ISC 2026 | Bundle-of-care in ICH: lessons from other diseases, essential components, and real-world application

One of the problems we have in ICH and stroke is a lot of our clinical trials are based on just testing one single thing in isolation, and then it can be hard to find that there’s a benefit of just doing that one thing compared to everything else. And what other diseases have found is that sometimes you need to do multiple things together in parallel to both give the best benefit for your patient, but also for that intervention to help, it’s best in combination with other things. So we have learned this from sepsis, where people need a bundle of care of resuscitation. You need early antibiotics and improving the blood pressure and fixing hemodynamics and, you know, fixing abnormal glucose levels or abnormal temperature levels. We’ve learned this from studies in ischemic stroke where bundles of care such as temperature control, glucose control, NPO before a swallow screen, et cetera, that putting all these things together is what provides the most benefit. We’ve learned it from cardiac arrest with targeted temperature management as part of a bundle of care. And so close management and monitoring of things is really the way to go. And we should be looking at our interventions as part of these bundles. So I would say the essential elements would be early blood pressure control and then good blood pressure control, both in the initial phase and then managed over time. Early anticoagulation reversal, time is your enemy, and having clear time metrics that everybody knows and holds themselves to and are held to. Early temperature control, early glucose control, probably also NPO before a swallow screen. And frankly, I think as time goes on, earlier evaluation for surgical evacuation. I think those would be all great parts of the bundle. In real-world settings, the problem is always people are busy. They have multiple things going on, especially in the acute phase of medical care. And so the ideal way to approach this would be to have formalized protocols that every time this ICH is diagnosed, that it launches a set of things. A lot of times with ischemic stroke, people rush to give IV thrombolytics, but they don’t have the same rush to do all the other pieces. Intracerebral hemorrhage, we just had a great presentation on the FASTEST trial, and maybe in the future there’ll be a role for recombinant Factor VIIa, but we still know that early blood pressure control, early anticoagulation reversal, and doing these things quickly matters, and people are busy, and we just have to tell them that all the things matter, and doing all the things quickly is what’s time-dependent, and track that, reinforce it to people, and make it a priority for our staff, really for our nurses, for our advanced practice providers, for our doctors, that everybody feels like they have a role and that they know what they’re supposed to do and that it’s not just one thing they’re being tracked on, it’s are they doing all the things together.

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