Race and Medicine

Race and Medicine

Disclosures: Castello reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
May 03, 2021
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Cerebral small vessel disease implicated in greater ICH recurrence risk among minorities

Disclosures: Castello reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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An analysis of more than 900 patients demonstrated significant differences in cerebral small vessel disease subtypes and severity among white and minority patients who survived a primary intracerebral hemorrhage.

The results, which were published in Neurology, have “direct implication[s] for known disparities” in the risk for recurrent intracerebral hemorrhage, according to the researchers.

“Survivors of [intracerebral hemorrhage] are at high risk of recurrent [intracerebral hemorrhage], which is particularly fatal. Individuals of Black and Hispanic racial/ethnic background are at an even higher risk for recurrence, and thus mortality, compared to their white counterparts,” Juan Pablo Castello, MD, and colleagues wrote. “Hypertension is the most potent risk factor for first-ever and recurrent [intracerebral hemorrhage]. While minority [intracerebral hemorrhage] survivors in the United States display greater hypertension severity and higher blood pressure variability, these differences in hypertension control do not fully account for disparities in [intracerebral hemorrhage] recurrence risk.”

As a result, the identification of other risk factors for recurrent intracerebral hemorrhage among these minority groups is necessary to “guide future clinical research, develop more effective treatment guidelines and inform public health efforts,” Castello and colleagues wrote. Castello is a research fellow in the Aging & Brain Health Research Group in the department of neurology at Massachusetts General Hospital.

The researchers analyzed data from the Massachusetts General Hospital ICH study (n = 593) and the Ethnic/Racial Variations of ICH (n = 329) studies. They used cerebral small vessel disease (CSVD) markers obtained from MRIs taken within 90 days of the index intracerebral hemorrhage to categorize intracerebral hemorrhage cases as related to cerebral amyloid angiopathy (CAA), hypertensive arteriopathy (HTNA) or mixed etiology. They calculated CSVD burden according to validated global, CAA-specific and HTNA-specific scores. Castello and colleagues also compared CSVD subtype and severity among white, Black and Hispanic survivors of intracerebral hemorrhage and examined its relationship with intracerebral hemorrhage recurrence risk.

The total study population of 922 survivors of intracerebral hemorrhage included 655 white patients, 130 Black patients and 137 Hispanic patients.

Castello and colleagues found that minority survivors of intracerebral hemorrhage demonstrated greater CVSD (P = .011) and HTNA (P = .021) burdens on MRI. Additionally, minority survivors of intracerebral hemorrhage with HTNA-related etiology and mixed etiology experienced a greater HTNA burden, which led to an increased risk for intracerebral hemorrhage recurrence (all values, P < .05).

These results are “in agreement with previous studies,” according to Castello and colleagues.

The researchers also noted that, in a prior study, they identified “significant differences in average systolic BP and its variability between white and minority [intracerebral hemorrhage] survivors.” That research also found that differences in hypertension control following an intracerebral hemorrhage “did not fully account” for racial/ethnic disparities in the risk for recurrence.

“The present analyses point to underlying CSVD subtype and severity as independent factors accounting for this health inequality,” Castello and colleagues wrote. “These findings will be critical in guiding future clinical and research efforts in the realm of secondary prevention after [intracerebral hemorrhage]. Specifically, the role of MRI-based CSVD evaluation in identifying at-risk minority [intracerebral hemorrhage] survivors deserves attention in future studies.”

The researchers pointed to the examination of whether CSVD burden, according to a validated rating score such as a global CSVD score, would inform goals related to BP control in patient groups with an increased risk for recurrent intracerebral hemorrhage as one example of what to look at in future studies.

The findings from the present study also “reinforce the importance of implementing secondary stroke prevention strategies aimed at minority [intracerebral hemorrhage] survivors,” according to the researchers.

“We and other[s] previously showed that hypertension control rates are low among [intracerebral hemorrhage] survivors, and lower still among minority individuals,” Castello and colleagues wrote. “Secondary stroke prevention after [intracerebral hemorrhage] will therefore benefit from focusing clinical care on adequate antihypertensive management (focusing on drug selection, avoiding medication undertreatment and encouraging medication adherence), regular outpatient follow-up, and lifestyle modifications (increased physical activity, dietary modification, smoking cessation, weight reduction).”