allows for the identification of the underlying cause of stroke, which can inform treatment strategies and prognosis. Despite the growing recognition of the impact of gender on stroke outcomes, studies specifically from Armenia are sparse. The ECSC in Yerevan, being Armenia’s largest stroke unit, offers an ideal setting to explore this issue due to its extensive patient registry, advanced treatment capabilities, and high volume of stroke cases. This study aims to fill this gap by analyzing gender differences in the clinical characteristics, etiology, treatment, and functional outcomes of patients with acute ischemic stroke in Armenia’s largest comprehensive stroke unit [6].
METHODS
This prospective observational study was conducted at the ECSC, Yerevan, Armenia. The center serves as a referral hospital for acute stroke cases from across the country and is equipped with advanced diagnostic and therapeutic facilities, including reperfusion therapies. The study period was from September 2023 to September 2024, during which all consecutive patients diagnosed with AIS were included in the registry. Patients included in the study were those who presented with AIS and were admitted to the stroke unit during the study period. Only patients with confirmed AIS, based on clinical assessment and neuroimaging (computed tomography or magnetic resonance imaging), were included. Patients with transient ischemic attacks (TIAs), hemorrhagic strokes, or non-acute ischemic events were excluded from the analysis. Demographic and clinical data were collected from the hospital’s stroke registry, which is maintained as part of routine clinical practice. Data collected included age, gender, comorbidities (such as hypertension, diabetes, and atrial fibrillation), stroke subtype, and stroke severity at admission (measured by NIHSS) [7]. The etiology of the stroke was classified according to the TOAST criteria, and functional outcomes at discharge were evaluated using the mRS, a tool used to measure the degree of disability or dependence after a stroke [7]. Stroke severity was assessed at the time of admission using the NIHSS, a standardized scale that assesses the severity of neurological impairment on a scale from 0 to 42, with higher scores indicating more severe deficits. The NIHSS score is widely used in both clinical practice and research to quantify the severity of ischemic stroke. The etiology of the stroke was classified using the TOAST criteria (Table 1), which categorizes strokes into 5 subtypes [3].
Reperfusion therapy, including intravenous thrombolysis and mechanical thrombectomy, was administered according to established guidelines. The decision to proceed with reperfusion therapy was made based on the patient’s clinical condition, time from symptom onset, and availability of treatment resources. The mRS was used to assess functional outcomes at discharge. The mRS ranges from 0 (no symptoms) to 6 (death). A score of 0-2 indicates functional independence, while scores of 3-6 indicate varying degrees of disability or dependence. Descriptive statistics were used to summarize demographic and clinical characteristics. Continuous variables were compared using t-tests or Mann-Whitney U tests, depending on the distribution of the data, while categorical variables were compared using χ2 tests. A p-value of <0.05 was considered statistically significant.
RESULTS
A total of 1,034 patients were included in the study, of which 519 (39.8%) were female and 785 (60.2%) were male. The mean age of female patients was significantly higher than that of male patients, with a mean age of 73±10.7 years for women and 68±10.8 years for men (p=0.0001). This difference in age is consistent with the general trend that women tend to experience ischemic strokes at an older age than men. The mean NIHSS score on admission was statistically significantly higher for women (7.55±6.4) than for men (6.77±5.9), p=0.04. This suggests that women, on average, presented with more severe strokes at the time of admission compared to men. The distribution of stroke subtypes according to the TOAST criteria showed several gender-related differences. Cardioembolic strokes: women had a statistically significantly higher prevalence of cardioembolic strokes (38.2%, 198/519) compared to men (26.5%, 208/785), p=0.0001. This is in line with previous studies that suggest women are more likely to experience strokes caused by emboli from the heart, such as those due to atrial fibrillation. Atherosclerotic strokes: men had a statistically significantly higher prevalence of atherosclerotic strokes (12.4%, 97/785) compared to women (8.3%, 43/519), p=0.02. This finding supports the notion that men may have a higher burden of traditional vascular risk factors such as hypertension and smoking, which predispose them to large artery atherosclerosis. There was no significant gender difference in the prevalence of lacunar strokes, with 24.7% of men (194/785) and 21% of women (109/519) experiencing this subtype (p=0.15). The rates of reperfusion therapies, including thrombolysis and thrombectomy, were similar between genders. A total of 51.1% of women and 57.1% of men received reperfusion therapies (p=0.1). This suggests that both genders had similar access to advanced treatments, despite differences in stroke severity and etiology. The proportion of patients who achieved functional independence (mRS 0-2) at discharge was similar between genders: 25.0% (130/519) of women and 21.3% (167/785) of men (p=0.1). These results suggest that, despite differences in stroke severity and etiology, both genders experienced similar levels of recovery. In-hospital mortality was also similar between the genders, with 13.1% (68/519) of women and 11.7% (92/785) of men dying during their hospital stay (p=0.4) [8].
DISCUSSION
This study reveals several gender-related differences in the etiology of AIS. Women were more likely to experience cardioembolic strokes, while men were more likely to have strokes due to atherosclerosis. These findings are consistent with previous studies that suggest women are at greater risk for cardioembolic events, potentially due to a higher prevalence of atrial fibrillation and other cardiac conditions. Men, on the other hand, may be more prone to large artery atherosclerosis, possibly due to higher rates of smoking and hypertension [9]; in this study, they presented with more severe strokes, as indicated by their higher NIHSS scores at admission. This finding aligns with other studies showing that women tend to experience more severe strokes, possibly due to older age and the presence of comorbidities such as atrial fibrillation. Despite this, the outcomes in terms of functional independence at discharge were similar between men and women. This suggests that the comprehensive care provided at the stroke center helped mitigate potential gender disparities in recovery. The similar rates of reperfusion therapy between genders are notable. While women tend to have more severe strokes and a different stroke etiology, they had similar access to advanced therapies, including thrombolysis and thrombectomy. This finding highlights the importance of equitable healthcare practices in ensuring that all patients, regardless of gender, receive optimal care. This study has several limitations. First, it is observational, meaning that causal relationships cannot be established. Second, the study was conducted at a single center, which may limit its generalizability to other populations or healthcare settings. Additionally, while gender differences in stroke etiology and severity were examined, other factors such as socioeconomic status, access to healthcare, and lifestyle factors were not considered.
CONCLUSION
This study from Armenia’s largest comprehensive stroke center suggests that there are gender differences in the etiology of ischemic stroke, with women more likely to experience cardioembolic strokes and men more likely to have atherosclerotic strokes. Despite differences in stroke severity and etiology, access to reperfusion therapies and functional outcomes at discharge were similar between men and women. These findings highlight the importance of equitable healthcare interventions in improving stroke outcomes for both genders.
Table 1. Subtypes of stroke by etiology according to the TOAST classification system [3].
Cause | Mechanism description |
Large artery atherosclerosis | Strokes caused by the narrowing or blockage of large arteries due to atherosclerotic plaque. |
Cardioembolism | Strokes caused by emboli from the heart, often due to atrial fibrillation or other cardiac conditions. |
Small vessel disease (lacunar strokes) | Strokes caused by the occlusion of small arteries in the brain, leading to small, deep infarcts. |
Other determined causes | Strokes with a clear cause other than the three major subtypes, such as vasculitis or dissection. |
Undetermined cause | Strokes where no clear cause can be identified after extensive testing |
References
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