Non-traumatic intracerebral haemorrhage (ICH) remains a high mortality and morbidity disease with few single intervention clinical trials demonstrating improvements in functional outcome. The failure of ICH trials to establish robust evidence useful for guidelines can be attributed to several factors. These include the timing of interventions which have remained incongruent with known timeframes for disease progression. In addition, trials have necessarily focused on single therapeutic interventions, while their likely benefit is greatest in synergy when combined with similar targeted interventions. There are impacts of the long recovery phase of ICH patients where subsequent health events may dilute the efficacy of an upfront treatment. While there have been a limited number of well-executed ICH trials that consistently show a mortality benefit, mortality reduction alone is insufficient. Finally, the design of ICH trials often uses selection criteria that lack generalisability, especially to higher disease severity and has been slow to adapt newer trial concepts such as platform trials and adaptive randomisation. These shortcomings create gaps between available trial evidence and real-world practice. Recent strategies implementing pragmatic acute care bundles into ICH care, including the prehospital phase may be improving this landscape. The main interventions evaluated in ICH care bundles so far are time metrics for earlier initiation of blood pressure (BP) control, reversal of anticoagulation if applicable, achieving blood glucose and body temperature targets and early consultation with neurosurgery. These can be facilitated by an acute alert system for protocol implementation, as in other medical emergency systems, conceptualised as an ‘ICH code’. Figure 1 shows gaps, challenges and some recommendations towards code ICH implementation.

Gaps, challenges and suggestions towards code ICH implementation. ICH, intracerebral haemorrhage.

Two studies evaluating care bundles for acute ICH management have been instrumental in promoting this concept. Parry-Jones et al conducted a single-centre implementation study of a goal-directed …