한빛사논문
Wi-Sun Ryu, MD, PhD,* Jinyong Chung, PhD,* Dawid Schellingerhout, MD, Sang-Wuk Jeong, MD, PhD, Hang-Rai Kim, MD, PhD, Jung E. Park, MD, PhD, Beom Joon Kim, MD, PhD, Joon-Tae Kim, MD, PhD, Keun-Sik Hong, MD, PhD, Kyungbok Lee, MD, PhD, Tai Hwan Park, MD, PhD, Sang-Soon Park, MD, Jong-Moo Park, MD, PhD, Kyusik Kang, MD, PhD, Yong-Jin Cho, MD, PhD, Hong-Kyun Park, MD, MSc, Byung-Chul Lee, MD, PhD, Kyung-Ho Yu, MD, PhD, Mi Sun Oh, MD, PhD, Soo Joo Lee, MD, PhD, Jae Guk Kim, MD, MSc, Jae-Kwan Cha, MD, PhD, Dae-Hyun Kim, MD, PhD, Jun Lee, MD, PhD, Moon-Ku Han, MD, PhD, Man Seok Park, MD, Kang-Ho Choi, MD, PhD, Juneyoung Lee, PhD, Hee-Joon Bae, MD, PhD, and Dong-Eog Kim, MD, PhD
From the Department of Neurology (W.-S.R., S.-W.J., H.-R.K., J.E.P., D.-E.K.), Dongguk University Ilsan Hospital; National Priority Research Center for Stroke (W.-S.R., J.C., D.-E.K.),
Goyang, South Korea; Departments of Neuroradiology and Imaging Physics (D.S.), University of Texas MD Anderson Cancer Center, Houston; Department of Neurology (B.J.K., M.-
K.H., H.-J.B.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam; Department of Neurology (J.-T.K., M.S.P., K.-H.C.), Chonnam
National University Hospital, Gwangju; Department of Neurology (K.-S.H., Y.-J.C., H.-K.P.), Inje University Ilsan Paik Hospital, Goyang; Department of Neurology (K.L.), Soonchunhyang University Hospital, Seoul; Department of Neurology (T.H.P., S.-S.P.), Seoul Medical Center; Department of Neurology (J.-M.P.), Uijeongbu Eulji Medical Center; Department of Neurology (K.K.), Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul; Department of Neurology (B.-C.L., K.-H.Y., M.S.O.), Hallym University Sacred Heart Hospital, Anyang; Department of Neurology (S.J.L., J.G.K.), Eulji University Hospital, Daejeon; Department of Neurology (J.-K.C., D.-H.K.), Dong-A University Hospital, Busan; Department of Neurology (Jun Lee), Yeungnam University Hospital, Daegu; and Department of Biostatistics (Juneyoung Lee), Korea University, Seoul, South Korea.
*These authors contributed equally to this work as cofirst authors
Correspondence : Dr. Kim
Abstract
Background and objectives: Female patients tend to have greater disability and worse long-term outcomes after stroke than male patients. To date, the biological basis of sex difference in ischemic stroke remains unclear. We aimed to (1) assess sex differences in clinical manifestation and outcomes of acute ischemic stroke and (2) investigate whether the sex disparity is due to different infarct locations or different impacts of infarct in the same location.
Methods: This MRI-based multicenter study included 6,464 consecutive patients with acute ischemic stroke (<7 days) from 11 centers in South Korea (May 2011-January 2013). Multivariable statistical and brain mapping methods were used to analyze clinical and imaging data collected prospectively: admission NIH Stroke Scale (NIHSS) score, early neurologic deterioration (END) within 3 weeks, modified Rankin Scale (mRS) score at 3 months, and culprit cerebrovascular lesion (symptomatic large artery steno-occlusion and cerebral infarction) locations.
Results: The mean (SD) age was 67.5 (12.6) years, and 2,641 (40.9%) were female patients. Percentage infarct volumes on diffusion-weighted MRI did not differ between female patients and male patients (median 0.14% vs 0.14%, p = 0.35). However, female patients showed higher stroke severity (NIHSS score, median 4 vs 3, p < 0.001) and had more frequent END (adjusted difference 3.5%; p = 0.002) than male patients. Female patients had more frequent striatocapsular lesions (43.6% vs 39.8%, p = 0.001) and less frequent cerebrocortical (48.2% vs. 50.7% in patients older than 52 years, p = 0.06) and cerebellar (9.1% vs. 11.1%, p = 0.009) lesions than male patients, which aligned with angiographic findings: female patients had more prevalent symptomatic steno-occlusion of the middle cerebral artery (MCA) (31.1% vs 25.3%; p < 0.001) compared with male patients, who had more frequent symptomatic steno-occlusion of the extracranial internal carotid artery (14.2% vs 9.3%; p < 0.001) and vertebral artery (6.5% vs 4.7%; p = 0.001). Cortical infarcts in female patients, specifically left-sided parieto-occipital regions, were associated with higher NIHSS scores than expected for similar infarct volumes in male patients. Consequently, female patients had a higher likelihood of unfavorable functional outcome (mRS score >2) than male patients (adjusted absolute difference 4.5%; 95% CI 2.0-7.0; p < 0.001).
Discussion: Female patients have more frequent MCA disease and striatocapsular motor pathway involvement with acute ischemic stroke, along with left parieto-occipital cortical infarcts showing greater severity for equivalent infarct volumes than in male patients. This leads to more severe initial neurologic symptoms, higher susceptibility to neurologic worsening, and less 3-month functional independence, when compared with male patients.
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