International Care Bundle Evaluation in Cerebral Hemorrhage Research

In situations of either an elevated INR with the use of warfarin - treatment with either 3- or 4-factor prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) within 30 minutes of ICH diagnosis on NCCT to reach and maintain an INR target \<1.3; or where there has been recent use (\<48 hours) of a direct oral anticoagulant (DOAC), use of an appropriate reversal agent within 30 minutes, where available, and according to local approvals.

A systolic blood pressure (BP) target of 130-140 mmHg within 30 minutes of ICH diagnosis on NCCT is strived for, and to maintain this BP level for the first 7 days (for patients presenting with blood pressure \<200 mmHg). If blood pressure ≥200 and \<220, a target BP of 160 mmHg should be targeted at 30 minutes, and 130-140 mmHg should be achieved in 60 minutes. If BP ≥220, target BP of 160 mmHg and should be achieved in 60 minutes.

To achieve a body temperature target \<37.5 °C within the first 24h following ICH diagnosis on NCCT

To maintain a blood glucose level 7-10 mmol/L within the first 24h following ICH diagnosis on NCCT

Refrain from the use of DNR or withdrawal of care orders for 48 hours

Immediate (\<30 min) referral to intensive care if airway, breathing and/or circulation are compromized

"Immediate (\<30 min) referral to neurosurgery if any of the following criteria are fulfilled:~* Large and/or rapidly evolving supratentorial ICH (\>20 ml volume)~* Any intraventricular extension~* Posterior fossa bleed, irrespective of volume~* Suspicion of a vascular malformation, independent of volume or location~* Reduction in reaction to sensory stimulation or drowsiness"

Repeat 6-12-hour brain imaging with the physicians choice of modality, preferably computed tomography (CT), if clinical deterioration or the patient received OAC reversal treatment

For patients in the usual-care group, decisions about the location of care delivery, investigations, monitoring, and all treatments are made by the treating clinical team. Data will be collected regarding the management of patients, including insertion of invasive monitoring devices, intravenous fluid resuscitation, BP lowering, vasoactive support, glycemic control, mechanical ventilation, neurosurgery, and other supportive therapy.