Impact of a Standardized Care Pathway on the Management of Intracerebral Hemorrhage in the Emergency Department: A Before-and-After Study​

Introduction: intracerebral hemorrhage (ICH) remains one of the most fatal forms of stroke, associated with high mortality and significant long-term disability. Structured diagnostic and therapeutic care pathways (PDTA) may improve early management and clinical outcomes. This study aimed to evaluate the impact of a standardized PDTA for spontaneous ICH in a tertiary stroke center. Methods: We conducted a single-center, observational before–after cohort study including 578 consecutive patients with spontaneous ICH admitted between 2019 and 2025. Patients were divided into pre-PDTA (n=382) and post-PDTA (n=195) groups. Primary outcomes were 30-day mortality and process-of-care indicators, including early neurosurgical consultation and initiation of antihypertensive and anti-edema therapies in the emergency department. Results: Baseline characteristics were comparable between groups, including age (71.8±15.2 vs 73.8±13.9 years) and admission severity (GCS 10.7±4.7 vs 10.8±4.6). Following PDTA implementation, significant improvements were observed in process-of-care measures. The proportion of patients receiving neurosurgical consultation within 60 minutes increased from 30.9% to 57.4% (p=0.02), while the use of antihypertensive therapy rose from 16.5% to 36.4% (p=0.003) and anti-edema therapy from 9.7% to 19.0% (p=0.002). At the same time, the overall rate of neurosurgical intervention decreased from 35.6% to 25.6% (p=0.02). Despite these improvements, 30-day mortality did not significantly differ between groups (30.5% vs 35.6%, p=0.20), and this finding was confirmed after adjustment (HR 1.30, 95% CI 0.85–2.00, p=0.23). However, among patients undergoing neurosurgical treatment, mortality decreased from 25.7% in the pre-PDTA period to 16.0% in the post-PDTA period (HR 0.628, 95% CI 0.397–0.995, p=0.047). Multivariable analysis identified admission GCS (HR 0.897, p<0.001), midline shift greater than 1 mm (HR 1.66, p=0.045), and hematoma volume (HR 1.017 per mL increase) as independent predictors of 30-day mortality. Conclusions: implementation of a structured PDTA improved key process-of-care measures and was associated with better outcomes among surgically treated patients, although no overall reduction in 30-day mortality was observed. Outcomes in ICH appear to depend not only on hemorrhage characteristics but also on the organization and coordination of care, supporting the role of structured, system-based approaches in this time-sensitive condition.