Educational attainment in hemorrhagic stroke severity and functional outcome

Abstract

Introduction: While stroke education is a hallmark of clinical care in primary stroke centers, the educational attainment of patients is rarely considered. The objective of this study is to determine whether educational attainment, in addition to traditional risk factors, is associated with intracerebral hemorrhage (ICH) severity and functional outcomes.<break><break>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. Data on social determinants of health (SDOH), past medical history for ICH risk factors, and ICH severity were obtained on admission. The primary outcome was stroke severity, calculated using the ICH score. The secondary outcome was 12-month modified Rankin Score (mRS). <break><break>Results: Of 2,539 patients eligible for analyses, 1,744 (69%) presented with mild ICH (ICH Score < 3) and 795 (31%) presented with severe ICH (ICH score 3). In a multivariable logistic regression analysis controlling for age, income, and a pre-stroke diagnosis of coronary artery disease, only educational attainment was associated with stroke severity, with patients with high school-only education more likely to present with a severe ICH compared to college diplomates (odds ratio 2.37, 95% CI 1.77, 3.19). Additionally, those with high school-only education were less likely to recover to a good functional outcome (mRS<4) after ICH when compared to college diplomates (odds ratio 0.43, 95% CI 0.19, 0.93) when controlling for stroke severity, and pre-stroke diagnoses of hypertension and dementia. <break><break>Discussion: Pre-stroke educational attainment is an independent predictor of ICH severity and subsequent functional outcomes at 12-month post-stroke. Given the association with recovery, tailoring inpatient stroke education to level of educational attainment may serve to reduce the disparity in outcomes after hemorrhagic stroke. Educational attainment may act as both a social and a biological determinant, and could represent a modifiable risk factor for ICH survivors.