Cognitive impairment is common after stroke and has a great impact on the disability, particularly in the elderly [22]. It has been shown that stroke patients experience an acute decline in global cognition after stroke with a faster course than before [22]. Stroke can lead to dementia but cognitive impairment and dementia itself are also associated with a higher risk of stroke. Stroke rates are threefold higher in individuals with mild dementia and are seven times more likely to occur in persons with severe dementia [23, 24]. Even though there are indications that the incidence of dementia, just as stroke, is declining in developed countries, longer life expectancy has led to an increased prevalence of dementia [25–27]. Dementia is usually divided into Alzheimer disease, for which stroke may precipitate the onset, vascular dementia, usually due to multiple lacunar infarctions, or mixed types [28]. It has been estimated that 5% of the population over 65 years old, and up to 50% by age 90, suffer from dementia [28]. Mild cognitive impairment (MCI) can be the first stage towards dementia and is common in older persons. The prevalence of MCI has been estimated to 10–20% in those above the age of 65 years [29]. Risk increases with age and seems to be lower in women than in men. There are several differential diagnoses such as depression, thyroid disorders, and polypharmacy with adverse events to be considered. Aortic and arterial stiffness and a disturbed cerebral microcirculation have been identified as provoking risk factors [30]. There is no specific treatment for mild cognitive impairment but reducing risk factors for stroke and cardiovascular disease are crucial preventive measures. To minimalize the risk of deterioration of cognitive function regular mental activity and aerobic exercise is recommended, regardless of medical history [29].

There are a number of risk factors for stroke that are listed in Table 12.1. Many are similar for men and women while some, such as reproductive and hormonal related factors, are unique to women. For some risk factors the risk is higher in women demanding a more intense treatment [31]. Hypertension is an important risk factor for stroke in both men and women [31–33]. In a large meta-analysis including 31 randomized clinical trials (103,268 men and 87,349 women) the effect of blood pressure lowering on reducing the risk of stroke was at least as good in women as in men [34]. Treatment of hypertension and obtaining normal blood pressure is important both in primary and secondary prevention of stroke [32]. Smoking cessation is another of the major behavioral risk modifiers for stroke [32, 33]. Pooled data from meta-analyses found that smoking has a more harmful effect in women compared to men in Western but not in Asian populations [33]. Quitting smoking has comparable beneficial effects in men and women [33] (Tables 12.2, 12.3 and 12.4).

While the number of individuals who smoke and have untreated hypertension is decreasing, the prevalence of obesity is not. In the US 35% of women and 32% of men are currently obese. In many European countries however, obesity and overweight is less common among women compared to men [31, 35, 36]. Avoiding obesity and being physical active lowers the risk for stroke as well as for other manifestations of cardiovascular disease and cognitive impairment. So does a low to moderate alcohol consumption (<1 drink/day in non-pregnant women) and a healthy diet rich in fruit, vegetables, grain and nuts and low in saturated fats [32].

Depression and psychosocial stress are more common in women than in men. In the multinational INTERSTROKE study [31] the increased risk of stroke in persons with self-reported depression and psychosocial stress was 35% in women and 30% in men, after correcting for age. Sex divided analysis was not performed in this study.

Atrial fibrillation (AF) is an important risk factor for embolic ischemic stroke. Both prevalence and incidence of AF increases with age and is lower in women compared to men in all age groups [37–39]. The lifetime risk of AF is therefore lower in women [39, 40]. However, women with AF have a higher mortality and intrinsic risk of stroke than men with AF [40, 41], with higher risk of cardiovascular mortality, ischemic cardiac events and heart failure [41]. Estimating the stroke risk using CHADS₂-Vasc or CHADS₂ should be done in all patients with AF and treatment with anticoagulants encouraged if there are additional stroke risks, such as in women [42]. It should be noted that the novel oral anticoagulants (NOACs) dabigatran, rivaroxaban, and apixaban have been shown to lower the stroke risk similarly to warfarin but with a lower risk of intracranial hemorrhage [43, 44, 45]. To varying degree all these NOACs are excreted through the kidneys, necessitating control of kidney function regularly, particularly in elderly women who in general have a lower kidney function compared to men.

Similarly to AF, diabetes mellitus is also more prevalent in men but it carries a 27% higher risk of stroke in women according to a large meta-analysis [33]. A suggested explanation is that women have more metabolic and vascular disturbances related to their diabetes [33]. Moreover, treatment of diabetes may be less aggressive in women, although improvement has been shown [33, 46].

Migraine is a risk factor of stroke in both men and women, however migraine with aura is twice to four times as common in women and epidemiological studies estimate its prevalence to be around 15% in the female population [47]. Migraine is characterized by a unilateral pulsating headache that may be preceded by focal neurological symptoms such as homonymous visual disturbance, unilateral paraesthesia, numbness or weakness, or speech difficulties. These symptoms, labeled as migraine with aura, may last up to 30 min and occur in almost one third of those suffering migraines. Even though the risk of stroke among persons with migraine is low the risk is more than doubled in persons with migraine accompanied by aura [47]. In smoking women with migraine accompanied by aura the risk of stroke has been shown to be nine times higher than in non-smoking women without migraine with aura. Use of combined oral contraceptives also increases the risk of stroke two- to fourfold in women with migraine accompanied with aura [48]. It has been suggested that premenopausal women with migraine with aura could use progestin-only oral contraceptives, however, the evidence is not fully conclusive yet [48]. Women with migraine headaches with aura should be strongly advised not to smoke and to avoid at least combined oral contraceptives [49]. Triptans, such as sumatriptan, are contraindicated in patients with a previous cerebrovascular disease, as they may induce coronary or cerebrovascular spasm [50]. There is a lack of evidence regarding of the risk of triptan treatment in women having migraine with aura. Considering the elevated risk for stroke it seems sensible to avoid triptan use at least in those who also smoke, use oral contraceptives or have other stroke risk factors.

A very uncommon cause, about 0.5–1% of all strokes, is when thrombus formation in at least one of the venous sinuses causes a cerebral venous thrombosis. This condition is much more common in women than in men with a predominance of 70–75%. Headache is the predominant symptom, sometimes combined with nausea and psychiatric symptoms. The most common risk factor for cerebral venous thrombosis is pregnancy/puerperium. Other risk factors are dehydration, infections, trauma, oral contraceptives, recent neurosurgical procedures and myeloproliferative neoplasms. The recommended treatment is heparin or low-molecular heparin to dissolve the thrombus followed by oral anticoagulants. At present none of the NOACs have been approved for this indication. The condition can be difficult to diagnose. The prognosis, if treated correctly, has been shown to be good with full recovery in the vast majority of patients [70, 71].

In clinical practice the primary concern is to identify stroke and to transport the patient as fast as possible to the hospital. The earlier the patients arrive, the higher the chance of treatment success. As women in general are older at the time of an acute stroke than men, they are more dependent on others in their surrounding for contacting emergency medical services. This is not unique to women, but as many elderly women live alone, it is important that the general public is well aware of the signs and symptoms of stroke to ensure correct and immediate help when needed. In some studies it is suggested that women suffer more speaking difficulties in the acute phase of stroke, which complicates the possibility to get help [72–75].

Thrombolysis with rt-PA for acute ischemic stroke has been shown to be as effective in women as in men [76–80]. In pregnant women having an acute ischemic stroke, however, the choice of thrombolysis or not and the safety of mother and child is a difficult question for which good evidence is lacking [31]. Thrombectomy only could then be an alternative in large vessel occlusion. Secondary preventive medication for elevated blood pressure in all strokes and anti-thrombotics and statins in ischemic stroke has good evidence to prevent recurrent stroke or other cardiovascular morbidity in both women and men. However, adherence to guidelines has been shown to be modest in numerous publications. Use of Stroke Unit care has been shown to be equally effective in women and men and effective regardless of age [81]. Adherence for statins seems to be lower in women although treatment is equally effective in prevention of cardiovascular disease in both sexes and for stroke maybe even more pronounced in women [82]. Rehabilitation to regain lost function after stroke is imperative. Even though many women are older, the need of rehabilitation needs to be evaluated and met if possible. After stroke, HRT and oral contraceptives are usually discouraged as the risk of recurrent stroke increases [31].

Symptoms of stroke depend on which and how large part of the brain is affected by the impaired circulation. Sudden onset of hemiparesis and speech impairment are classical symptoms of stroke that have been used in many campaigns to raise awareness of stroke. There are studies finding that women to have more speech disturbances than men [73], while others find no difference [74]. Altered mental state is more frequently described for women than for men [75, 76]. This can make it more difficult to identify stroke and may delay presentation at hospital. With the availability of more effective treatments of stroke that are highly time dependent identification of stroke and immediate care has become even more important. It has been shown that pre-hospital identification of acute stroke increases the possibility of early acute treatment and better outcomes. The chance of having thrombolysis is higher for patients arriving as “stroke alarms” to the emergency department [77–80]. Very few stroke patients call the emergency services themselves and importantly depend on family or other bystanders for help [74, 76].

Diagnostic evaluation is the same in men and women. Neuroimaging of the brain should be performed as soon as possible in the acute phase to distinguish between ischemic or hemorrhagic stroke. CT-scan is extremely sensitive in detecting hemorrhage. Early after ischemic stroke onset, a CT scan of the brain may appear to be normal. Diffusion weighted MRI is more sensitive in spotting early ischemic changes. If there is a large vessel occlusion, as can be detected by CT or MRI angiography, thrombectomy can be useful. An angiography can also show vascular malformations causing hemorrhagic stroke and is thus indicated regardless of stroke type. Imaging of carotid arteries and detection of AF with ECG or long term ECG-monitoring should also be done to determine a potential cause of stroke and to apply optimal treatment. In both women and men, with significant symptomatic carotid stenosis, suspected of causing an ischemic stroke or TIA, carotid end artery surgery is recommended within 2 weeks of the event [83]. The perioperative risk seems to be comparable in men and women [84]. There is limited data on how to treat asymptomatic carotid stenosis, i.e. a carotid stenosis that had not yet caused a TIA or ischemic stroke [85]. Improvement of “best medical treatment”, particularly with the introduction of statins, has made it difficult to rely on results of the old, large asymptomatic carotid stenosis studies. While both men and women with stenosis progression are at increased risk of ipsilateral stroke, the degree of stenosis and presence of irregular plaque surface increases the stroke risk only in men but not in women [86]. For cognitive assessment the Montreal Cognitive Assessment (MoCA) test is easy to administer and is validated in stroke patients with a high sensitivity and specificity [87, 88].