Sex differences in the three-dimensional morphology of unruptured intracranial aneurysms

Objective: Women have a higher rupture risk of intracranial aneurysms than men. One possible explanation is that aneurysm volume and shape irregularity, both linked to rupture risk, may differ between women and men. We investigated this with 3-dimensional morphological aneurysm parameters. Methods: In a random sample of consecutive patients with unruptured intracranial aneurysms diagnosed between 2008 and 2018, we quantified volume and shape parameters describing global (sphericity, elongation, and flatness) and local shape (shape index and curvedness) on CT or MR angiography scans. We compared these parameters between women and men (reference) with univariable and multivariable linear regression analysis (global parameters) and binary logistic regression analysis (local parameters). The multivariable analysis was adjusted for the confounders: age, hypertension, smoking status, aneurysm size, location, and imaging modality. Results: We included 326 patients (239 women [73%], mean age 58 years [SD 12 years]). Women had smaller aneurysm volumes than men in multivariable analysis (β -0.30 SD, 95%CI -0.55 to -0.06). The global shape parameters sphericity, elongation, and flatness were comparable between sexes. Of the local shape parameters, women had higher aneurysm shape index (OR 2.38, 95%CI 1.03 to 5.49) and lower curvedness (OR 0.50, 95%CI 0.29 to 0.88) in multivariable analysis. Conclusions: Women have intracranial aneurysms with smaller volumes and shape characteristics associated with lower rupture risk. Therefore, factors other than aneurysm morphology are likely responsible for the higher risk of aneurysm rupture in women.