Sex differences in stroke prognosis across reperfusion strategies: implications for prevention and quality of life

Abstract Sex-specific trajectories of vascular aging may influence stroke recovery, yet their impact on access to reperfusion and long-term outcomes remains uncertain. We analysed 3760 consecutive patients with angiography-confirmed cerebral vessel occlusion transferred for endovascular therapy (EVT) between 2015 and 2022. Women accounted for 45.1% of patients and were significantly older (median 77 vs. 70 years) with greater baseline stroke severity (NIHSS 14 vs. 12). Access to acute stroke care was equivalent across sexes, including workflow intervals, intravenous thrombolysis, EVT use, and angiographic success (TICI 2b–3). In the full cohort, 12-month survival did not differ between sexes (log-rank p = 0.38). After 1:1 propensity score matching for age and NIHSS (1302 matched pairs), women showed markedly better 12-month survival (log-rank p < 0.0001). Among EVT-treated patients ( n = 2795), functional independence at 90 days was similar (mRS 0–2 in 49.2% of men vs. 47.8% of women; p = 0.58), while procedural safety profiles were largely comparable, with lower rates of PH2 haemorrhage in women (3.1% vs. 4.9%; p = 0.016). In a multivariable Cox model adjusting for comorbidities, intravenous thrombolysis, and reperfusion success, female sex remained independently associated with reduced 12-month mortality (HR 0.77, 95% CI 0.66–0.89; p < 0.001). These findings suggest a robust female survival advantage despite older age and similar access to modern reperfusion therapies. The results may implicate the presence of sex-specific resilience mechanisms relevant to vascular aging and postischaemic recovery, with implications for prevention and long-term poststroke management. Graphical Abstract