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ARTICLES: D. L. Labovitz, A. Halim, B. Boden-Albala, W. A. Hauser, and R. L. Sacco The incidence of deep and lobar intracerebral hemorrhage in whites, blacks, and Hispanics Neurology 2005; 65: 518-522 [Abstract] [Full text] [PDF]

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Reply to Flaherty et al

Daniel L. Labovitz, MD, MS, A. Halim, PhD, B. Boden-Albala, PhD, W. A. Hauser, MD and R. L. Sacco, MD, MS   (27 September 2005)

Racial Variations in Location of Intracerebral Hemorrhage

Matthew L. Flaherty, MD, Daniel Woo, MD and Joseph Broderick, MD   (27 September 2005)

Reply to Flaherty et al 27 September 2005
Daniel L. Labovitz, MD, MS, St. Luke's-Roosevelt Hospital Center 1111 Amsterdam Avenue, New York, NY 10025, A. Halim, PhD, B. Boden-Albala, PhD, W. A. Hauser, MD and R. L. Sacco, MD, MS Send Correspondence to journal: Re: Reply to Flaherty et al dll20{at}columbia.edu Daniel L. Labovitz, MD, MS, et al.	We admire Flaherty et al's article on racial differences in incidence of deep versus lobar hemorrhage in Greater Cincinnati/Northern Kentucky.[2] The findings for blacks versus whites in the two studies were broadly similar but the large number of cases in their study permitted further distinction between deep cerebral, brainstem and cerebellar locations.[1,2] They assert that their study substantiates our hypothesis that prevalence of hypertension would influence risk of deep ICH more than lobar ICH. Thus, in blacks compared to whites, the risk ratio for deep ICH would be greater than the RR for lobar ICH. Flaherty et al did not perform a statistical test to confirm such a difference. Casual inspection of the RR point values and confidence intervals in their paper suggests that, versus lobar ICH (RR 1.4 95% CI 1.0-1.8), the RR appears to be significantly higher for brainstem ICH (3.3, 95% CI 2.0-5.5) but may not be for deep cerebral (1.7, 95% CI 1.4-2.1) or cerebellar ICH (0.9, 95% CI 0.5-1.6).[2] Why such variation might exist between deep structures considered particularly vulnerable to stroke mediated by hypertension is puzzling. Flaherty et al highlight that blacks were not only at higher risk than whites of suffering ICH, but that their hemorrhages occurred earlier in life, regardless of location. [2] We also found that blacks (mean age 66) were significantly younger than whites (mean age 76, p<0.01). Strikingly, Hispanics (mean age 57) were significantly younger even than blacks (p<0.01). Age gaps that wide make the burden of disease greater. The authors report no conflicts of interest.
Racial Variations in Location of Intracerebral Hemorrhage 27 September 2005
Matthew L. Flaherty, MD, University of Cincinnati University of Cincinnati Medical Center, 231 Albert Sabin Way, MSB Room 5060, Cincinnati, OH 45267, Daniel Woo, MD and Joseph Broderick, MD Send Correspondence to journal: Re: Racial Variations in Location of Intracerebral Hemorrhage matthew.flaherty{at}uc.edu Matthew L. Flaherty, MD, et al.	Dr. Labovitz et al hypothesize that compared to whites, among blacks and Hispanics “race-ethnic differences in the risk of deep ICH would be greater than for lobar ICH, reflecting high prevalence or inadequate treatment of hypertension.” [1] While their point estimates for rate ratios (RRs) suggest such a relationship, their sample size of 155 cases provided insufficient power to reach statistical significance. Our own population- based study of 1038 ICH cases in the Greater Cincinnati area (an essentially bi-racial population of blacks and whites) substantiates this hypothesis. [2] While the risk of ICH in Cincinnati was greater in blacks than whites for deep cerebral, lobar, and brainstem (but not cerebellar) locations, the greatest excess risk was found among young and middle-aged blacks in deep cerebral and brainstem locations, with RRs as high as 9.8 for brainstem ICH in blacks age 35-54. Although hypertension is the leading candidate for the observed differences in risk, the design of our study prohibited definitive conclusions in this regard. [2] Unlike Manhattan, we did not find excess risk among men compared to women (RR 1.1), though men tended to have more deep ICH and women (especially very elderly women) more lobar ICH. [2] Labovitz et al also raise the question of whether hypertension is a risk factor for lobar ICH. The interim analysis of our case control study of ICH did not show a relationship, but a more recent analysis suggests that untreated hypertension may increase risk of lobar ICH. [3,4] We hope that with further recruitment our study will be able to clarify the relationship of lobar ICH, age, race, and treated or untreated hypertension. Finally, Labovitz et al indicate that our case-control study found current smoking to be a risk factor for lobar ICH. [1] While the odds ratio for smoking was significant in univariate analysis, this association did not persist in multivariate modeling. [3] References 1. Labovitz DL, Halim A, Boden-Albala B, Hauser WA, Sacco RL. The incidence of deep and lobar intracerebral hemorrhage in whites, blacks, and Hispanics. Neurology. 2005;65:518-522. 2. Flaherty ML, Woo D, Haverbusch M, et al. Racial variations in location and risk of intracerebral hemorrhage. Stroke. 2005;36:934-937. 3. Woo D, Sauerbeck LR, Kissela BM, et al. Genetic and environmental risk factors for intracerebral hemorrhage: Preliminary results of a population- based study. Stroke. 2002;33:1190-1196. 4. Woo D, Kaushal R, Chakraborty R, et al. Association of apolipoprotein E4 and haplotypes of the apolipoprotein E gene with lobar intracerebral hemorrhage. Stroke. 2005;in press. The authors report no conflicts of interest.