Mission Statement

Intracerebral hemorrhage (ICH) is the most devastating subtype of stroke, leading to high rates of severe disability and mortality.

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

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.

Rapid neuroimaging

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.

Imaging goals:

  • CT within 25 minutes.
  • CTA for most patients.

Blood Pressure Control

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!

Blood pressure goals:

Different centers will likely adopt different targets; the most important thing is to create a target and work systematically to hit it. For example:

  • INTERACT-3: For those presenting within 6 hours of onset, target SBP 130-140mmHg within 1 hour of arrival
  • ABC-ICH: For those presenting within 6 hours of onset, Target SBP 130-140mmHg within 1 hour of initiating BP lowering therapy.
  • Stratify by SBP:
    • If initial SBP<190mmHg, then target a goal SBP of 130-150mmHg within 60 minutes.
    • If initial SBP>=190mmHg, then aim to lower this by 60mmHg within 60 minutes.

Anticoagulation Reversal

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!

Anticoagulant reversal goals:

  • Choose the right agent, and treat within 60 minutes:
    • Vitamin K antagonists (warfarin, coumarins): IV vitamin K and 4F-PCC to achieve INR <=1.4
    • Factor II inhibitor (dabigatran): Idarucizumab
    • Factor Xa inhibitor (rivaroxaban, apixaban): Andexanet if available; 4F-PCC as second line
    • Antiplatelet agents (aspirin, clopidogrel): Desmopressin (note- platelet transfusions are probably harmful)

Neurologic assessment

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.

Neurologic exam goals:

Surgical therapy

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.

Surgical goals:

  • Early communication (within 60 minutes) with a specialist, such as a neurosurgeon, neurointensivist, or stroke neurologist, to determine best available options.
  • For those candidates for neurosurgery, evaluation within 24 hours of onset for surgical evacuation.

Glucose control

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.

Glycemic goals:

  • Hyper or hypoglycemia: Initial treatment within 60 minutes
  • Then aim for normoglycemia
    • Target blood glucose level of 110mg/dL-140mg/dL for nondiabetic patients
    • Target blood glucose level of 110mg/dL-180mg/dL for diabetic patients
    • Maintain this for 7 days or hospital discharge.

Temperature control

It is not clear whether cooling, or targeted temperature management, provides specific benefit for ICH. However, hyperthermia is most likely harmful, particularly in the acute phase. One large trial showed that treatment of temperature elevations, as part of a care bundle, improved outcomes in both ischemic and hemorrhagic stroke, and observational studies are all consistent with this.

Temperature goals:

Serial temperature checks, and treat elevated temperature with medication first, and active cooling if needed. We recommend the temperature control approach used in INTERACT-3.
  • Check temperature every 4 hours.
  • Treat body temperature >= 37.5°C.
    • 1st line: Acetaminophen (or Paracetamol)
    • 2nd line: Metamizole IM 0.25g
    • 3rd line: Physical cooling methods (ice, mechanical cooling device)
    • 4th line: 500mL NaCL 0.9% at 4°C IV.
  • Goal: achieve a body temperature <37.5°C within 1 hour of treatment, and maintain this for 7 days or hospital discharge.

Nothing by mouth before swallow screen

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.

Swallow screen goals:

  • Minimize oral intake until the patient passes a swallow screen.

Head of bed

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.

Head of bed goals:

  • Unless otherwise specified, head of bed at least 30 degrees.