The female stroke: Sex differences affect stroke presentation and management

The female stroke: Sex differences affect stroke presentation and management

1000 562 Shawn Haigh

Women have a unique experience when it comes to stroke. Several differences between the sexes exist in stroke; in the epidemiology of the disease, clinical presentation, medical care and patient outcomes.1 Women have more stroke events due to their greater life expectancy, and the prevalence of stroke in women is increasing rapidly, particularly among older women.1 At this year’s “Stroke Summer School 2021” in Basel, Switzerland, Christine Kremer (Department of Neurology, Skåne University Hospital, Sweden) gave a presentation on stroke in women, detailing sex differences at all stages of stroke management.


Differences in presentation and aetiology

To open her talk, Prof. Kremer noted that stroke presentation and mortality differ greatly between the two sexes. Women have higher rates of non-traditional stroke signs and symptoms, more stroke mimics, and greater treatment delays.2 Prof. Kremer remarked that women have greater associations between stroke and vascular risk factors, including diabetes, metabolic syndrome and smoking.


Prof. Kremer also asked her audience to consider the causes of stroke, as this is another aspect of the disease that differs between men and women. She cited a 2009 study, which found that while large and small vessel disease was a more frequent cause of stroke in men, cardio embolism was found more frequently in women.3 Atrial fibrillation was also found to be significantly higher in women than in men.3


Stroke in pregnancy

While women often have a more complicated experience with stroke than men, even greater complications can arise with pregnancy, as Prof. Kremer suggests. Stroke is estimated to affect 30 women for every 100,000 pregnancies.4 Pregnant women have a 13-fold greater risk of stroke than nonpregnant women, according to Prof. Kremer. She also notes that there are increases in risk for dangerous conditions during pregnancy and postpartum, such as preeclampsia and cerebral venous thrombosis.



Next, Prof. Kremer discussed outcomes in stroke, which can also differ between men and women. She remarked that women have more severe strokes than men, but also receive less aggressive treatment. Women are more likely to experience post-stroke depression and have a higher risk of cognitive impairment due to stroke than men.5 There is a higher prevalence of atrial fibrillation in women than in men, and women have a greater risk of functional dependency and stroke recurrence.6


Future directions

To conclude her presentation, Prof. Kremer presented some ideas and hopes for the future of stroke research and management, specifically for women.  In everyday stroke care, she hopes that more individualised monitoring and follow-up will be considered for female stroke patients. Prof. Kremer cites an underrepresentation of women in randomised clinical trials, and a general exclusion of older women. She believes that future research should look to bridge these gaps, along with performing sex-specific analyses to further elucidate the uniqueness of the female stroke.


  1. Reeves J et al. Lancet Neurol. 2008;10: 915–26
  2. Bushnell C et al. Lancet Neurol. 2018;17: 641–65
  3. Förster A et al. Stroke. 2009;40:2428–32
  4. McDermott M et al. Stroke. 2018;49:524–30.
  5. Gall S et al. Stroke. 2018;49:531–53
  6. Hong Y et al. Front Neurol. 2017;8:166
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