Project Details
About the Project
Spontaneous Intracerebral Hemorrhage (ICH) stands as a significant contributor to neurological morbidity, disability, and mortality [1]. However, it has often been overshadowed by acute ischemic stroke, leading to a lack of attention in both clinical practice and academic discourse. This discrepancy may also exacerbate neurological outcomes for patients with an acute ICH. As a result, neurocritical care leaders have championed the creation of a CODE ICH—an initiative focused on early bundled intervention and guided by time-based metrics to enhance neurological outcomes [2].
Dr. Colin Casault partnered with colleagues in ICU Nursing Education, Critical Care, Neurosurgery, Trauma, and ICU Pharmacy to implement a pilot study to develop and implement a standardized Code ICH protocol. This intracerebral hemorrhage order set aimed at achieving a standardized blood pressure target (<140mmHg) and promptly administering reversal agents to patients on anticoagulants. In short, it involved applying many of the quality metrics from acute ischemic stroke and applying them to hemorrhagic stroke.
After creating a REDCap database in which to collect data, Dr. Casault worked with two second year medical students – Anthony Preston and Nicholas Mitchell – to collect detailed physiologic data on a total of 23 patients who presented to the Victoria General Hospital Emergency Department between Sept 2024 and June 2025. While it is a small cohort, there were 1,104 blood pressure measurements acquired. Based on this data, the team generated a list of recommendations to both process and systems to improve care of patients with acute hemorrhagic stroke.
To foster further discussion on the neurosurgical care of ICH, the team coordinated a dinner featuring a talk by Dr. Lissa Peeling, a recognized expert in neurosurgery. This talk included approximately 20 members of the medical staff, representing critical care, neurosurgery, emergency medicine, and neurology. The discussion that followed this talk has led to further engagement between neurosurgery and vascular neurology about the best course of care for ICH patients.
Having started with this small cohort, Dr. Casault has plans to continue this work, through a project to review outcomes of ICU ICH patients and ward ICH patients at Nanaimo General Hospital. By generating evidence-based and actionable key recommendations, as well as enlisting the support of different members of the medical staff and administration for the next phase of the project, this small pilot study has had an outsized impact. Commenting on the value of having taken on data collection in the first phase, Dr. Casault shared, “It’s hard to get physicians together to discuss things without data”.
[1] van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ: Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 2010, 9(2):167-176.
[2] Li Q, Yakhkind A, Alexandrov AW, Alexandrov AV, Anderson CS, Dowlatshahi D, Frontera JA, Hemphill JC, Ganti L, Kellner C et al: Code ICH: A Call to Action. Stroke 2024, 55(2):494-505.