Woman and ictus

Authors: Z. Kalita
Authors‘ workplace: Neurologické oddělení, Krajská nemocnice T. Bati, a. s., Zlín
Published in: Cesk Slov Neurol N 2008; 71/104(2): 148-155
Category: Review Article


Brains strokes are serious and frequent disorders.  According to randomised clinical studies and experimental research, there are differences between the sexes in terms of incidence and nature of ictuses, specifically with respect to age distribution, specific ictus risk factors (pregnancy, oral contraception, postmenopausal hormone replacement therapy and migraine) and different distribution or atherosclerotic stenosing changes in cerebral arteries. Statistically significant benefit of acetylsalicylic acid has been recorded primary prevention in women aged 45 and above and there are also certain differences between the sexes both in terms of acute treatment (intra-arterial thrombolysis) and secondary prevention. Estrogen and the fluctuation of its level during the menstrual cycle, in menopause and postmenopause, play a central role in the above differences. Estrogen modulates the formation of endothelial factors, maintains vasodilatation, and the antiproliferative and antiadhesive properties of the endothelium. Estrogen suppresses inflammation and also influences haemostasis and increases the risk of venous thromboembolia.  It mostly acts via the bond to specific receptors and its action is influenced by gene polymorphism.

Key words:
brain stroke – pregnancy – hormone therapy - acetylsalicylic acid – estrogen – neurovascular unit – gene polymorphism


1. Olesen J, Baker MG, Freund T, di Luca M, Mendlewicz J, Ragan I et al. Consensus document on European brain research. J Neurol Neurosurg Psychiatry 2006; 77(Suppl I): i1–i49.

2. Bushnell CD, Hurn P, Colton C et al. Advancing the study of stroke in women: summary and recommendations for future research from an NINDS-Sponsored Multidisciplinary Working Group. Stroke 2006; 37: 2387–2399.

3. Kalita Z. Epidemiologie cévních mozkových příhod. In: Kalita Z et al. Akutní cévní mozkové příhody. Diagnostika, patofyziologie, management. Praha: Maxdorf 2006: 6–19.

4. UZIS ČR. Zemřelí 2005. Praha: UZIS ČR 2006.

5. American Heart Association. Heart Disease and Stroke Statistics – 2004 Update. Dallas, Texas: American Heart Association 2003.

6. Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD et al. Primary prevention of ischemic stroke: a guideline from American Heart Association/American Stroke Association Stroke Council. Stroke 2006; 37: 1583–1633.

7. Kalita Z. Subarachnoidální hemoragie. In: Kalita Z et al. Akutní cévní mozkové příhody. Diagnostika, patofyziologie, management. Maxdorf: Praha 2006: 443–461.

8. Weir B. Unruptured intracranial aneurysms: a review. J Neurosurg 2002; 96: 3–42.

9. Kalita Z. Rizikové faktory ischemického iktu a primární prevence. In: Kalita Z et al. Akutní cévní mozkové příhody. Diagnostika, patofyziologie, management. Maxdorf: Praha 2006: 111–151.

10. Kořenek A. Hormonální kontracepce v premenopauze – úvod. Moderní gynekologie a porodnictví 2003; 12(Suppl 4): 712–716.

11. Unzeiting V. Aktivita hormonů a jejich vliv na organismus uživatelky kombinované orální antikoncepce (COC). Moderní gynekologie a porodnictví 2005; 14(Suppl 1): 3–10.

12. Čepický P. Doporučení WHO k užívání kombinované hormonální antikoncepce 2004. Moderní gynekologie a porodnictví 2005; 14(Suppl 1): 11–22.

13.Sacco RL, Boden-Albala B, Gan R, Chen X, Kargman DE, Shea S et al. Stroke incidence among white, black, and Hispanic resident of an urban community: the Northern Manhattan Stroke Study. Am J Epidemiol 1998; 147: 259–268.

14. Wenger NK. Coronary heart disease and women: magnitude of the problem. Cardiol Rev 2002; 10: 211–213.

15. Viscoli CM, Brass LM, Kernan WN, Sarrel PM, Suissa S, Horwitz RI. A clinical trial of estrogen-replacement therapy after ischemic stroke. N Engl J Med 2001; 345: 1243–1249.

16. Simon JA, Hsia J, Cauley JA, Richards C, Hartus F, Fong J et al. Postmenopausal hormone therapy and risk of stroke: The Heart and Estrogen-progestin Replacement Study (HERS). Circulation 2001; 103: 638–642.

17. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML et al. Risk and benefit of estrogen plus progestin in healthy postmenopausal women: principl results From the Womens's Health Initiative randomized controlled trial. JAMA 2002; 288: 321–333.

18. Barrett-Connor E, Grady D, Sashegyi A, Anderson PW, Cox DA, Hoszowski K et al. Raloxifene and cardiovascular events in osteoporotic postmenopausal women: four-year results from the MORE (Multiple outcomes of raloxifene evaluation) randomized trial. JAMA 2002; 287: 847–857.

19. Mosek A, Marom R, Korczyn AD. Bornstein N. A history of migraine is not a risk factor to develop an ischemic stroke in the elderly. Headache 2001; 41: 339–401.

20. Kurth T, Gaziano JM, Cook NR, Logroscino G, Diener HC, Buring JE. Migraine and risk of cardiovascular disease in women. JAMA 2006; 296: 283–291.

21. Milhaud D, Bogousslavsky J, van Melle G, Liot P. Ischemic stroke and active migraine. Neurology 2001; 57: 1805–1811.

22. Kittner SJ, Helms A. Pregnancy and stroke. MedLink Neurology [online]. 2006. Dostupné z: < http://www.medlink.com/medlinkcontent.asp>.

23. James A, Bushnell CD, Jamison M, Myers E. Incidence and risk factors for stroke in puerperium. Obstet Gynecol 2005; 106: 509–516.

24. Singhal AB. Postpartum angiopathy with reversible posterior leukoencephalopathy. Arch Neurol 2004; 61: 411–416.

25. Brown DW, Dueker N, Jamieson DJ, Cole JW, Wozniak MA, Stern BJ et al. Preeclampsia and risk of ischemic stroke among young women: result from the Stroke Prevention in Young Women Study. Stroke 2006; 37: 1055–1059.

26. Ridker PM, Cook NR, Lee IM, Gordon D, Gaziano JM, Manson JE et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005; 352: 1293 –1304.

27. Campbell CL, Smyth S, Montalescot G, Steinhubl S. Aspirin dose for prevention of cardiovascular disease: a systematic review. JAMA 2007; 297: 2018–2024.

28. O'Leary DH, Polak JF, Kronmal RA, Kittner SJ, Bond MG, Wolfson SK jr et al. Distribution and correlates of sonographically detected carotid artery disease in Cardiovascular Health Study. The CHS Collaborative Research Group. Stroke 1992; 23: 1752–1760.

29. Goldstein LB, Adams R, Becker K et al. Primary prevention of ischemic stroke: A statement for healthcare professional from the Stroke Council of the American Heart Association. Stroke 2001; 32: 280–299.

30. Hack W, Kaste M, Bogousslavsky J et al. European Stroke Initiative recommendations for Stroke Management-update 2003. Cerevrovasc Dis 2003; 16: 311–337.

31. Goldstein LB, Samsa GP, Matchar DB, Oddone EZ. Multicenter review of preoperative risk factors for endarterectomy for asymptomatic carotid artery stenosis. Stroke 1998; 29: 750–753.

32. Sternbach Y, Perler BA. The influence of female gender on the outcome for carotid endarterectomy: a challenge to the ACAS findings. Surgery 2000; 127: 272–275.

33. Krejza J, Arkuszewski M, Kasner SE, Weigele J, Ustymowicz A, Hurst RW et al. Carotid artery diameter in men and women and the relation to body and neck size. Stroke 2006; 37: 1103–1105.

34. Rothwell PM, Goldstein LB. Carotid endarterectomy for asymptomatic carotid stenosis: asymptomatic carotid surgery trial. Stroke 2004; 35: 2425–2427.

35. Schulz UG, Rothwell PM. Sex differences in carotid bifurcation anatomy and the distribution of atherosclerotic plaque. Stroke 2001; 32: 1525–1531.

36. Caplan LR, Gorelick PB, Hier DB. Race, sex and occlusive cerebrovascular disease: a review. Stroke 1986; 17: 648–654.

37. Kasner SE, Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS et al. Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation 2006; 113: 555–563.

38. Wityk RJ, Lehman D, Klag M, Coresh J, Ahn H, Litt B. Race and sex differences in the distribution of cerebral atherosclerosis. Stroke 1996; 27: 1974–1980.

39. Ramani S, Byrne-Logan S, Freud KM, Ash A, Yu W, Moskowitz MA. Gender differences in treatment of cerebrovascular disease. J Am Geriatr Soc 2000; 48: 741–745.

40. Niewada M, Kobayashi A, Sandercock PA Kamiński B, Członkowska A. Influence of gender on baseline features and clinical outcomes among 17,370 patients with confirmed ischaemic stroke in the international stroke trial. Neuroepidemiology 2004; 24: 123–128.

41. Kent DM, Price LL, Ringleb P, Hill MD, Selker HP. Sex-based differences in response to recombinant tissue plasminogen activator in acute ischemic stroke: a pooled analysis of randomized clinical trials. Stroke 2005; 36: 62–65.

42. Hill MD, Kent DM, Hinchey J, Rowley H, Buchan AM, Wechsler LR et al. Sex-based differences in the effect of intra-arterial treatment of stroke: analysis of the PROACT-2 study. Stroke 2006; 37: 2322–2325.

43. Kalita Z. Sekundární prevence ischemických cévních mozkových příhod/TIA. In: Kalita Z et al. Akutní cévní mozkové příhody. Diagnostika, patofyziologie, management. Praha: Maxdorf 2006: 337–396.

44. Rothwell PM, Coull AJ, Silver LE, Fairhead JF, Giles MF, Lovelock CE et al. Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study). Lancet 2005, 366: 1773–1783..

45. Harrison P, Segal H, Blasbery K, Furtado C, Silver L, Rothwell PM. Screening for aspirin responsiveness after transient ischemic attack and stroke: compararison of 2 point-of-care platelet function tests with optical aggregometry. Stroke 2005; 36: 1001–1105.

46. Cavallari LH, Helgason CM, Brace LD, Viana MA, Nutescu EA. Sex difference in the antiplatelet effect of aspirin in patients with stroke. Ann Pharmacotherapy 2006; 40: 812–817.

47. Jochmann N, Stangl K, Garbe E, Baumann G, Stangl V. Female-specific aspects in the pharmacotherapy of chronic cardiovascular diseases. Eur Heart J 2005; 26: 1585–1595.

48. Nakano Y, Oshima T, Matsuura H, Kajiyama G, Kambe M. Effect of 17beta-estradiol on inhibition of platelet aggregation in vitro is mediated by an increase in NO synthesis. Arteriosclerosis Thromb Vasc Biol 1998; 18: 961–967.

49. Kalita Z. Endotel – jeho úloha v patofyziologii iktu. In: Kalita Z et al. Akutní cévní mozkové příhody. Diagnostika, patofyziologie, management. Praha: Maxdorf 2006: 197–208.

50. Mouton PR, Long JM, Lei DL, Howard V, Junker M, Calhoun M et al. Age and gender effects on microglia and astrocyte numbers in brains of mice. Brain Res 2002; 956: 30–35.

51. Zhang L, Li B, Zhao W, Chang YH, Ma W, Dragan M et al. Sex-related differences in MAPKs activation in rat astrocytes: effects of estrogen on cell death. Brain Res Mol Brain Res 2002; 103: 1–11.

52. Kalita Z. Ateroskleróza. In: Kalita Z et al. Akutní cévní mozkové příhody. Diagnostika, patofyziologie, management. Praha: Maxdorf 2006: 208–218.

53. Colton CA, Brown CM, Vitek MP. Sex steroids, APOE genotype and the innate immune system. Neurobiol Aging 2005; 26: 363–372.

54. Pradhan AD, Manson JE, Rossouw JE, Siscovick DS, Mouton CP, Rifai N et al. Inflammatory biomarkers, hormone replacement therapy, and incident coronary heart disease: prospective analysis from the Women's Health Initiative observational study. JAMA 2002; 288: 980–987.

55. Cushman M, Kuller LH, Prentice R, Rodabough R, Psaty BM, Stafford RS et al. Estrogen plus progestin and risk of venous thrombosis. JAMA 2004; 292: 1573–1580.

56. Cushman M, Meilahn EN, Psaty BM, Kuller LH, Dobs AS, Tracy RP. Hormone replacement therapy, inflammation, and hemostasis in elderly women. Arterioscler Thromb Vasc Biol 1999; 19: 893–899.

57. Scarabin PY, Alhenc-Gelas M, Plu-Bureau G, Taisne P, Agher R, Aich M. Effect of oral and transdermal estrogen/progresterone regimens on blood coagulation and fibrinolysis in postmenopausal women: A randomized controlled trial. Arterioscler Thromb Vasc Biol 1997; 17: 3071–3078.

58. Fortmann SP, Ford E, Criqui M, Folsom AR, Hartus T, Hong Y et al. CDC/AHA Workshop on Markers of Inflammation and Cardiovascular Disease: Application to Clinical and Public Health Practice: report from the population science discussion group.. Circulation 2004; 110: 554–559.

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