(Stroke. 1997;28:961-964.)
© 1997 American Heart Association, Inc.
Articles |
Intracerebral Hemorrhage in Blacks
Risk Factors, Subtypes, and Outcome
From the Department of Neurology, Emory University School of Medicine, Atlanta, Ga.
Correspondence to Michael R. Frankel, MD, Department of Neurology, Grady Memorial Hospital, BG 001, 80 Butler St, Atlanta, GA 30335.
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Abstract |
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Background and Purpose Blacks are at a higher risk for intracerebral hemorrhage (ICH) than whites; however, few data are available regarding the demographic and clinical characteristics of ICH among blacks.
Methods We determined the frequency of risk factors, etiologic subtypes, and outcome among consecutive black patients admitted with nontraumatic ICH to a university-affiliated public hospital.
Results The most common risk factors in the 403 black patients with ICH were preexisting hypertension (77%), alcohol use (40%), and smoking (30%). Among the 91 nonhypertensive patients, 21 (23%) were diagnosed with hypertension after onset. Compared with women, men had a younger age of onset (54 versus 60 years; P<.001) and higher frequency of alcohol use (54% versus 22%; P<.001) and smoking (39% versus 17%; P<.001). ICH secondary to hypertension (n=311) and of undetermined etiology (n=73) were the most common subtypes in blacks. Patients aged 65 years and older (compared with those aged 15 to 44 years; P=.001) and women (compared with men; P=.02) were more likely to be dependent at discharge.
Conclusions Primary preventive strategies are required to reduce the high frequency of modifiable risk factors predisposing to ICH in blacks.
Key Words: alcohol drinking • blacks • hypertension • intracerebral hemorrhage
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Introduction |
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Intracerebral hemorrhage (ICH) is a major cause of morbidity and mortality in patients with stroke.1 2 3 Previous reports have suggested that the rate of ICH is higher in blacks than in whites.4 5 6 7 However, previous studies of ICH in adults have primarily included other races.8 9 10 11 12 13 14 15 Therefore, the risk factors for ICH in blacks, which may be useful in developing strategies of prevention and management, remain largely uninvestigated. Moreover, etiologic subtypes and outcomes of ICH in blacks are not well defined.
To examine risk factors, subtypes, and outcome of ICH in blacks, we undertook a retrospective study in our university-affiliated public hospital, which serves a predominantly black population.
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Subjects and Methods |
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Patients
We studied all patients with ICH admitted to Grady Memorial Hospital in Atlanta, Ga, between January 1, 1990, and December 31, 1995. Eligible patients were identified by computerized search of all discharges with International Classification of Diseases, 9th Revision (ICD-9) codes 431 and 432.9. The discharge transcription of each patient was reviewed. We excluded patients with ICH secondary to trauma and patients in whom further evaluation excluded an ICH.
Data Collection
We collected the following information from each eligible
patient's discharge transcription: (1) age, sex, and race as
determined by the triage clerk; and (2) presence of the following risk
factors before onset of stroke (noted in the discharge transcription):
hypertension, diabetes mellitus, current smoking, use of cocaine, use
of alcohol, history of stroke, heart disease (coronary heart
disease and cardiac failure), and renal disease. We accepted physician
diagnosis of the aforementioned medical conditions made during previous
clinic visit or hospital admission. The information was acquired on
presentation from either the patients and their family or
previous medical records. We also recorded use of
antihypertensive, anticoagulant, and antithrombotic medications before
admission with compliance status. We attempted to obtain information
not mentioned in the discharge transcription by reviewing previous
discharge summaries, results of previous laboratory tests, and the
pharmacy record from preceding clinic visits. The information was
presumed to be absent if we were unable to find clear
documentation.
Diagnosis of Hypertension
Hypertension was divided into two categories: (1) established if
diagnosis of hypertension was made before onset of ICH or (2) newly
diagnosed if a previously undiagnosed patient required long-term
antihypertensive medication for control of blood pressure 1 week after
the onset of ICH. Newly diagnosed hypertension was not assigned in
patients who died within 1 week after onset of ICH.
Etiologic Classification of ICH
The definition of ICH was based on the criteria of the National
Institute of Neurological Disorders and Stroke and required
confirmation by CT.13 One physician (M.A.K.S.) classified
all ICH into the following categories: (1) probable hypertensive ICH
defined on the basis of presence of established or newly diagnosed
hypertension with hematoma at typical sites for hypertensive bleeding
(basal ganglia, thalamus, or pons) or at sites less likely to be
associated with hypertension or to have a high frequency of underlying
vascular lesions (lobar, cerebellar, or
intraventricular), after other etiologies were
ruled out with conventional angiography and/or MRI; (2) possible
hypertensive ICH defined on the basis of presence of established or
newly diagnosed hypertension with hematoma at sites less likely to be
associated with hypertension or to have a high frequency of underlying
vascular lesions (lobar, cerebellar, or
intraventricular) without exclusion of other
etiologies; (3) related to arteriovenous malformation; (4) secondary to
aneurysmal rupture (categories 3 and 4 were angiographic or MRI
diagnoses); (5) related to cavernous malformation diagnosed by MRI; (6)
secondary to thrombolysis or anticoagulation; and (7)
of undetermined etiology defined as ICH without features typical of
hypertensive etiology and normal or no angiograms.
Outcome
A modified Rankin scale16 was used to assess each
patient's functional status at discharge. One investigator (M.A.K.S.)
determined the Rankin scale for all patients based on description of
neurological deficits at discharge in the discharge summary. Patients
with a Rankin score of 3 or less at discharge were defined as
independent.
Statistical Analysis
We performed univariate analysis with Epi
Info 5.117 using the 
2 method.
Results are given as mean±SD. We considered a value of
P<.05 significant. Means were compared with ANOVA.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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We identified 581 patients by computerized search of all discharges with the aforementioned ICD-9 codes. Patients with traumatic ICH (n=18), subarachnoid hemorrhage (n=13), subdural hemorrhage (n=12), other brain mass lesions (n=10), no documented hemorrhage (n=33), sepsis (n=5), seizure (n=1), no available records (n=37), anoxic encephalopathy (n=1), cerebral infarction (n=14), and pediatric patients (n=9) were not included in the analysis. A total of 428 patients were admitted to our hospital with the diagnosis of ICH from January 1990 through December 1995. There were 403 blacks, 22 whites, and 3 Asian Americans. The mean age of onset in black patients was 56.4±14.3 years; 228 were men and 175 were women. Men had a younger age of onset than women (54 versus 60 years; P<.001). Each patient had a CT scan of the head at admission. Of these, 80 patients were further investigated with a conventional angiography (n=55) and/or MRI (n=43). Of the 403 patients, surgical evacuation of hematoma was performed in 48 patients (12%).
Risk Factors
The frequency of risk factors among black patients according to
age strata is shown in Table 1
. Established hypertension
was the most common risk factor among blacks with ICH in all age
strata. Of the 312 patients with established hypertension, 34% (n=106)
were noncompliant with antihypertensive medication, 13% (n=41) were
not receiving any treatment, 7% (n=22) were on regular medication, and
treatment status was unknown in 46% (n=143). Hypertension was newly
diagnosed in 21 (23%) of the 91 patients with no previous history of
hypertension. Alcohol and cocaine use were significantly higher in
patients between the ages of 15 and 44 years than in patients aged 65
years or older (Table 1). Of the 403 patients, 98 patients had a
previous history of stroke, heart disease, and/or renal disease.
Compared with women, men had a higher frequency of alcohol use (54%
versus 22%; P<.001) and smoking (39% versus 17%;
P<.001). There were no differences in the frequency of the
following factors in men compared with women: hypertension (78% versus
77%; P=.8), cocaine use (12% versus 10%;
P=.9), coronary artery disease (19% versus 13%;
P=.2), and renal disease (14% versus 9%; P=.2).
Women had a higher frequency of previous stroke than men (19% versus
11%; P=.05). There were no differences between the
frequency of hypertension, alcohol use, and smoking in nonblacks
compared with blacks.
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Subtypes of ICH
The etiology of ICH with site of hematoma in black patients is
shown in Table 2. Hypertensive ICH was the most common
subtype of ICH. Of the 311 patients with probable or possible
hypertensive ICH, 105 were noncompliant with antihypertensive
medication, 38 were receiving no treatment, and 18 had previously
undetected hypertension. Only 19 of the 311 patients with hypertensive
ICH had documented compliance with antihypertensive medication, and
treatment status was unknown in 131 patients. Patients with unknown
treatment status were more likely to have lobar hemorrhages
than those with known treatment status (26 of 162 versus 50 of 149;
P=.002). There was no relationship between treatment status
and location of hematoma among patients with known treatment status.
The diagnostic yield of vascular neuroimaging for
structural lesions associated with ICH was 13% (n=11) in the 80
patients who underwent conventional angiography (positive yield in 5 of
55) and/or MRI (positive yield in 6 of 43).
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Outcome
At discharge, 162 black patients (40%) were functionally
independent. Overall mortality was 40% (n=162). Of these 162 patients,
115 (71%) died within 1 week of presentation. There was no
relationship between mortality within the first week and presence of
hypertension (P=.2), diabetes mellitus (P=.9),
smoking (P=.2), cocaine use (P=.9), or alcohol
use (P=.5). The outcome at discharge according to age strata
is shown in the Figure. Although mortality was similar
in all age groups, patients aged 65 years or older were more likely to
be functionally dependent at discharge than patients aged 15 to 44
years (32% versus 12%; P=.001). There was no difference in
mortality in women compared with men; however, women were more likely
to be dependent at discharge (25% versus 15%; P=.02).
Mortality was similar among black patients and nonblack patients (40%
versus 24%; P=.2). In patients with hypertensive
hemorrhages, there was no relationship between treatment status
of hypertension and outcome (P=.9).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Presently, there is no effective treatment for ICH, and therefore efforts must be directed toward better understanding and modification of risk factors in patients at risk for ICH. Our study identified a high prevalence of modifiable risk factors1 8 9 10 15 in a population shown to be at high risk for ICH in previous studies.4 5 6 7 This study is an extension of a previous study at our hospital18 investigating factors associated with mortality in black patients with spontaneous ICH. In the present study we investigated all nontraumatic cases of ICH with main emphasis on the risk factor burden in this patient population. To our knowledge, this is the first study to estimate the risk factor burden in black patients with ICH. We believe that this is the first step toward designing effective strategies for primary prevention of ICH in blacks. In addition, we provide an account of the subtypes and outcome of ICH in black patients stratified by age, which may be of benefit to clinicians involved in the management of blacks with ICH in urban hospitals.
Hypertension was the most common risk factor for ICH in blacks, as recognized in previous studies.19 20 21 22 We found a high prevalence of hypertensive patients without treatment in our study because of noncompliance, lack of treatment, or early detection. The frequency of inadequate treatment is underestimated in our study because treatment status was not available for half of the patients, and our criteria for defining undiagnosed hypertension could not be applied to patients who died during the acute phase of ICH. We believe that poor control of hypertension, as demonstrated by the premorbid presence of diseases associated with hypertension such as stroke and heart and renal disease, had an important contribution to the association between hypertension and ICH in our population. The reasons for this large proportion of inadequately treated hypertension among our patients remain to be defined. In a previous study of stroke in young black patients with stroke, we found that almost half of the patients were uninsured.23 Medication in our hospital is not provided without cost for many patients, and therefore it is conceivable that inability to afford medical care, including medication, may have played a role. Alcohol use and smoking were other important risk factors in our population, particularly in younger men, which is similar to findings in other studies1 8 9 10 15 and may account for the earlier onset of ICH in men than in women.
Hypertensive ICH was the most common form of ICH in blacks, and almost half of these patients had untreated hypertension. Eighteen percent of patients did not have an underlying etiology for ICH. This group may represent hemorrhages due to undetected hypertension or other yet undefined predisposing conditions. In contrast to other populations,24 25 our data suggest that underlying cerebrovascular lesions such as arteriovenous malformation may be uncommon causes of ICH in blacks. This was demonstrated by the low yield of vascular neuroimaging (13%) in patients considered at high risk by their referring physicians based on the clinical presentation and CT appearance of the hematoma.
The mortality of blacks with ICH was similar to that reported for ICH in other populations.1 26 Almost half of the patients were functionally independent at discharge. Patients aged 65 years or older and women were more likely to be dependent at discharge. The association of age with poor functional outcome is recognized in previous studies.16 27 The poor functional outcome in women may be secondary to the higher frequency of previous stroke. More studies are required to understand these sex-related differences in risk factors and outcome of ICH in blacks.
This study has certain important limitations. The results presented are representative of a public hospital serving a predominantly black population of lower socioeconomic status23 and therefore may not reflect the characteristics of patients at other hospitals. Furthermore, since this is a retrospective case series, certain variables such as alcohol and drug abuse may be underrepresented. Because conventional imaging and/or MRI was not performed in all patients, our data may underestimate the frequency of vascular abnormalities in patients with undetermined etiology of stroke.
In conclusion, we found a high frequency of modifiable risk factors and behaviors, including untreated hypertension, smoking, and alcohol and cocaine use, particularly among young black men. Multiple studies have demonstrated the efficacy of active treatment of hypertension in reducing the incidence of stroke, particularly fatal strokes.28 29 30 These observations suggest that efforts directed toward modification of risk factor profile, particularly active treatment of hypertension, could potentially reduce the incidence of ICH in blacks.
Received January 15, 1997; revision received February 27, 1997; accepted February 27, 1997.
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