Sex differences in imaging features including cerebral amyloid angiopathy markers in intracerebral hemorrhage

Reports on sex differences in radiological characteristics of intracerebral hemorrhage (ICH) are few. Sex-related differences in hematoma location, volume, and imaging markers may contribute to variations in clinical presentation and outcome. We aimed to assess sex differences in non-contrast computed tomography (NCCT) features in an unselected ICH cohort.

This observational study included 1,398 patients with spontaneous supratentorial ICH from the Skåne Hospital Region, Sweden (2016-2021), registered in Riksstroke. Radiological characteristics were compared between males and females. Multivariable logistic regression, adjusted for confounders, analyzed sex differences overall and stratified by hematoma location (deep/lobar). CAA probability was assessed using the simplified Edinburgh CT criteria.

Among 785 males and 613 females, hematoma volume, location, and antithrombotic use were similar. Women were older (79 vs. 73 years; p < 0.001), more often had severe white matter changes on baseline NCCT, with overall differences in white matter change distribution between sexes (p = 0.006), intraventricular hemorrhage (45.2% vs. 38.7%; p = 0.02), finger-like projections (18.1% vs. 10.6%; p < 0.001), subarachnoid extension (25.1% vs. 15.7%; p < 0.001), and hydrocephalus (16.6% vs. 10.0%; p = 0.001). In lobar ICH (n = 666), high CAA probability was more common in women (28.8% vs. 15.0%, p < 0.001), and in multivariable analysis, female sex was independently associated with subarachnoid extension (OR 1.89 95%CI 1.29-2.77).

In this large, unselected cohort of supratentorial ICH, no sex differences were observed in hematoma volume, location, or intraventricular extension. However, in lobar ICH, female sex was independently associated with subarachnoid extension and CT features suggestive of higher CAA probability. These findings indicate similar hemorrhage severity between sexes but differences in lobar hemorrhage morphology that require further validation and explanation.