Code ICH: A Call to Action

Abstract

Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. 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 recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.

Neuro-imaging in intracerebral hemorrhage: updates and knowledge gaps

“…Early identification enables initiation of ultra-early treatment to prevent hematoma expansion and mitigate neuroinflammation. The potential of reduced morbidity and mortality associated with ICH through timely recognition and intervention has led to an increasing emphasis on its prompt diagnosis ( Li et al, 2024 ).…”

Door-in-Door-Out Times at Referring Hospitals and Outcomes from Hemorrhagic Stroke

“…8 Additionally, a 2024 systematic review from the Blood Pressure in Acute Stroke Collaboration showed a clear time relation between early vs late blood pressure control in ICH patients with improvement in functional outcomes and a lower risk of hematoma expansion. 4 Ongoing efforts including the recent consensus statement for “Code ICH” emphasize the importance of early bundled care for ICH and adherence to time-based metrics, 9 which could change the landscape of care for hemorrhagic stroke.…”