When the Brain Says “Not So Fast”:
Sex Differences in Delayed Cerebral Ischemia After Subarachnoid Hemorrhage
When ischemia strikes the brain after a burst aneurysm, the game changes, and according to a new JAHA study, women play with higher stakes than men.
A High-Wire Act
Aneurysmal subarachnoid hemorrhage (aSAH) is already a high-wire act: one wrong move in the ICU, and your patient tumbles into vasospasm, infarction, or worse. Delayed cerebral ischemia (DCI) is the main villain in this story.
Zhang and colleagues sifted through nearly a decade of prospectively collected cases (2015–2023). They used propensity score matching to balance 215 men and 215 women who underwent endovascular coiling. Then they asked: who gets DCI, and why?
The Punchline Numbers
Women paid the price: 64.6% developed DCI vs. 35.4% of men. That’s an odds ratio of 2.17 (P<0.001).
Shared risk factors: Both sexes were more likely to develop DCI if they had acute hydrocephalus or higher modified Fisher scores.
Extra risk factors for women:
· Age (OR 2.66)
· Higher fasting glucose (OR 1.15)
· Higher Hunt–Hess grade (OR 3.18)
· Intracerebral hematoma (OR 2.40)
· Slower perfusion transit times (OR 1.49)
Men? They got away with fewer red flags.
What This Means in the OR (and Beyond)
For surgeons, these findings sound familiar: women present later, bleed differently, and often carry more comorbidities that complicate perioperative management. In the brain, just as in the heart, they’re not playing on a level field.
This study doesn’t suggest different treatment yet, but it does shout: risk stratify differently. If you’re operating on—or co-managing—an older woman with aSAH, diabetes, and poor Hunt–Hess grade, you’re not just looking at a ruptured aneurysm. You’re looking at a near coin-flip chance of DCI.
The Take-Home for Surgeons
Women bleed, and then they ischemize more. Keep a sharper eye on DCI risk post-aSAH.
Metabolic stress matters. Fasting glucose was a risk factor—yet another reason to monitor the glycemic rollercoaster closely.
· Tailored vigilance. Same aneurysm, different risks. Women require a different level of monitoring intensity.
If coronary disease taught us anything, it’s that sex differences aren’t academic—they’re clinical. The same applies upstairs in the circle of Willis.
So next time you’re in a surgical huddle and someone mentions a ruptured aneurysm case, remember: if it’s a woman, the clock on delayed ischemia may be ticking louder.
Source Study: Comparing the “Life's Essential 8” Scores of Older Adults Living With Cardiovascular Diseases: NHANES, 2013 to 2018
Authors: James M. Walker, BA https://orcid.org/0000-0002-9661-6322 james.walker@northwestern.edu, Daniel J. Won, BS, Ravi S. Patel, BS https://orcid.org/0000-0002-1347-290X, Hongyan Ning, MD, MS https://orcid.org/0000-0003-1157-6614, and Donald M. Lloyd‐Jones, MD, ScM https://orcid.org/0000-0003-0847-6110