Sex Disparities in Mortality After Endovascular Therapy in Large Core Infarcts

In recent large core endovascular therapy (EVT) trials of large vessel occlusion acute ischemic stroke (AIS), treatment was associated with reduced rates of mortality. Because post-AIS mortality can be influenced by societal and biological factors that differ between women and men, we investigate sex-based differences in mortality outcomes following EVT in large core AIS.

From our prospectively collected multicenter registry across 4 comprehensive stroke centers in the Greater Houston area, we identified patients from 2017 to 2022 with large vessel occlusion AIS and large infarct core. Large infarct core was defined by computed tomography perfusion exceeding 70 mL (by regional cerebral blood flow measurements using automated postprocessing) or computed tomography Alberta Stroke Program Early CT [Computed Tomography] Score<6. The primary outcome of this study was the likelihood of mortality at 90 days, determined through multivariable logistic regression adjusted for EVT, sex, and EVT/sex interaction term. Secondary outcomes included 90-day disability outcomes and intracerebral hemorrhage.

Among 190 patients who met inclusion criteria, 50% were female and 45.3% received EVT. Demographic differences between the sexes were largely balanced apart from the older age of presentation for women compared with men (75 versus 67, women versus men; P<0.01). In univariable analysis, women who did not receive EVT had greater mortality (27.4% difference; P<0.001) compared with men, with comparable rates in EVT-treated cohorts. In multivariable analysis, non-EVT management was strongly associated with mortality in women compared with men at discharge (odds ratio [OR] 5.81, 95% CI [1.96-17.23]) and 90-days (OR 6.77, 95% CI [2.09-21.94]). In the secondary analysis, which additionally adjusted the model for age and National Institutes of Health Stroke Scale score, these findings were unchanged. The sex/EVT interaction term showed significant interaction for mortality both at discharge and 90 days (P<0.01).

EVT in large core AIS populations may disparately reduce mortality in women compared to men.