Platelets, gender and acute cerebral infarction
© Järemo et al. 2015
Received: 9 June 2015
Accepted: 6 August 2015
Published: 16 August 2015
Platelets may well be significant in the pathogenesis of cerebral infarction. Platelets vary substantially according to gender. The scope of our current work is to establish if female and male stroke sufferers differ regarding platelet reactivity.
Patients and methods
73 Consecutive individuals stricken by acute ischemic cerebral infarction (31 females, 42 males) participated. All stroke subtypes were included. Platelet counts was determined electronically. Platelet reactivity i.e. the presence of surface-bound fibrinogen following provocation was analyzed with a flow cytometer. ADP (1.7 μmol/L) and a thrombin receptor agonist (TRAP-6) (57 μmol/L) were the agonists used.
Female stroke sufferers had higher platelet counts (p = 0.013) but their platelets were less reactive. The p values were (p = 0.038) and (p = 0.016) for ADP and TRAP-6, respectively.
The current study demonstrates that women suffering acute cerebral infarction have less reactive platelets. It is concluded that gender affects platelets. Our study indicates that it may be beneficial to individualize platelet inhibition of stroke sufferers according to gender.
KeywordsFlow cytometry Gender Inflammation Myeloperoxidase Platelet activation Platelet reactivity Platelets P-selectin
Drugs that suppress platelets e.g. aspirin, are beneficial for preventing stroke recurrence . Some workers have associated acute cerebral infarctions with increased platelet reactivity . In contrast, recent work have found either lower platelet reactivity  or no reactivity alterations . Research into platelet activity in the event of acute stroke has also produced disparate findings. Several researchers found increased platelet activity [5, 6] whereas recent work has revealed reduced activation [3, 4]. Platelets display substantial gender differences; women have increased platelet counts [7, 8] and female platelets display increased sensitivity to aggregating agents both before [8, 9] and after [7, 10] the menopause. The diversities encouraged us to undertake the current work which evaluates stroke victims with respect to gender differences in platelet behavior.
Demographic data at hospital admission for females and males with acute cerebral infarctions
78 ± 9
71 ± 9
Body weight (kg)a
70 ± 16
83 ± 13
Sampling time after the acute stroke (days)a
2.4 ± 1.6
2.0 ± 1.3
Cardiogenic stroke (n)
Small artery disease (n)
Large artery disease (n)
Recurrent stroke (n)
Current smokers (n)
Previous myocardial infarction (n)
Aspirin 75 mg (n)
Vitamin K antagonists (n)
Determinations of surface-bound fibrinogen and membrane-attached P-selectin were carried out in citrate anticoagulated whole blood with a Beckman Coulter EPICS XL-MCL™ Flow Cytometer (Beckman Coulter, Inc., Brea, Cal, USA). Earlier communications have described the laboratory procedures in detail [4, 7, 11]. An antibody against glycoprotein Ib (Dako AS, Glostrup, Denmark) detected platelets. Chicken antihuman fibrinogen polyclonal antibody (Biopool AB, Umeå, Sweden) identified surface-bound fibrinogen. An IgG1 (mouse) monoclonal antibody identified platelet bound P-selectin (Immunotech, France). The values of a negative control were subtracted from the experimental ones. The control contained EDTA to prevent platelet antibody binding. When determining platelet reactivity, ADP (1.7 and 8.5 μmol/L) (Sigma-Aldrich, St Louis, MO, USA) and a thrombin receptor-activating peptide-6 (TRAP-6) (57 and 74 μmol/L) (Biotechnology Centre of Oslo, Norway) were used as agonists. Platelet-bound P-selectin without agonist provocation served as an estimate of platelet activity in vivo [4, 11]. Soluble P-selectin and myeloperoxidase were used as markers of platelet/endothelial [11, 12] and neutrophil activity , respectively. ELISA kits (R&D system, Abingdon, GB) were employed for both determinations. To avoid platelet in vitro activity, a blocking solution was used as an anticoagulant [4, 14]. High sensitive C-reactive protein (hsCRP) was determined using a turbiometric technique. Student’s t test and the Chi square test were employed for the statistical evaluations.
Female stroke sufferers were older than their male counterparts (Table 1). As expected female body weights were lower. At hospital admittance neither stroke subtypes nor concomitant diseases differed significantly with respect to gender. With one exception (ACE-inhibitors) the study groups had similar drug prescriptions.
Platelet reactivity and activity
Platelet reactivity and activity of female and male stroke sufferers
Females (mean ± SD) (n = 31)
Males (mean ± SD) (n = 42)
Platelet counts (×109/L)
295 ± 105
245 ± 58
Platelet distribution width (%)
15.7 ± 1.7
16.4 ± 0.9
Platelet-bound fibrinogen after agonist provocation
ADP (1.7 μmol/L) (%)
23 ± 16
32 ± 17
ADP (8.5 μmol/L) (%)
54 ± 21
62 ± 19
TRAP-6 (57 μmol/L) (%)
35 ± 23
52 ± 29
TRAP-6 (74 μmol/L) (%)
51 ± 24
63 ± 22
Platelet-bound P-selectin after agonist provocation
TRAP-6 (57 μmol/L) (%)
20 ± 13
15 ± 7
TRAP-6 (74 μmol/L) (%)
41 ± 22
44 ± 18
Without agonist (%)
4 ± 2
4 ± 1
Soluble P-selectin (μg/L)
70 ± 37
82 ± 47
Inflammatory response and erythrocytes
The inflammatory response and red cell parameters for female and male patients with acute cerebral infarctions
Females (mean ± SD) (n = 31)
Males (mean ± SD) (n = 42)
High sensitive C-reactive protein (g/L)
17 ± 18
9 ± 17
Neutrophil counts (×1012/L)
5.6 ± 1.7
4.6 ± 1.6
16 ± 13
7 ± 6
141 ± 13
149 ± 13
Red cell counts (×109/L)
4.6 ± 0.5
4.8 ± 0.5
Red cell distribution width (%)
13.2 ± 1.4
12.4 ± 0.9
This work has revealed gender differences concurrent with acute stroke. Female stroke sufferers displayed less platelet reactivity (Table 2). We further confirm earlier findings  in showing that females had higher platelet counts. Finally, at the acute stroke women had enhanced neutrophil counts. These cells circulate more activated in females based on plasma myeloperoxidase values (Table 3).
We found that platelets of women stroke patients responded less to agonist (Table 2). Previous work showed increased female platelet reactivity concurrent with coronary heart disease . Furthermore, women with atherosclerosis have increased reactivity . Several researchers describe how platelets of stroke sufferers are less reactive than in suitable control groups [3, 4]. It is difficult to decide why coronary heart disease platelets differ from platelet behavior in conjunction with cerebral infarction. One can hypothesize that stroke and coronary heart disease have differing pathologies making platelets react differently.
Stroke incidence is lower in women and they are on average older than males at their first cerebral infarction [15–17]. Female stroke patients have higher prevalence of hypertension and cardioembolic stroke whereas diabetes and lacunar stroke are less frequent . It agrees to a certain extent with this study. In our hands, however, probably due to the small sample size, the differences failed to reach significance (Table 1). Demographic and clinical characteristics differed further as women weighted less and more frequently had ACE-inhibitors (Table 1). In particular, differences with respect to ongoing prescriptions could affect platelets and inflammatory reactions. The time point of blood sampling varied substantially but did not differ significantly between groups (Table 1). It constitutes an uncertainty as the current activity measures could rapidly change after an acute cerebral infarction. Female patients were older at hospital admission constituting a possible confounder. However, in our hands platelets and neutrophils do not demonstrate any significant dependence on age (unpublished data). In everyday clinical practice it is practically impossible to divide stroke events into subcategories. Previously, we were unable to see that stroke subtypes differ with respect to platelets and the inflammatory response . Therefore, in this study all patients were evaluated together.
Lower platelet reactivity could be one of many reasons as to why women on average get their first cerebral infarction later in life. Female stroke sufferers have higher 1-month case fatality than men . Age and disease severity may be possible reasons for the dissimilarities [16, 17]. The inflammatory response has substantial impact upon long term survival after coronary heart disease . It is to evaluate if inflammatory parameters may have prognostic influence after an acute cerebral infarction as well.
The current study indicates that subsequent work is necessary to evaluate if platelet inhibition after acute stroke should be individualized according to gender. At present new powerful platelet inhibitory drugs are introduced. This work suggests that clinical trials are necessary before using these new drugs in particular in female stroke sufferers.
PJ designed the study and secured financial resources. Research nurse. ME-F selected suitable patients and performed venous blood punctures. MM made the practical work in the laboratory. All authors evaluated the scientific results and together they wrote the manuscript. All authors read and approved the final manuscript.
We acknowledge the assistance of devoted nursing personnel of the Stroke Unit in Norrköping. An unrestricted donation from Bristol Myers Squibb is deeply appreciated. Generous economic backing from the Swedish Stroke Foundation, the Medical Research Council of Southeast Sweden and the Ståhl´s foundation made the study possible.
Compliance with ethical guidelines
Competing interests All authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Antithrombotic Trialists’ Collaboration (2002) Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 324:71–86View ArticleGoogle Scholar
- Mulley GP, Heptinstall S, Taylor PM, Mitchell JR (1983) ADP-induced platelet release reaction in acute stroke. Thromb Haemost 50:524–526PubMedGoogle Scholar
- Lukasik M, Rozalski M, Luzak B, Michalak S, Kozubski W, Watala C (2010) Platelet activation and reactivity in the convalescent phase of ischaemic stroke. Thromb Haemost 103:644–650View ArticlePubMedGoogle Scholar
- Järemo P, Eriksson M, Lindahl TL, Nilsson S, Milovanovic M (2013) Platelets and acute cerebral infarctions. Platelets 24:407–411View ArticlePubMedGoogle Scholar
- McCabe DJ, Harrison P, Mackie IJ, Sidhu PS, Purdy G, Lawrie AS et al (2004) Platelet degranulation and monocyte-platelet complex formation are increased in the acute and convalescent phases after ischaemic stroke or transient ischaemic attack. Br J Haematol 125:777–787View ArticlePubMedGoogle Scholar
- Cevik O, Adiguzel Z, Baykal AT, Somay G, Sener A (2013) The apoptotic actions of platelets in acute ischemic stroke. Mol Biol Rep 40:6721–6727View ArticlePubMedGoogle Scholar
- Järemo P, Milovanovic M, Richter A (2005) Gender and stable angina pectoris: women have greater thrombin-evoked platelet activity but similar adenosine diphosphate-induced platelet responses. Thromb Haemost 94:227PubMedGoogle Scholar
- Johnson M, Ramey E, Ramwell PW (1975) Sex and age differences in human platelet aggregation. Nature 253:355–357View ArticlePubMedGoogle Scholar
- Faraday N, Goldschmidt-Clermont PJ, Bray PF (1997) Gender differences in platelet GPIIb-IIIa activation. Thromb Haemost 77:748–754PubMedGoogle Scholar
- Becker DM, Segal J, Vaidya D, Yanek LR, Herrera-Galeano JE, Bray PF et al (2006) Sex differences in platelet reactivity and response to low-dose aspirin therapy. JAMA 295:1420–1427View ArticlePubMedGoogle Scholar
- Järemo P, Milovanovic M, Buller C, Nilsson S, Winblad B (2013) P-selectin paradox and dementia of the Alzheimer type: circulating P-selectin is increased but platelet-bound P-selectin after agonist provocation is compromised. Scand J Clin Lab Invest 73:170–174View ArticlePubMedGoogle Scholar
- Milovanovic M, Nilsson E, Järemo P (2004) Relationships between platelets and inflammatory markers in rheumatoid arthritis. Clin Chim Acta 343:237–240View ArticlePubMedGoogle Scholar
- Järemo P, Shaba A, Kutti J (1992) Some storage characteristics of buffy coats used for the preparation of platelet concentrates. Ann Hematol 65:269–273View ArticlePubMedGoogle Scholar
- Järemo P, Lindahl TL, Fransson SG, Richter A (2002) Individual variations of platelet inhibition after loading doses of clopidogrel. J Int Med 252:233–238View ArticleGoogle Scholar
- Appelros P, Stegmayr B, Terent A (2009) Sex differences in stroke epidemiology. A systematic review. Stroke 40:1082–1090View ArticlePubMedGoogle Scholar
- Arboix A, García-Eroles L, Massons J, Oliveres M, Targa C (2000) Lacunar infarcts in patients aged 85 years and older. Acta Neurol Scand 101:25–29View ArticlePubMedGoogle Scholar
- Arboix A, Cartanyà A, Lowak M, García-Eroles L, Parra O, Oliveres M et al (2014) Gender differences and woman-specific trends in acute stroke: results from a hospital-based registry (1986–2009). Clin Neurol Neurosurg 127:19–24View ArticlePubMedGoogle Scholar
- Järemo P, Nilsson O (2008) Interleukin-6 and neutrophils are associated with long-term survival after acute myocardial infarction. Eur J Int Med 19:330–333View ArticleGoogle Scholar