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Review
. 2024 Feb;55(2):494-505.
doi: 10.1161/STROKEAHA.123.043033. Epub 2023 Dec 15.

Code ICH: A Call to Action

Qi Li #  1 , Aleksandra Yakhkind #  2 , Anne W Alexandrov  3 , Andrei V Alexandrov  4 , Craig S Anderson  5 , Dar Dowlatshahi  6 , Jennifer A Frontera  7 , J Claude Hemphill  8 , Latha Ganti  9 , Chris Kellner  10 , Casey May  11 , Andrea Morotti  12 , Adrian Parry-Jones  13 , Kevin N Sheth  14 , Thorsten Steiner  15 , Wendy Ziai  16 , Joshua N Goldstein #  17 , Stephan A Mayer #  18
Affiliations
Review

Code ICH: A Call to Action

Qi Li et al. Stroke. 2024 Feb.

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.

Keywords: antihypertensive agents; cerebral hemorrhage; clinical protocols; hemostasis; patient care bundles.

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Conflict of interest statement

Disclosures Dr Andrei Alexandrov has received consulting fees from AstraZeneca. Dr Anne Alexandrov has received speakers bureau honoraria and reimbursement for travel expenses via an unrestricted educational grant from AstraZeneca. Dr Anderson has received grants from the National Health and Medical Research Council of Australia, the Medical Research Council of the UK, Penumbra, and Takeda paid to his institution, and is Vice-President of the World Stroke Organisation and Editor-in-Chief of Cerebrovascular Disease. Dr Dowlatshahi has received consulting fees from Astra Zeneca, serves as Canadian national PI for the FASTEST trial (Factor VIIa for Acute Hemorrhagic Stroke Administered at Earliest Time; 5U01NS110772-02) and holds a patent for automatic detection of contrast extravasation (CARL). Dr Frontera is a site PI for the ANNEXA-I trial (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of fXa Inhibitors; funded by AstraZeneca), the National Institutes of Health (NIH)/National Institute of Neurological Disorders and Stroke (NINDS)-funded ASPIRE (Anticoagulation in ICH Survivors for Stroke Prevention and Recovery) and SATURN (Statins in Intracerbral Hemorrhage) trials, has received consulting fees from Lusmosa, has received support for attending meetings and travel from Alexion, and was a member of the NIH/NINDS-funded SHINE (Stroke Hyperglycemia Insulin Network Effort) trials data safety monitoring board. Dr Ganti is a speaker bureau member and has received consulting fees from AstraZeneca and has received royalties from McGraw Hill and Springer for writing textbooks and review books. Dr Hemphill has played a leadership or fiduciary role in the 2022 AHA/ASA ICH guidelines and the 2023 AHA/ASA ICH performance measures and has received gifts from AstraZeneca. Dr Kellner is treasurer of the cerebrovascular section of the American Association of Neurological Surgeons/Congress of Neurological Surgeons; receives research grant support from Cerebrotech, Siemens, Penumbra, Medtronic, Minnetronix, vizAI, Integra, Longeviti, IRRAS, ICE Neurosystems, CVAid, Inc, and Endostream and has equity in Precision Recovery, Borealis, E8, Borvo, and Metis Innovative. Metis Innovative is an investment group that has coordinated investments in Synchron, Proprio, Fluid Biomed, Von Medical, and Precision Recovery. C. May has received consulting fees and travel support from AstraZeneca and speaking honoraria from Voxmedia LLC. Dr Morotti has received consulting fees and honoraria from EMG-REG international. A. Parry-Jones has received consulting fees and speaking honoraria from AstraZeneca. Dr Sheth is supported by the NIH (U24NS107136, U24NS107215, R01NR018335, R01NS107215, R01EB031114, R01MD016178, U01NS106513) and the American Heart Association (Bugher Grant AHA000BFCHS00199732). He has also received consulting fees from Astrocyte, Zoll, Certus, CSL Behring, Rhaeos, and Cerevasc, and equity from Alva. Dr Sheth reports stock holdings in AbbVie; stock options in BrainQ; stock holdings in verve therapeutics; service as President for Advanced Innovation in Medicine; a patent pending for stroke wearables licensed to Alva Health; and has received stock options from Astrocyte and Rhaeos, meeting and travel support from Biogen. He has participated in data and safety monitoring board or advisory boards for Zoll, Sense, and Philips; and has received ad hoc payment for legal testimony. Yale has received grants to support Dr Sheth’s research from Biogen, Hyperfine, Novartis, and Bard. Dr Steiner has received consulting and speaker fees from Bayer, Boehringer, BMS Pfizer, AtraZeneca, Daiichi Sankyo. Dr Ziai has received grants from the NIH, serves as the Associate Editor of Neurocritical Care, and reports consulting fees from C. R. Bard (data monitoring committee) and Lumosa Therapeutics. Dr Goldstein has received research support from the NIH, Pfizer, Octapharma, and Takeda and has received consulting fees from Astra Zeneca, CSL Behring, Prothya, nControl, Cayuga, and Lumosa. Dr Mayer has received consulting fees from CSL Behring, AstraZeneca, and MaxQ AI and grant support from the NIH (IMSM) for the FASTEST trial (5U01NS110772-02). The other authors report no conflicts.