Consensus Statement Advocates for Immediate Change to Intracerebral Hemorrhage Protocol

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An international consortium of clinicians recommended evidence-based guidelines for intracerebral hemorrhage, in which early intervention, bundled care, and time-based metrics substantially improve neurological outcomes.

Stephan A. Mayer, MD, FCCM, FNCS, director of neurocritical care and emergency neurology services at Westchester Medical Center Health System, and professor of neurology and neurosurgery at New York Medical College

Stephan A. Mayer, MD, FCCM, FNCS

In the journal Stroke, an international consortium of clinicians published a consensus statement on intracerebral hemorrhage (ICH), claiming that quality improvement efforts in the emergency management of ICH should be a priority for patients.1

After reviewing evidence, the report suggested that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the potential for limiting hematoma expansion and improving functional recovery compared with other approaches. Research has shown that patients with ICH who fail to receive early aggressive care have worse outcomes, which the authors noted suggests an important treatment opportunity exists.

Top Clinical Takeaways

  • Early bundled care, incorporating multiple interventions simultaneously, emerges as a promising approach to limit hematoma expansion and enhance functional recovery.
  • Establishment of Code ICH, inspired by acute ischemic stroke protocols, represents a step towards ensuring timely and standardized care for intracerebral hemorrhage.
  • Adoption of a focused early bundle of care, with an emphasis on time-based metrics for critical interventions, is crucial for optimizing the benefits of widely-used treatments.

“Neurologists typically cite the phrase ‘time is brain’ to educate the public about the importance of acting quickly when someone is suspected of having a stroke,” cosenior author Stephan A. Mayer, MD, FCCM, FNCS, director of neurocritical care and emergency neurology services at Westchester Medical Center Health System, and professor of neurology and neurosurgery at New York Medical College, said in a statement.2 “The fact of the matter is that this principle is unevenly applied. Hospitals are required to treat ischemic stroke urgently and report their performance but are under no obligation to do the same for ICH, even though it’s a more deadly disease. This disconnect has to change.”

READ MORE: Understanding Optimal Time to Initiate Anticoagulation: The START Trial

An international panel of 18 experts in ICH care from the United States, Canada, China, Australia, Italy, the United Kingdom, and Germany, reviewed the latest evidence for treating ICH supporting the effectiveness of various strategies. These strategies included lowering of elevated blood pressure, reversal of blood thinners, treatment for brain swelling, and surgical hematoma removal. Based on the research, the experts advocated for the immediate and widespread adoption of a “care bundle” designed to reduce blood pressure and reverse the effects of blood thinners in 1 hour of arrival to the hospital.

“ICH is an emergency and should be treated as one,” cosenior author Joshua N. Goldstein, MD, PhD, professor of emergency medicine at the Harvard Medical School, said in a statement.2 “We know that during the first hours after a brain hemorrhage there is active bleeding that causes continued damage in up to 40% of patients. Stroke centers regularly treat hypertension and reverse anticoagulation, but there are currently no standards or requirements to give these treatments as quickly as possible.”

According to the gathered evidence, investigators observed that hematoma expansion is an independent predictor of poor functional outcome and thus, is a compelling target for intervention. In addition, randomized trials over the past decades aimed at decreasing hematoma expansion through single interventions but failed to meet their primary outcomes of statistically significant improvement in neurological outcomes.

“Care bundles that emphasize ultra-early intervention for ICH have been studied; they dramatically reduce treatment times and improve outcome” lead author Qi Li, MD, PhD, Chair of Neurology at The Second Affiliated Hospital of Anhui Medical University, in Hefei, China, said in a statement.2“Evidence-based guidelines from professional organizations are used to codify best practices, but they can take years to develop. We wrote this consensus statement because our patients can’t wait that long. ICH is a life and death situation, and the time to act is now.”

All told, prevention of hematoma expansion and early evacuation of larger lobar hemorrhages stands could be a main target for improving outcomes among patients with ICH. Investigators noted algorithms for prehospital diagnosis of ICH, advanced imaging including artificial intelligence and radiomics to predict hematoma expansion, and ultra-early hemostatic therapy for noncoagulopathic ICH may be promising areas in further research. Authors also noted that other promising areas of research may include specific reversal agents for coagulopathic ICH, neuroprotective therapies that minimize hemoinflammation, early surgical intervention, and refinements of nursing care and neurocritical care support. 

REFERENCES
1. Li Q, Yakhkind A, Alexandrov AW, et al. Code ICH: A Call to Action. Stroke. Published online December 15, 2023. doi:10.1161/STROKEAHA.123.043033
2. Mayer S. Global Experts Call for Tighter Standards to Speed Emergency Treatment for Hemorrhagic Stroke – A “Life and Death Situation,” They Say. News release. New York Medical College. Published December 19, 2023. Accessed January 3, 2023.
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