Golden hour management in the patient with intraparenchymal cerebral hemorrhage: an Italian intersociety document

Abstract

Background: Spontaneous intracerebral hemorrhage (ICH) accounts for 9-27% of all strokes worldwide and is associated with high mortality and disability. The main causes include vascular malformations, small- and large-vessel angiopathies, and coagulation disorders. Mortality rates reach approximately 40% at 1 month and 54% at 1 year, largely influenced by early management decisions. Rapid intervention, particularly within the first hour, is crucial, especially for patients initially treated in peripheral hospitals. This consensus document, developed by SIAARTI with the endorsement of multiple medical societies, aims to standardize ICH management based on hospital capabilities, aligning with the "time is brain" principle and the 2022 AHA guidelines.

Methods: A multidisciplinary panel of experts-including neurointensivists, neuroanesthesiologists, neurologists, neuroradiologists, emergency physicians, and neuroscience nurses-developed this consensus document. The process combined a systematic literature review with a modified Delphi method, prioritizing clinical questions using the UCLA-RAND appropriateness methodology. Literature searches were conducted on PubMed following PRISMA 2020 guidelines. Statements were formulated based on both evidence and expert consensus, and the final document underwent external peer review.

Results: Computer tomography (CT) angiography, with over 90% sensitivity and specificity, is a key tool for identifying macrovascular abnormalities and detecting active bleeding, a critical factor in poor outcomes. Prognostic models, such as the ICH score, assist in clinical decision-making. Strict blood pressure control (target 130-140 mmHg) and early intubation in appropriate cases help mitigate hematoma expansion. Anticonvulsants are recommended only for patients with documented seizures. In cases of anticoagulant-related hemorrhage, prothrombin complex concentrates are effective for rapid reversal, though their long-term impact remains uncertain. Intensive care unit (ICU) admission is determined by ICH severity, with severe cases benefiting from specialized neurocritical care.

Conclusion: A multidisciplinary and inter-societal discussion provided key recommendations for the immediate management of ICH, based on the available literature. While only a few topics are supported by robust evidence, experts strongly recommend early brain angio CT, risk stratification using scoring systems, clear communication of patient data, and intubation for impaired consciousness. Blood pressure should be controlled with alpha- and beta-blockers, avoiding hypotension. Anticoagulant reversal should be appropriately managed, and eligible patients should be centralized in ICU and neurosurgical centers using dedicated scoring systems.

Keywords: Clinical questions; Computed tomography angiography; Electroencephalogram; Glasgow Coma Scale; Intracerebral hemorrhage; Systolic blood pressure; Tranexamic acid.