Educational attainment in hemorrhagic stroke severity and functional outcome

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. 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). 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. 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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Drs. Yechoor, Rist, Mayerhofer, and Parodi received no external funding. Drs. Anderson Rosand receive research support from the National Institute of Health and the American Heart Association. Dr. Rosand has served on the scientific advisory board for Takeda Pharmaceuticals and receives consulting fees from the National Football League. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The MassGeneral Brigham IRB provided approval for this research study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Not Applicable The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.