Factors influencing sex differences in poststroke functional outcome
Open accessAbstract
Background and Purpose—: Our objective was to identify factors that contribute to or modify the sex difference in poststroke functional outcome. Methods—: Ischemic strokes (n=439) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project (2008–2011). Data were ascertained from interviews (baseline and 90 days post stroke) and medical records. Functional outcome was measured as an average of 22 activities of daily living (ADL)/instrumental ADL items (range, 1–4; higher scores worse function). Tobit regression was used to estimate sex differences and to identify confounding and modifying factors. Results—: Fifty-one percent were women. Median age was 71 (interquartile range, 59–80) years in women and 64 (interquartile range, 56–77) years in men. Median ADL/instrumental ADL score at 90 days was 2.7 (interquartile range, 1.8–3.6) in women and 2.0 (interquartile range, 1.3–3.1) in men ( P <0.01); this difference remained after age-adjustment ( P <0.001). Factors contributing to higher ADL/instrumental ADL scores in women included prestroke function, marital status, prestroke cognition, nursing home residence, stroke severity, history of stroke/transient ischemic attack, and body mass index; prestroke function was the largest contributor. Stroke severity modified the sex difference in outcome such that differences were apparent for mild to moderate but not severe strokes. After adjustment, women still had significantly worse functional outcome than men. Conclusions—: These findings yield insight into possible strategies and subgroups to target to reduce the sex disparity in stroke outcome; demographics and prestroke and clinical factors explained only 41% of the sex difference in stroke outcome highlighting the need for future research to identify modifiable factors that contribute to sex differences.
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Women in North America carry a larger stroke burden than men, including higher lifetime stroke risk, higher lifetime stroke death risk, and worse post-stroke outcomes.
“In North America, women bear a greater burden of disease due to a higher lifetime risk of stroke,1 a higher lifetime risk of death from stroke, and a higher risk of poor outcomes following stroke compared with men.2–4”
From Sex Differences in Physical Activity and Incident Stroke: A Systematic Review (2022) · cites this paper as [3]
The Results and Discussion report worse 90-day functional outcomes for women after stroke. They do not establish a higher lifetime risk of stroke or death from stroke; the Results instead report no sex difference in age-adjusted 90-day mortality. The Discussion also cautions that findings from one south Texas community may not generalize across North America. (LLM, conf=0.88)
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“7 Thus, in the era of endovascular thrombectomy (EVT), a treatment that has revolutionized stroke management, it is important to examine whether EVT-related care delivery and clinical outcomes differ between men and women.”
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Assessment of Sex Differences in Recovery of Motor and Sensory Impairments Poststroke
Hawe, R. L., Cluff, T., Dowlatshahi, D. D., Hill, M. D., & Dukelow, S. P. (2020) · Neurorehabilitation and neural repair · doi:10.1177/1545968320935811 · Cited by 7 · see citing works
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“The BI consists of a ten-item ordinal scale assessing performance in ADL and mobility (Mahoney and Barthel, 1965).”
The Women Independently Living Alone with a Medical Alert Device (WILMA) trial
Morgenstern, L. B., Adelman, E. E., Hughes, R., Wing, J. J., & Lisabeth, L. D. (2015) · Translational Stroke Research · doi:10.1007/s12975-015-0411-0 · Cited by 7 · see citing works
“Among those that survive stroke, functional and neurologic outcome is worse in women compared with men [3].”
BackgroundSelf-citationSex-Related Differences in Functional and Neurological Outcomes of Spinal Cord Injury
Benedict, B. C., Javeed, S., Kaleem, M., Zhang, J. K., Yakdan, S. M., Botterbush, K. S., Wen, H., Chen, Y., Belzberg, A. J., TUFFAHA, S. H., et al. (2025) · Neurosurgery · doi:10.1227/neu.0000000000003615 · Cited by 6 · see citing works
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Stroke in women: experience in a developing country
Nahas, N. M. E., Aref, H., Kenawy, F. F., Georgy, S. S., Abushady, E. M., Dawood, N. L., Hamdy, S., Abdelmohsen, N., Hamid, Y. H. A., Roushdy, T. M. E. S., et al. (2023) · BMC Neurology · doi:10.1186/s12883-023-03314-3 · Cited by 5 · see citing works
Chan, N. H., & Ng, S. S. M. (2023) · Frontiers in Neurology · doi:10.3389/fneur.2023.1248589 · Cited by 4 · see citing works
“Second, as women had significantly worse functional performance than men after stroke (48), the uneven sex ratio of the participants may have affected the results in this study.”
Resultde Miguel-Yanes, J. M., Jiménez‐García, R., López‐de‐Andrés, A., Hernández‐Barrera, V., de Miguel‐Díez, J., Méndez‐Bailón, M., Muñoz‐Rivas, N., Pérez‐Farinós, N., & López‐Herránz, M. (2021) · International Journal of Clinical Practice · doi:10.1111/ijcp.14984 · Cited by 5 · see citing works
Irie, F., Matsuo, R., Nakamura, K., Wakisaka, Y., Ago, T., Kitazono, T., Kamouchi, M., & on behalf of the Fukuoka Stroke Registry Investigators (2023) · Cerebrovascular Diseases · doi:10.1159/000526940 · Cited by 5 · see citing works
Comprehensive review on sexual dimorphism to improve scalp acupuncture in nervous system disease
Wang, C., Wang, J., Wu, X., Liu, T., Feng, W., Zhou, H., Chen, C., Shi, L., Lin, M., Liu, T., et al. (2023) · CNS Neuroscience & Therapeutics · doi:10.1111/cns.14447 · Cited by 5 · see citing works
“71,72 SA is an effective therapy for stroke as it stimulates damaged brain tissue, stimulates undamaged brain tissue, and compensates for the lost function of damaged tissue.”
BackgroundThompson, E. D., Miller, A. E., & Reisman, D. S. (2023) · Topics in Stroke Rehabilitation · doi:10.1080/10749357.2023.2202018 · Cited by 4 · see citing works
The impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke
Comer, A. R., Jawed, A., Roeder, H. J., & Kramer, N. M. (2024) · Journal of Stroke and Cerebrovascular Diseases · doi:10.1016/j.jstrokecerebrovasdis.2024.107820 · Cited by 4 · see citing works
Obayashi, S., & Saito, H. (2022) · Applied Sciences · doi:10.3390/app12020810 · Cited by 4 · see citing works
Stroke in women: Is it different?
Corbière, S., & Tettenborn, B. (2021) · Clinical and Translational Neuroscience · doi:10.1177/2514183x211014514 · Cited by 4 · see citing works
“A population-based study supports these findings; after adjusting for age, the mortality rate in women and men was equal.(10)”
BackgroundResultSex Differences in Outcomes Over the First Year After Ischemic Stroke
Chen, C., Kwicklis, M., Morgenstern, L. B., & Lisabeth, L. D. (2025) · Neurology · doi:10.1212/wnl.0000000000214508 · Cited by 3 · see citing works
Self-citationMiyata, K., Takeda, R., Kotajima, K., Takahashi, Y., Akiyama, H., Hayashi, S., Igarashi, T., Tamura, S., & Usuda, S. (2026) · Neurorehabilitation and neural repair · doi:10.1177/15459683261418670 · Cited by 3 · see citing works
Šaňák, D., Gurková, E., Štureková, L., Šaňáková, Š., Zapletalová, J., Franc, D., & Bartoníčková, D. (2024) · European Neurology · doi:10.1159/000535685 · Cited by 3 · see citing works
Stroke Rehabilitation in India: Addressing Gender Inequities
Pathan, N. M., Saxena, R., Kumar, C., Kamlakar, S., & Yelikar, A. (2024) · Journal of Lifestyle Medicine · doi:10.15280/jlm.2024.14.2.94 · Cited by 3 · see citing works
“Pre-existing co-morbidities such as diabetes mellitus and hypertension, pose a higher risk for stroke development in women when compared to men and higher stroke severity are, in turn, connected to negative functional outcomes following a stroke [18-20].”
BackgroundGrundtvig, J. L. G., Sværke, K., Preskou, M., Christensen, L. M., Steiner, T., & Christensen, H. (2025) · Global Epidemiology · doi:10.1016/j.gloepi.2025.100201 · Cited by 3 · see citing works
“It has been suggested that less than half of sex-differences in outcome are explained by demographics, pre-stroke function and clinical variables [35].”
Nelson, S. E., Husseini, N. E., Bahouth, M. N., Fleming, T. K., Harvey, R. L., Hayman, L. L., & Raghavan, P. (2026) · Stroke · doi:10.1161/str.0000000000000520 · Cited by 2 · see citing works
Zhao, Y., Yang, D., Li, G., Zhao, P., Luan, X., & Li, H. (2021) · BioMed Research International · doi:10.1155/2021/6624245 · Cited by 2 · see citing works
RetractedSexual dimorphism in the cerebrovascular network: Brain MRI shows lower arterial density in women
Barbeau‐Meunier, C., Bernier, M., Cote, S. R., Gilbert, G., Bocti, C., & Whittingstall, K. (2021) · Journal of Neuroimaging · doi:10.1111/jon.12951 · Cited by 2 · see citing works
Fang, M., Xu, C., Ma, L., Sun, Y., Zhou, X., Deng, J., & Liu, X. (2022) · Frontiers in Neurology · doi:10.3389/fneur.2022.989166 · Cited by 2 · see citing works
Kitamura, S., Otaka, Y., Uehara, S., Murayama, Y., Ushizawa, K., Narita, Y., Nakatsukasa, N., Matsuura, D., Osu, R., Kondo, K., et al. (2024) · Journal of Rehabilitation Medicine · doi:10.2340/jrm.v56.40055 · Cited by 2 · see citing works
“Previous studies have consistently reported a similar association, linking younger age (9–12), male sex (11, 13–15), shorter post-onset time (11, 45), and mild motor (13, 16), cognitive (14, 16), and language (46) dysfunctions to improved ADL in patients with stroke.”
BackgroundResultOgawa, Y., Akiyama, H., Horii, T., & Mihara, K. (2025) · BMC Geriatrics · doi:10.1186/s12877-024-05666-y · Cited by 2 · see citing works
Escolà, J. K., Bozkurt, B., Brune, B., Milles, L. S., Pommeranz, D., Dammann, P. R., Li, Y., Deuschl, C., Forsting, M., Kill, C., et al. (2025) · Cerebrovascular Diseases Extra · doi:10.1159/000543835 · Cited by 1 · see citing works
Liu, Q., Liu, S., Yang, J., & He, Q. (2026) · Frontiers in Surgery · doi:10.3389/fsurg.2025.1708117 · Cited by 1 · see citing works
Ezeugwu, V. E., Peters, S., Hung, S. H., Bayley, M. T., Best, K. L., Connell, L. A., Donkers, S. J., Dukelow, S. P., Milot, M.-H., Sakakibara, B. M., et al. (2026) · Disability and Rehabilitation · doi:10.1080/09638288.2026.2661476 · Cited by 1 · see citing works
Sex-Specific Factors in Stroke
Chauhan, A., Moser, H., & McCullough, L. D. (2017) · Springer series in translational stroke research · doi:10.1007/978-3-319-45345-3_32 · Cited by 1 · see citing works
Identifying Strategies to Reduce Poor Outcomes in Women With Stroke
Madsen, T. E., & Lisabeth, L. D. (2017) · Circulation Cardiovascular Quality and Outcomes · doi:10.1161/circoutcomes.117.003546 · Cited by 1 · see citing works
“in poor functional outcomes after stroke but did not investigate mortality.(2) In addition, some previous studies of sex differences in stroke mortality have used hospital-based data,(6)”
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Khan, M. (2022) · Pakistan Journal of Neurological Sciences · doi:10.56310/pjns.v17i01.159 · Cited by 1 · see citing works
Pre‐stroke patient characteristics that influence skeletal muscle quality: A cross‐sectional study
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Academic, Administrative, and Clinical Appointments
Hammer, G. D., Schembechler, M., & Goodman, R. M. (2016)
Diferenças de Género no Tratamento de Fase Aguda do Acidente Vascular Cerebral Isquémico
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“Median NIHSS (IQR) 11 (4-25) 10 (3-18) 13 (5-21) <0.”
BackgroundInfluentialEtiologic Subtypes, Risk Factors and Early Outcome of Acute Ischemic Stroke in Females
Aslanbaba, E., Sorgun, M. H., Aksun, Z. Ö., Allahverdiyev, T., Bulut, O., Erdoğan, Ş., Karaarslan, F. T., Nadirova, A., Ölmez, B., Önder, C., et al. (2021) · Turkish Journal Of Neurology · doi:10.4274/tnd.2021.09086
“Bilinen AF, (n, %) 112 (25,9) 55 (10,5) <0,001”
InfluentialTojaga, A., Salcin, L. O., & Damjanović, V. M. (2020) · Zdravstveni glasnik · doi:10.47960/2303-8616.2020.11.51
STROKE IN WOMEN: TIME TO ACKNOWLEDGE SEX DIFFERENCES
Khan, M. (2022) · Khyber Medical University Journal · doi:10.35845/kmuj.2022.22516
Jameie, M., Jameie, M., Farahmand, G., Ilkhani, S., Magrouni, H., Ranjbar, Z., Havadaragh, S. H., Shahbazi, M., Kaeedi, M., Amani, K., et al. (2022) · The Neurologist · doi:10.1097/nrl.0000000000000467
Sex/Gender Differences in Clinical Aspects of Physical Medicine and Rehabilitation
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Stroke Rehabilitation and Recovery in Women
Bushnell, C., & Kapral, M. K. (2025) · Stroke · doi:10.1161/strokeaha.125.049844
- Authors
- Lisabeth, L. D., Reeves, M. J., Baek, J., Skolarus, L. E., Brown, D. L., Zahuranec, D. B., Smith, M. A., & Morgenstern, L. B.
- Affiliations
- University of Michigan (US)
- ORCID
- Venue
- Stroke
- Published
- 2015-03
- Volume
- 46
- Issue
- 3
- Pages
- 860-863
- ISSN
- 0039-2499 (ISSN-L)
- 1524-4628
- PMC
- PMC4342324
- OpenAlex
- W2013573491
- Cited by
- 108
- References
- 8
- Citations by year
- 2026: 9 · 2025: 15 · 2024: 11 · 2023: 6 · 2022: 14 · 2021: 10 · 2020: 15 · 2019: 6 · 2018: 5 · 2017: 6 · 2016: 8 · 2015: 3
- FWCI
- 7.40
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Stroke (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Aging (K23AG038731)
- National Institute of Diabetes and Digestive and Kidney Diseases (P30DK092926)
- National Institute of Neurological Disorders and Stroke (K23NS073685, R01NS070941, R01NS038916, U24NS107214, R01NS38916)
- Topics
- Health Sciences › Medicine › Rehabilitation › Stroke Rehabilitation and Recovery
- Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Sex and Gender in Healthcare
- Keywords
- sex differences, functional outcome, activities of daily living, instrumental activities of daily living, ischemic stroke, stroke severity, marital status, nursing home residence, transient ischemic attack, body mass index
- MeSH terms
- Stroke Rehabilitation, Activities of Daily Living, Aged, Aged, 80 and over, Ischemic Attack, Transient, Cognition, Female, Follow-Up Studies, Humans, Male, Medical Records, Middle Aged, Regression Analysis, Risk Factors, Sex Factors, Texas, Treatment Outcome, Recovery of Function
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