Educational attainment, severity, and prognosis of intracerebral hemorrhage

Abstract Background and Objectives: Despite advances in acute stroke management, the prevalence and incidence of intracerebral hemorrhage (ICH) are increasing, warranting study beyond biological and clinical determinants to improve primary and secondary prevention. Educational attainment is a critical social determinant of health that impacts risk of all-cause mortality, acute cardiovascular events, as well as severity of incident ischemic stroke, but less is known of its impact on ICH. The objective of this study is to determine whether educational attainment is associated with ICH severity and prognosis. Methods Subjects were enrolled in a prospectively ascertained cohort of patients with primary ICH from 1994 until 2020 at the Massachusetts General Hospital Neurosciences Intensive Care Unit. Educational attainment, medical history of ICH risk factors, ICH volume, and ICH score were obtained on admission. The primary outcomes were ICH volume and the ICH score. Results Of 2,539 patients eligible for analysis, the median age of the sample was 74 (IQR 64–82) and 2,159 (85%) had high school only education, including diplomates and those with some high school education. 1655 (65%) presented with an ICH volume less than or equal to 30mL and 1,744 (69%) presented with an ICH score less than 30. In multivariable logistic regression analyses controlling for age, income bracket, employment history, and pre-stroke diagnoses of hypertension and coronary artery disease, patients with high school-only education were more likely to have an ICH volume greater than 30mL compared to college diplomates (odds ratio 1.61, 95% 1.24, 2.08) and also more likely to have an ICH score of 3 or greater compared to college diplomates (odds ratio 2.37, 95% CI 1.77, 3.19). Discussion Pre-stroke educational attainment carries an independent association with ICH severity and prognosis, with lower educational attainment associated with larger ICH volumes and higher ICH scores. These results suggest that primary and secondary prevention strategies should consider the important social determinant of educational attainment as an independent risk factor for ICH, in addition to traditional clinical risk factors. Future studies are needed to examine how educational attainment impacts exposures to traditional clinical risk factors, healthcare access, and health-related behaviors.