Sex Differences in Ischemic Stroke Outcomes

Ischaemic stroke outcomes differ markedly between women and men at multiple stages, from incident events through acute severity to long-term recovery. Women tend to experience strokes at older ages, often with greater pre-existing disability and comorbidities. Biological factors such as the loss of oestrogen’s vasoprotective effects after menopause contribute to increased infarct severity and poorer functional outcomes in older women. In contrast, men more frequently present with modifiable risk factors such as smoking and heavy alcohol use at younger ages, driving higher incidence rates. Sex modifies responses to both acute therapies—thrombolysis and thrombectomy—and secondary prevention, with differential associations between lipid profiles, body mass index and recurrence risk. Moreover, anatomical lesion patterns and cerebral network asymmetries appear to underlie sex-specific variations in stroke severity and recovery trajectories. Sociocultural and healthcare system factors further compound these disparities, influencing time to presentation, access to specialised care and rehabilitation intensity. A nuanced understanding of these intersecting influences is essential to inform sex-stratified prevention, acute management and rehabilitation strategies.

Research from Nature Portfolio

Recent neuroimaging studies have applied low-dimensional lesion mapping and hierarchical modelling to acute stroke cohorts. These analyses reveal that while motor and language regions are critical in both sexes, women exhibit more widespread lesion patterns that disproportionately affect left posterior circulation territories, accounting for higher acute severity scores. This work highlights the importance of sex-specific cerebral asymmetries and suggests that tailoring reperfusion strategies and early rehabilitation to these patterns could improve outcomes in female patients.

Sex Differences in Ischemic Stroke Outcomes publication trend

The graph below shows the total number of articles in sex differences in ischemic stroke outcomes across all publications each year (not limited to Nature Index journals).

Technical terms

Ischaemic stroke: Cerebral infarction caused by arterial occlusion leading to tissue ischaemia.

Recanalisation: Restoration of blood flow through a previously occluded vessel, often by pharmacological or mechanical means.

Leptomeningeal collaterals: Secondary microvascular channels that provide alternative perfusion pathways during arterial blockage.

Bayesian hierarchical modelling: A statistical framework that estimates effects at multiple levels (e.g., individual and group) and incorporates prior information.

Modified Rankin Scale (mRS): A six-point scale assessing global disability and functional independence after stroke.

References

1. Sex differences in modifiable risk factors for stroke incidence and recurrence: the UCC-SMART study. Journal of Neurology (2024).
2. Exploring sex differences for acute ischemic stroke clinical, imaging and thrombus characteristics in the INTERRSeCT study. Cerebrovascular and Brain Metabolism Reviews (2023).
3. Outcome after acute ischemic stroke is linked to sex-specific lesion patterns. Nature Communications (2021).