Social Determinants of Health Attenuate the Relationship Between Race and Ethnicity and White Matter Hyperintensity Severity but not Microbleed Presence in Patients with Intracerebral Hemorrhage.
Cerebral hemorrhage
Social determinants of health
Journal
Neurocritical care
ISSN: 1556-0961
Titre abrégé: Neurocrit Care
Pays: United States
ID NLM: 101156086
Informations de publication
Date de publication:
06 2022
06 2022
Historique:
received:
12
07
2021
accepted:
15
11
2021
pubmed:
18
12
2021
medline:
20
5
2022
entrez:
17
12
2021
Statut:
ppublish
Résumé
The association between race and ethnicity and microvascular disease in patients with intracerebral hemorrhage (ICH) is unclear. We hypothesized that social determinants of health (SDOHs) mediate the relationship between race and ethnicity and severity of white matter hyperintensities (WMHs) and microbleeds in patients with ICH. We performed a retrospective observational cohort study of patients with ICH at two tertiary care hospitals between 2013 and 2020 who underwent magnetic resonance imaging of the brain. Magnetic resonance imaging scans were evaluated for the presence of microbleeds and WMH severity (defined by the Fazekas scale; moderate to severe WMH defined as Fazekas scores 3-6). We assessed for associations between sex, race and ethnicity, employment status, median household income, education level, insurance status, and imaging biomarkers of microvascular disease. A mediation analysis was used to investigate the influence of SDOHs on the associations between race and imaging features. We assessed the relationship of all variables with discharge outcomes. We identified 233 patients (mean age 62 [SD 16]; 48% female) with ICH. Of these, 19% were Black non-Hispanic, 32% had a high school education or less, 21% required an interpreter, 11% were unemployed, and 6% were uninsured. Moderate to severe WMH, identified in 114 (50%) patients, was associated with age, Black non-Hispanic race and ethnicity, highest level of education, insurance status, and history of hypertension, hyperlipidemia, or diabetes (p < 0.05). In the mediation analysis, the proportion of the association between Black non-Hispanic race and ethnicity and the Fazekas score that was mediated by highest level of education was 65%. Microbleeds, present in 130 (57%) patients, was associated with age, highest level of education, and history of diabetes or hypertension (p < 0.05). Age, highest level of education, insurance status, and employment status were associated with discharge modified Rankin Scale scores of 3-6, but race and ethnicity was not. The association between Black non-Hispanic race and ethnicity and moderate to severe WMH lost significance after we adjusted for highest level of education, suggesting that SDOHs may mediate the association between race and ethnicity and microvascular disease.
Sections du résumé
BACKGROUND
The association between race and ethnicity and microvascular disease in patients with intracerebral hemorrhage (ICH) is unclear. We hypothesized that social determinants of health (SDOHs) mediate the relationship between race and ethnicity and severity of white matter hyperintensities (WMHs) and microbleeds in patients with ICH.
METHODS
We performed a retrospective observational cohort study of patients with ICH at two tertiary care hospitals between 2013 and 2020 who underwent magnetic resonance imaging of the brain. Magnetic resonance imaging scans were evaluated for the presence of microbleeds and WMH severity (defined by the Fazekas scale; moderate to severe WMH defined as Fazekas scores 3-6). We assessed for associations between sex, race and ethnicity, employment status, median household income, education level, insurance status, and imaging biomarkers of microvascular disease. A mediation analysis was used to investigate the influence of SDOHs on the associations between race and imaging features. We assessed the relationship of all variables with discharge outcomes.
RESULTS
We identified 233 patients (mean age 62 [SD 16]; 48% female) with ICH. Of these, 19% were Black non-Hispanic, 32% had a high school education or less, 21% required an interpreter, 11% were unemployed, and 6% were uninsured. Moderate to severe WMH, identified in 114 (50%) patients, was associated with age, Black non-Hispanic race and ethnicity, highest level of education, insurance status, and history of hypertension, hyperlipidemia, or diabetes (p < 0.05). In the mediation analysis, the proportion of the association between Black non-Hispanic race and ethnicity and the Fazekas score that was mediated by highest level of education was 65%. Microbleeds, present in 130 (57%) patients, was associated with age, highest level of education, and history of diabetes or hypertension (p < 0.05). Age, highest level of education, insurance status, and employment status were associated with discharge modified Rankin Scale scores of 3-6, but race and ethnicity was not.
CONCLUSIONS
The association between Black non-Hispanic race and ethnicity and moderate to severe WMH lost significance after we adjusted for highest level of education, suggesting that SDOHs may mediate the association between race and ethnicity and microvascular disease.
Identifiants
pubmed: 34918215
doi: 10.1007/s12028-021-01403-0
pii: 10.1007/s12028-021-01403-0
doi:
Types de publication
Journal Article
Observational Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
955-963Informations de copyright
© 2021. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.
Références
Pantoni L. Cerebral small vessel disease: from pathogenesis and clinical characteristics to therapeutic challenges. Lancet Neurol. 2010;9:689–701.
doi: 10.1016/S1474-4422(10)70104-6
Greenberg SM, Vernooij MW, Cordonnier C, et al. Cerebral microbleeds: a guide to detection and interpretation. Lancet Neurol. 2009;8:165–74.
doi: 10.1016/S1474-4422(09)70013-4
Caunca MR, Del Brutto V, Gardener H, et al. Cerebral microbleeds, vascular risk factors, and magnetic resonance imaging markers: The Northern Manhattan study. J Am Heart Assoc. 2016;5.
Shahjouei S, Tsivgoulis G, Singh M, et al. Racial Difference in Cerebral Microbleed Burden among Ischemic Stroke Patients. J Stroke Cerebrovasc Dis. 2017;26:2680–5.
doi: 10.1016/j.jstrokecerebrovasdis.2017.06.040
Cordonnier C, Al-Shahi Salman R, Wardlaw J. Spontaneous brain microbleeds: systematic review, subgroup analyses and standards for study design and reporting. Brain. 2007;130:1988–2003.
doi: 10.1093/brain/awl387
Copenhaver BR, Hsia AW, Merino JG, et al. Racial differences in microbleed prevalence in primary intracerebral hemorrhage. Neurology. 2008;71:1176–82.
doi: 10.1212/01.wnl.0000327524.16575.ca
Noorbakhsh-Sabet N, Tsivgoulis G, Shahjouei S, et al. Racial Difference in Cerebral Microbleed Burden Among a Patient Population in the Mid-South United States. J Stroke Cerebrovasc Dis. 2018;27:2657–61.
doi: 10.1016/j.jstrokecerebrovasdis.2018.05.031
Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372:1661–9.
doi: 10.1016/S0140-6736(08)61690-6
Reshetnyak E, Ntamatungiro M, Pinheiro LC, et al. Impact of Multiple Social Determinants of Health on Incident Stroke. Stroke. 2020;51:2445–53.
doi: 10.1161/STROKEAHA.120.028530
Kothari RU, Brott T, Broderick JP, et al. The ABCs of measuring intracerebral hemorrhage volumes. Stroke. 1996;27:1304–5.
doi: 10.1161/01.STR.27.8.1304
Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32:891–7.
doi: 10.1161/01.STR.32.4.891
Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA. MR signal abnormalities at 1.5 T in Alzheimer's dementia and normal aging. AJR Am J Roentgenol. 1987;149:351–356.
Fazekas F, Kleinert R, Roob G, et al. Histopathologic analysis of foci of signal loss on gradient-echo T2*-weighted MR images in patients with spontaneous intracerebral hemorrhage: evidence of microangiopathy-related microbleeds. AJNR Am J Neuroradiol. 1999;20:637–42.
pubmed: 10319975
pmcid: 7056037
Wilson D, Ambler G, Shakeshaft C, et al. Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2): a multicentre observational cohort study. Lancet Neurol. 2018;17:539–47.
doi: 10.1016/S1474-4422(18)30145-5
Akoudad S, Portegies ML, Koudstaal PJ, et al. Cerebral microbleeds are associated with an increased risk of stroke: the rotterdam study. Circulation. 2015;132:509–16.
doi: 10.1161/CIRCULATIONAHA.115.016261
Pasquini M, Benedictus MR, Boulouis G, Rossi C, Dequatre-Ponchelle N, Cordonnier C. Incident Cerebral Microbleeds in a Cohort of Intracerebral Hemorrhage. Stroke. 2016;47:689–94.
doi: 10.1161/STROKEAHA.115.011843
Perry LA, Rodrigues M, Al-Shahi Salman R, Samarasekera N. Incident Cerebral Microbleeds After Intracerebral Hemorrhage. Stroke. 2019;50:2227–30.
doi: 10.1161/STROKEAHA.118.023746
Morotti A, Shoamanesh A, Oliveira-Filho J, et al. White Matter Hyperintensities and Blood Pressure Lowering in Acute Intracerebral Hemorrhage: A Secondary Analysis of the ATACH-2 Trial. Neurocrit Care. 2020;32:180–6.
doi: 10.1007/s12028-019-00761-0
Caprio FZ, Maas MB, Rosenberg NF, et al. Leukoaraiosis on magnetic resonance imaging correlates with worse outcomes after spontaneous intracerebral hemorrhage. Stroke. 2013;44:642–6.
doi: 10.1161/STROKEAHA.112.676890
Benedictus MR, Hochart A, Rossi C, et al. Prognostic factors for cognitive decline after intracerebral hemorrhage. Stroke. 2015;46:2773–8.
doi: 10.1161/STROKEAHA.115.010200
Charidimou A, Boulouis G, Shams S, Calvet D, Shoamanesh A. Intracerebral haemorrhage risk in microbleed-positive ischaemic stroke patients with atrial fibrillation: Preliminary meta-analysis of cohorts and anticoagulation decision schema. J Neurol Sci. 2017;378:102–9.
doi: 10.1016/j.jns.2017.04.042
Walsh KB, Woo D, Sekar P, et al. Untreated Hypertension: a Powerful Risk Factor for Lobar and Nonlobar Intracerebral Hemorrhage in Whites, Blacks, and Hispanics. Circulation. 2016;134:1444–52.
doi: 10.1161/CIRCULATIONAHA.116.024073
Rodriguez-Torres A, Murphy M, Kourkoulis C, et al. Hypertension and intracerebral hemorrhage recurrence among white, black, and Hispanic individuals. Neurology. 2018;91:e37–44.
doi: 10.1212/WNL.0000000000005729
Leasure AC, King ZA, Torres-Lopez V, et al. Racial/ethnic disparities in the risk of intracerebral hemorrhage recurrence. Neurology. 2020;94:e314–22.
doi: 10.1212/WNL.0000000000008737
Churchwell K, Elkind MSV, Benjamin RM, et al. Call to action: structural racism as a fundamental driver of health disparities: a presidential advisory from the American heart association. Circulation. 2020;142:e454–68.
pubmed: 33170755
Kleindorfer DO, Lindsell C, Broderick J, et al. Impact of socioeconomic status on stroke incidence: a population-based study. Ann Neurol. 2006;60:480–4.
doi: 10.1002/ana.20974
Vivanco-Hidalgo RM, Ribera A, Abilleira S. association of socioeconomic status with Ischemic stroke survival. Stroke. 2019;50:3400–7.
doi: 10.1161/STROKEAHA.119.026607
Havranek EP, Mujahid MS, Barr DA, et al. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American heart association. Circulation. 2015;132:873–98.
doi: 10.1161/CIR.0000000000000228
Mszar R, Mahajan S, Valero-Elizondo J, et al. Association between sociodemographic determinants and disparities in stroke symptom awareness among US young adults. Stroke. 2020;51:3552–61.
doi: 10.1161/STROKEAHA.120.031137