A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional outcome. Similarly, patients who fail to receive early aggressive care have worse outcomes, suggesting that a tremendous treatment opportunity exists. We call to establish the concept of “Code ICH,” similar to current protocols for ischemic stroke. We advocate for widespread adoption of an early bundle of care focused on early blood pressure control, emergency reversal of anti-coagulation, and early supportive care, with the goal of optimizing the benefit of these already widely-used interventions.
Bundled care improves outcomes in the management of many different health conditions, including stroke and ICH. It may be that no individual factor improves outcome in isolation; rather, it is the combined effort of multiple interventions that minimizes bleeding and saves brain function.
All patients with acute onset of stroke or ICH symptoms should undergo rapid brain imaging. In addition, early CT angiography (CTA) can detect underlying vascular abnormalities that may have caused the ICH, and can help predict which patients will develop ICH expansion.
Hypertension is a common finding in the acute phase of ICH, and is associated with hematoma expansion and poor clinical outcome. Control of hypertension in the acute phase is therefore a reasonable mechanistic action that might alleviate the risk of expansion and improve outcome. Several sources of evidence are suggestive that intensive BP lowering, especially when started very early, may provide benefit. However, there may be risks associated with overly rapid BP lowering, SBP lower than 120mmHg, and also with wide fluctuations in BP. We recommend, therefore, early initiation of BP lowering, and close monitoring to ensure smooth continuous control.
Several sources of evidence suggest that intensive BP lowering, especially when started very early, improves outcome. The most clear evidence comes from the INTERACT-3 trial. In this trial, those presenting within 6 hours received benefit from a target of SBP<140 within 1 hour (even if it took more than an hour, and even though many actually only achieved SBP<150). It turns out that actively trying to lower SBP quickly is beneficial, even if you don’t literally accomplish that specific goal!
Different centers will likely adopt different targets; the most important thing is to create a target and work systematically to hit it. For example:
Anticoagulation-associated ICH is associated with higher risk of ICH expansion and worse outcomes. For most existing anticoagulants, specific reversal agents are available, and should be used rapidly. We recommend rapid identification of which, if any, anticoagulant agents patients are using; laboratory testing (if available) to measure the anticoagulant effect (such as INR in vitamin K antagonists), or last dose taken for those agents with no available test. Note that DOACs (Direct Oral Anticoagulants) may not affect the routinely performed coagulation tests (PT, INR, PTT), so normal levels are not necessarily reassuring. The benefits of anticoagulation reversal are probably highly time dependent, as hematoma expansion happens early; providing treatment later incurs all the same costs and risks, while minimizing benefit. Treat quickly!
Performing, and documenting, an initial neurologic exam, is critical to document disease severity. Serial neurologic assessments then help providers track changes in neurologic status that can be the first signal of ICH expansion, edema formation, hydrocephalus, mass effect, or other changes that can be treated early if diagnosed. We recommend an initial neurologic exam with a commonly used tool such as the NIHSS, and an initial severity score such as the ICH score, then serial exams by nurses trained in performing them.
The optimal surgical therapeutic time window and surgical technique is not yet clear. HOWEVER, existing data suggest that experienced surgeons who successfully remove most of the hematoma with minimally invasive techniques can improve outcome. The ENRICH trial found that ICH evacuation within 24 hours using a specialized approach improved outcome.
Both hyperglycemia and hypoglycemia are clearly associated with worse outcomes, and normoglycemia should be rapidly achieved and maintained. One large trial showed that treatment of hyperglycemia, as part of a care bundle, improved outcomes in both ischemic and hemorrhagic stroke, and observational studies are all consistent with this.
Patients with ICH are at risk for abnormal swallow function, and at risk of aspirating. One large trial showed that minimizing oral intake in those who do not pass a swallow screen, as part of a care bundle, improves outcomes.
Many patients with ICH are at risk of aspiration, and ICP elevation. Raising the head of the bed to 30 degrees may minimize this. One large trial failed to demonstrate benefit of this intervention; however, it showed no harm, and it may be that specific patients truly do need this, and that it is difficult in the acute phase to distinguish these. As a result, we recommend the default for ICH, absent a reason otherwise such as hypotension, be head of bed at least 30 degrees.