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Table of Contents    
ORIGINAL ARTICLE
Year : 2020  |  Volume : 68  |  Issue : 5  |  Page : 1073-1078

Influence of Sex Difference on Distribution of Risk Factors and Etiologic Subtypes of Acute Ischemic Stroke: Reality of Facts


Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia

Date of Web Publication27-Oct-2020

Correspondence Address:
Dr. Azra Zafar
Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, 2835 King Faisal Road, Dammam 34212
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.294553

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 » Abstract 


Background and Purpose: Sex-related differences have been documented in risk factors distribution, etiologic subtypes, diagnostic evaluation, offered management, and outcome of patients with acute ischemic stroke (AIS) from all over the world. Nevertheless, studies from Saudi Arabia are lacking. This study aimed to investigate the influence of sex on distribution of risk factors and etiologic subtype of AIS in patients admitted to our hospital.
Materials and Methods: Record of patients admitted to King Fahd Hospital of the University between 2010 and 2017 with ischemic stroke (IS) were reviewed. Base line characteristics, risk factors, and etiologic subtypes according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification were compared between men and women.
Results: Among 453 patients with IS, 300 (66.2%) were men and 153 (33.7%) were women. The mean age of all patients was 61.5 ± 14.5 years. Women were older than men (P = 0.00). Hypertension (P = 0.00), atrial fibrillation (P = 0.00), and past history of stroke (P = 0.03) were more frequent in women compared to men. Fewer carotid Doppler studies (47.1 vs. 68.3%, P = 0.00) and echocardiogram (75.1 vs. 83%, P = 0.01) were done in women as compared to men. Cardioembolic etiologic subtype (26.1 vs. 17.7%) was found more frequently, whereas small vessel occlusive (23.5 vs. 31%) and large artery disease less (10.5 vs. 16.3%) frequently in women.
Conclusion: Significant sex-related differences were found in risk factors and subtypes of AIS in our cohort of patients. Findings of our study are in general comparable with studies from all over the world.


Keywords: Acute ischemic stroke, etiologic subtypes, risk factors, women
Key Message: Influence of sex difference on risk factors distribution and subtypes of AIS is a real fact. Women are more likely to have CE subtypes than men and affected at relatively greater age. Fewer diagnostic investigations are done in women compared with men.


How to cite this article:
Zafar A, Nazish S, Shahid R, Alkhamis FA, Albakr AI, Aljaafari D, Shariff EM, G Alshamrani FJ, Alabdali M. Influence of Sex Difference on Distribution of Risk Factors and Etiologic Subtypes of Acute Ischemic Stroke: Reality of Facts. Neurol India 2020;68:1073-8

How to cite this URL:
Zafar A, Nazish S, Shahid R, Alkhamis FA, Albakr AI, Aljaafari D, Shariff EM, G Alshamrani FJ, Alabdali M. Influence of Sex Difference on Distribution of Risk Factors and Etiologic Subtypes of Acute Ischemic Stroke: Reality of Facts. Neurol India [serial online] 2020 [cited 2020 Nov 26];68:1073-8. Available from: https://www.neurologyindia.com/text.asp?2020/68/5/1073/294553




Approximately, 87% of all strokes are of ischemic type and demand implementation of aggressive and effective preventive and treatment plans.[1] Sex has been recognized to have an influence on presentation, etiology, therapeutic outcome, and prognosis of AIS.[2],[3] Ischemic stroke (IS) is more prevalent in men compared with women in the general population.[4],[5] Women have manifestations of stroke, which are different from men and have worse therapeutic outcome.[6] Conventional risk factors such as hypertension, diabetes mellitus, atrial fibrillation (AF) and inflammation processes are some of the important sex-related considerations. In a recently published study, women were 6.4 years older than men and more likely to have AF and poor functional outcome at three months compared with men.[7] In another study; women were older than men, whereas obesity and hypertension were more prevalent in women than men.[8] In a study from Saudi Arabia (SA), the mean age at onset of IS in men was significantly lesser than women.[9] The difference has not only been observed in risk factors and types of IS but health-related quality of life (HRQoL) and post-stroke depression (PSD) as well. A recent review reporting the sex differences in patient-reported outcome measures after stroke (PROMS) confirmed that women experience worse HRQoL and more PSD and correlated it to advanced age at time of onset of stroke and greater severity of stroke.[10]

Understanding the sex-related complexities of IS are must in proper management care plan of such patients. Nonetheless, the studies describing the influence of sex difference on risk factors and sub-types of acute IS from SA are not available. Stroke is the leading cause of admission under the neurology service in our hospital.[11] This study aims to investigate the influence of sex on distribution of risk factors and etiologic subtype of AIS in patients admitted to our hospital.


 » Materials and Methods Top


The approval from ethical review board committee of Imam Abdulrahman Bin Faisal University was obtained for this study. This study consisted of retrospective data of patients admitted to the hospital between 2010 and 2017 with diagnosis of AIS. Medical record was retrieved through the electronic data bank system of the hospital. Charts of all patients fulfilling the diagnostic criteria for AIS defined by the World Health Organization[12] were reviewed. After excluding the patients with diagnoses other than AIS as hemorrhagic stroke, cerebral venous sinus thrombosis, transient ischemic attack (TIA), subarachnoid hemorrhage, and brain neoplasm based on CT/and MRI brain; a total of 453 patients were included in the study. Data collection method was the same as mentioned in our previous study.[9] AIS was further classified into five major etiologic categories according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification as follows: (1) large artery disease (LAD), (2) small vessel occlusive disease (SVO), (3) cardio embolic (CE), (4) stroke of other determined etiologies (OD), and (5) stroke of undetermined etiology (UD).[13] These patients were separated by sex. Age and vascular risk factors as diabetes mellitus, hypertension, dyslipidemia, current smoking, past history of stroke or TIA, coronary artery disease, valvular heart disease and AF was documented. Patients were identified as having diabetes mellitus if using anti diabetic medications or found to have serum fasting glucose level ≥126 mg/dL or Hb A1c ≥6.5%, hypertension if taking antihypertensive medications or found to have systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg and dyslipidemia if reported to use lipid lowering medications before admission or found to have fasting total cholesterol ≥240 mg/dL (6.2 mmol/L), or Triglyceride ≥200 mg/dL (2.3 mmol/L), or high density lipoprotein ≤40 mg/dL (1 mmol/L) or low density lipoprotein ≥160 mg/dL (4.1 mmol/L).[14] Routine blood sample analysis, as fasting blood sugar, Hb A1c, fasting serum lipid profile were mentioned. Work up for hypercoagulable state and vasculitis was done where needed. EKG Findings, echocardiogram, and Holter monitoring were also mentioned. CT scan/and MRI head and brain was done in all patients. Extracranial duplex, CT angiogram or MRA were done to look for significant extracranial or intracranial LAD. Stenosis ≥50% was considered as significant. Etiologic classification of stroke was done based on these results.

Data was entered and analyzed using Statistical Package for the Social Sciences software program, version 22.0 (SPSS, Chicago, Illinois). Mean and standard deviation (M ± SD) were computed for age and scaled data. Relevant descriptive statistics, frequency, and percentage were computed for vascular risk factors as diabetes mellitus, hypertension, IHD, dyslipidemia, AF, smoking, and previous history of stroke and TIA. Descriptive data were analyzed using either t tests, the rank-sum test, or χ2-based tests as appropriate. Age was compared among the stroke subtypes using one-way analysis of variance. Chi-square test was used to check proportion between men and women for qualitative variables and the limit of statistical significance was set at P value less than 0.05.


 » Results Top


Data of 453 patients were included. Of these, 300 (66.2%) were men and 153 (33.7%) women with M: F of nearly 2:1. The mean ± SD age of all patients was 61.5 ± 14.5 years. The mean age of women was greater than that of men (65.9 ± 15.5 vs. 59.2 ± 13.4; P = 0.00). Women outnumbered men significantly in higher age groups. Sex distribution in different age groups has been shown in [Figure 1]. Distribution of different risk factors for AIS was analyzed according to the sex. Demographic characteristics, vascular risk factors and etiologic subtypes of acute ischemic stroke in males and females are detailed in [Table 1]. The predominant risk factors for AIS in women were the hypertension, found in 87.2% compared to 73.6% men (P = 0.00) and AF; 40% in women compared with 20.3% in men (P = 0.00; odds ratio [OR], 1.96; 95% CI, 1.27–3.04). Past history of stroke was statistically more frequent in women than men (P = 0.03). Current smoking was also significantly different in both sexes as it was found in nearly 10% of men compared with only 1.9% women (P = 0.00) No significant difference was found in prevalence of diabetes mellitus, history of coronary artery disease, and dyslipidemia in both sexes. On multivariate analysis; arterial hypertension, AF, previous history of stroke, previous history of TIA and current smoking were different in both sexes. Women were less likely to have previous history of TIA than men (OR, 1.02, 95% CI, 1.00–1.04). Baseline biochemical values for fasting glucose, lipid profiles and other relevant investigations in males and females are detailed in [Table 2]. Mean values for LDL and TG were higher whereas HDL were lesser in men compared with women. Echocardiogram and Carotid Doppler studies were carried out less frequently in women compared with men (P = 0.001 and 0.00 respectively).
Figure 1: Gender distribution according to different age groups

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Table 1: Demographic characteristics, vascular risk factors and etiologic subtypes of acute ischemic stroke in males and females


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Table 2: Baseline biochemical values for fasting glucose and lipid profiles along with other relevant investigations in males and females


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Etiologic subtypes of AIS varied significantly according to the sex as shown in [Figure 2]. There were more UD strokes in women than in men (33.3% vs. 28.3%). Women suffered CE strokes (26.1% vs. 17.7%; P = 0.024; OR, 1.48; 95% CI, 1.03–2.12) statistically more frequently than men. Other etiologic subtypes, that is, LAD (10.5% vs. 16.3%; P = 0.05; OR, 0.64; 95% CI, 0.37–1.08) and SVO (23.5% vs. 31.0%; P = 0.05; OR, 0.75; 95% CI, 0.54–1.05) were less frequent in women compared with men. Possible causes for cardioembolic sources were AF either isolated or in combination with valve disease or cardiomyopathy in 64; valvular heart disease, 13; clot, 19; akinetic left ventricular segment, 2; dilated cardiomyopathy, 5; and patent foramen ovale, 3.
Figure 2: Etiologic subtypes of acute ischemic stroke according to TOAST classification in males and females

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 » Discussion Top


In this study, men (66.2%) outnumbered the women and this is similar to previous studies.[4],[5],[15],[16],[17] Although men have the higher age specific rate for IS, women have the higher life time risk for stroke.[18] Stroke is more common among men than women although the difference seems to decrease with increasing age.[19] The positive effect of estrogen on cerebral vasculature might be one of the reasons for women to have lower incidence for stroke than men,[20] which may protect them against IS excluding the CE etiology.[21] An incidence rate of 8.84 for men and 13.24 for women per 100,000 population has been reported from SA.[22] Men were more common than women in age group less than 71 years, the difference declined in 71–80 years and women outnumbered the men above 80 years of age group in our cohort of patients. Age is an important non-adjustable risk factor which plays a key role in determining sex-related differences observed in epidemiology of IS. Life expectancy is greater in women, and more of women than men live in ages known to have increased risk for IS.[23] Appelros et al.[19] have reported the mean age of first IS 68.6 years for men and 72.9 years for women. Studies from SA have reported that stroke is most frequent in the 61–70 years age group.[24],[25] We found it more frequently between 51 and 60 years of age and this finding reflects that younger age group is now getting affected more by stroke than observed in the past. The mean age for women was 65.8 ± 5.3 years at onset of stroke and this is lesser than studies from Japan (75.0 ± 11.7 years)[15] and Sweden; 80.4 years (Lund, Sweden)[19] but comparable to Brazil (65.3 ± 12.1).[26] Studies from Eastern Europe (Novosibirsk, Tartu, Uzhgorod, Tblisi) for stroke in women average at 69.1 years, from Western Europe 76.0 years, and from North America and Australasia average 73.3 years.[19] In a systematic review including epidemiological studies, mainly based on Western European surveys; the mean age at first-ever stroke was 68.6 years among men, compared to 72.9 years among women. Authors stated that women get first stroke on an average at age nearly four and a half years later than men.[19] Women were on average approximately seven years older than men at the time of onset of stroke in our study which is nearly similar to studies from Spain and Japan.[7],[15]

Significant sex difference has been observed in stroke evaluation as well in studies. In an American study; 71% of men with IS compared with 62% of women had their carotid arteries evaluation, and 57% of men had echocardiography vs. 48% of women. No difference was observed in MRI utilization rates.[27] Similar observation was made in an European study; Carotid duplex imaging, echocardiography, and angiography were done less frequently in women with stroke than men.[4] Carotid Doppler studies and echocardiogram were done less frequently in women than men in our study as well.

Concerning the risk factors for acute stroke, women were found to have hypertension more commonly and smoking less commonly than men, which is in agreement with other studies.[7],[16],[28] Hypertension and dyslipidemia were more common in women vs in men in a study by Maeda et al.[15] as well. Other studies have reported women to have diabetes mellitus[15],[28] and past history of stroke less commonly than men.[15] We did not find any statistically significant difference on univariate analysis for diabetes mellitus which is similar to finding by Rodrguez-Castro et al.[7] Previous history of stroke was more frequent in women than men in our patients and this could be explained by the fact that the women have higher life time risk of stroke in comparison with men and are therefore more likely to suffer from recurrent stroke events.[18] AF is found more frequently in women compared to men with IS[4],[8],[18] and has been identified as an independent predictor for worse outcome after stroke.[29],[30] Despite knowing the fact about poor outcome after stroke in women with AF, oral anticoagulation is not prescribed regularly in women which further increases the risk of CE events in them.[31] AF was found significantly more commonly in women compared with men (P = 0.00) in our patients as well. Regarding stroke etiology; statistically significant difference was identified between both sexes (P = 0.02). CE was observed more frequently, whereas SVO and LAD subtypes less frequently in women than men. Higher frequency of AF in women is the likely reason for increased prevalence of CE stroke in women. Other studies have also reported women having higher frequency of CE and lesser frequency of SVO subtype.[3],[16] Patients with stroke due to AF not only have poor prognosis, but an increased rate of complications and a higher in-hospital mortality than patients with stroke not having AF.[32] Greater number of women were categorized as Stroke of UD than men. This could be explained by fewer echocardiogram and carotid Doppler studies in women than men leading to incomplete diagnostic work up. The higher frequency of LAD etiologic subtype observed in men compared with women is similar to other studies.[16],[33],[34] Higher frequency of active smoking in men can be the possible explanation which is a recognized risk factor for atherothrombotic stroke.[16]

The major limitation of our study is its retrospective data collection. The difference in clinical presentations, given treatment, and outcome could not be studied because of deficiencies in documentation. Despite its limitations, significant differences in risk factors distribution and types of stroke between men and women have been highlighted in our study population. We have compared our findings with literature from other parts of the world and shown our data in detail as literature from SA on this important aspect of stroke is deficient. Furthermore, as the difference in outcome after IS has also been reported worse in women than men,[35] future studies are required in relevance to this subject including multicenter and population based studies.


 » Conclusion Top


Significant sex-related differences were observed in risk factor distribution and etiologic subtypes of AIS. Women were older and had higher frequency of hypertension, AF, and past history of stroke than men. Women were more likely to have CE etiologic subtypes of IS than men. SVO and LAD etiologic subtypes were observed less frequently in women than men. This study from KSA has highlighted the importance of sex-related difference in AIS as a primary objective. The effect of sex difference on AIS in our region from KSA is not different from the rest of world despite having different culture.

There is a need to design further studies including multicenter and population-based studies addressing the differences in clinical features, offered treatment (including thrombolysis, anticoagulation and intervention) and outcome between women and men with AIS.

Acknowledgement

This research made use of the computational resources and technical services provided by the Scientific and High Performance Computing Center at Imam Abdulrahman Bin Faisal University.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Executive summary: Heart disease and stroke statistics--2014 update: A report from the American Heart Association. Circulation 2014;129:399-410.  Back to cited text no. 1
    
2.
Gibson CL. Cerebral ischemic stroke: Is gender important? J Cereb Blood Flow Metabo 2013;33:1355-61.  Back to cited text no. 2
    
3.
Yesilot NF, Koyuncu BA, Coban O, Tuncay R, Bahar SZ. Gender differences in acute stroke: Istanbul medical school stroke registry. Neurol India 2011;59:174-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
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.  Back to cited text no. 4
    
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.  Back to cited text no. 5
    
6.
Kapral MK, Degani N, Hall R, Fang J, Saposnik G, Richards J, et al. Gender differences in acute stroke care and outcome in Ontario. Women Health Issues 2011;21:171-6.  Back to cited text no. 6
    
7.
Rodríguez-Castro E, Rodríguez-Yáñez M, Arias S, Santamaría M, López-Dequidt I, López-Loureiro I, et al. Influence of sex on stroke prognosis: A demographic, clinical, and molecular analysis. Front Neurol 2019;10:388.  Back to cited text no. 7
    
8.
Arboix A, Blanco-Rojas L, Oliveres M, García-Eroles L, Comes E, Massons J. Clinical characteristics of acute lacunar stroke in women: Emphasis on gender differences. Acta Neurol Belg 2014;114:107-12.  Back to cited text no. 8
    
9.
Zafar A, Al-Khamis FA, Al-Bakr AI, Alsulaiman AA, Msmar AH. Risk factors and subtypes of acute ischemic stroke. A study at King Fahd Hospital of the University. Neurosciences (Riyadh) 2016;21:246-51.  Back to cited text no. 9
    
10.
Gall S, Phan H, Madsen TE, Reeves M, Rist P, Jimenez M, et al. Focused update of sex differences in patient reported outcome measures after stroke. Stroke 2018;49:531-5.  Back to cited text no. 10
    
11.
Zafar A, Alabdali M, Shahid R, Aljaafari D, Al-khamis FA, Albakr AI, et al. Stroke and seizure continue to be the major brunt of in patient neurology care; An observation from teaching hospital. Neurosciences 2018;23:13-7.  Back to cited text no. 11
    
12.
Aho K, Harmsen P, Hatano S, Marquardsen J, Simirnov WE, Strasser T. Cerebrovascular disease in the community: Results of a WHO collaborative study. Bull World Health Organ 1980;58:113-30.  Back to cited text no. 12
    
13.
Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35-41.  Back to cited text no. 13
    
14.
Kim YD, Jung YH, Saposnik G. Traditional risk factors for stroke in East Asia. J Stroke 18;2016:273-85.  Back to cited text no. 14
    
15.
Maeda K, Toyoda K, Minematsu K, Kobayashi S; Japan Standard Stroke Registry Study Group. Effects of sex difference on clinical features of acute ischemic stroke in Japan. J Stroke Cerebrovasc Dis 2013;22:1070-5.  Back to cited text no. 15
    
16.
Roquer J, Campello AR, Gomis M. Sex Differences in first-ever acute stroke. Stroke 2003;34:1581-5.  Back to cited text no. 16
    
17.
Awada A, Al Rajeh S. The Saudi Stroke Data Bank: Analysis of the first 1000 case. Acta Neurol Scund 1999;100:265-9.  Back to cited text no. 17
    
18.
Reeves MJ, Bushnell CD, Howard G, Gargano JW, Duncan PW, Lynch G, et al. Sex differences in stroke: Epidemiology, clinical presentation, medical care, and outcomes. Lancet Neurol 2008;7:915-26.  Back to cited text no. 18
    
19.
Appelros P, Stegmayr B, Terént A. Sex differences in stroke epidemiology: A systematic review. Stroke 2009;40:1082-90.  Back to cited text no. 19
    
20.
Krause DN, Duckles SP, Pelligrino DA. Influence of sex steroid hormones on cerebrovascular function. J Appl Physiol 2006;101:1252-61.  Back to cited text no. 20
    
21.
de Leciñana MA, Egido JA, Fernández C, Martinez-Vila E, Santos S, Morales A, et al. Risk of ischemic stroke and lifetime estrogen exposure. Neurology 2007;68:33-8.  Back to cited text no. 21
    
22.
Al-Rajeh S, Bademosi O, Ismail H, Awada A, Dawodu A, al-Freihi H, et al. A community survey of neurological disorders in Saudi Arabia: The Thugbah study. Neuroepidemiology 1993;12:164-78.  Back to cited text no. 22
    
23.
Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics-2017 update: A report from the American Heart Association. Circulation 2017;135:e146-603.  Back to cited text no. 23
    
24.
Al-Jadid MS, Robert AA. Determinants of length of stay in an inpatient stroke rehabilitation unit in Saudi Arabia. Saudi Med J 2010;31:189-92.  Back to cited text no. 24
    
25.
Al-Eithan MH, Amin M, Robert AA. The effect of hemiplegia/hemiparesis, diabetes mellitus, and hypertension on hospital length of stay after stroke. Neurosciences (Riyadh) 2011;16:253-6.  Back to cited text no. 25
    
26.
Minelli C, Fen LF, Minelli DP. Stroke incidence, prognosis, 30-day, and 1-year case fatality rates in Matão, Brazil: A population-based prospective study. Stroke 2007;38:2906-11.  Back to cited text no. 26
    
27.
Smith MA, Lisabeth LD, Brown DL, Morgenstern LB. Gender comparisons of diagnostic evaluation for ischemic stroke patients. Neurology 2005;65:855-8.  Back to cited text no. 27
    
28.
Eriksson M, Glader EL, Norrving B, Terént A, Stegmayr B. Sex differences in stroke care and outcome in the Swedish national quality register for stroke care. Stroke 2009;40:909-14.  Back to cited text no. 28
    
29.
Bailey AL, Scantlebury DC, Smyth SS. Thrombosis and antithrombotic therapy in women. Arterioscler Thromb Vasc Biol 2009;29:284-8.  Back to cited text no. 29
    
30.
Glader EL, Stegmayr B, Norrving B, Terent 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.  Back to cited text no. 30
    
31.
Cheng EY, Kong MH. Gender differences of thromboembolic events in atrial fibrillation. Am J Cardiol 2016;117:1021-7.  Back to cited text no. 31
    
32.
Steger C, Pratter A, Martinek-Bregel M, Avanzini M, Valentin A, Slany J, et al. Stroke patients with atrial fibrillation have a worse prognosis than patients without: Data from the Austrian Stroke registry. Eur Heart J 2004;25:1734-40.  Back to cited text no. 32
    
33.
Grau AJ, Weimar C, Buggle F, Heinrich A, Goertler M, Neumaier S, et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: The German Stroke Data Bank. Stroke 2001;32:2559-66.  Back to cited text no. 33
    
34.
Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO. Ischemic stroke subtypes: A population-based study of incidence and risk factors. Stroke 1999;30:2513-6.  Back to cited text no. 34
    
35.
Phan HT, Blizzard CL, Reeves MJ, Thrift AG, Cadilhac D, Sturm J, et al. Sex differences in long-term mortality after stroke in the INSTRUCT (INternational STRoke oUtComes sTudy): A meta-analysis of individualparticipant data. Circ Cardiovasc Qual Outcomes 2017;10:e003436.  Back to cited text no. 35
    


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