Our study documented a suboptimal compliance to acute ICH therapeutic measures in an Italian real-world population of patients with ICH over 5 years even if showing some trend towards improvements over the study period. Suboptimal compliance was due not only to the lack of control of some parameters, but also to the lack of measurement of some of them. Changes in ICH management could be due to better awareness among clinicians on therapeutic strategies that emerged during the study period from relevant clinical studies on ICH bundles of care. In the same period, new antidotes for direct oral anticoagulants were approved, leading to better management of ICH in the acute phase. However, during the same period, international guidelines and local management protocols for ICH did not change.

The timeframe of the present study (2018–2022) coincided with a transition in ICH care. The publication in 2019 of the first results on a bundle of care approach [4] encouraged awareness and improved practices of acute ICH management. Those improvements might have influenced a gradual improvement in ICH acute management, even in our population, despite organizational challenges.

A crucial point to interpret our findings is the setting of our study. Our population is served by a public healthcare system which guarantees equal access to care to the whole population. Therefore, our population is comparable to those of other public healthcare systems, while comparability to private healthcare systems is limited. The availability of Emergency Medical Services and public hospitals is widespread over the district; therefore, the spread of new therapeutic measures such as anticoagulant reversal rapidly reached the entire population. The population is served by one neurosurgical ward that serves as referral for the whole regionwith potential logistic consequences on referrals. Of note, the district is a mountainous area in which transportations might be difficult in some cases.

Several gaps from ideal ICH therapeutic targets [2] were identified in our population. Firstly, two-thirds of the ICH patients in our study presented with high SBP at onset, yet less than half achieved optimal SBP within the first 24 h. The INTERACT3 trial emphasized the importance of early and aggressive SBP reduction after ICH onset to significantly improve functional outcomes [7]. The challenges we observed in our real-world setting, such as delays in treatment and organizational issues, may explain the suboptimal results, contrasting with the more controlled environment of randomized trials.

Another notable finding was the low rate of anticoagulation reversal within 24 h of ICH onset and limited neurosurgical interventions. In patients on anticoagulation therapy, timely reversal is critical to preventing hematoma expansion and improving outcomes [13]. However, our study found that only 21.4% of anticoagulated patients received anticoagulation reversal within 24 h, potentially contributing to the high case-fatality rate. Other real-world studies have reported similar findings, with up to 40% of patients not receiving timely reversal, particularly in non-tertiary care centers [14]. This could be due to several factors, such as the availability of specific reversal agents (e.g., andexanet alfa, idarucizumab), or the complexity of decision-making based on ICH characteristics and patients’ comorbidities.

Neurosurgical interventions are essential in managing ICH, particularly in cases involving mass effect, elevated intracranial pressure, or obstructive hydrocephalus [15]. The Early Minimally Invasive Removal of Intracerebral Hemorrhage trial (ENRICH) demonstrated that early minimally invasive hematoma evacuation can improve functional outcomes [16]. However, our study revealed a gap between neurosurgical referrals and the actual number of surgeries performed, suggesting that many referrals may have been unnecessary, while others who could have benefited from surgery did not receive it. Establishing clear criteria for neurosurgical referrals is critical for optimizing patient outcomes and reducing unnecessary strain on neurosurgical services [2, 17].

Hyperglycemia is also a common occurrence in the acute phase of ICH and is linked to worse outcomes, such as increased mortality and poor functional recovery, which aligns with our findings [18,19,20]. The INTERACT3 trial included glycemic control as part of its bundle of care, although it did not isolate the effect of glycemic control alone [7]. Managing hyperglycemia in ICH is challenging due to the prevalence of stress-induced hyperglycemia, which complicates the distinction from chronic hyperglycemia and negatively affects timely interventions [12, 21,22,23]. In our study, 62.2% of patients had hyperglycemia at onset, but only 22.8% achieved glucose control within 24 h, highlighting the need for a better approach to managing hyperglycemia in the acute phase of ICH.

Another critical factor in ICH management is controlling hyperpyrexia, whether from hyperthermia or infection-related fever. Proper temperature management has been shown to improve outcomes by reducing secondary brain injury and limiting metabolic demands [24, 25]. In our study, 13.7% of patients presented with hyperpyrexia, rising to 14.1% within 24 h. While not originally part of early care bundles [4], recent trials like INTERACT3 have recognized its importance and incorporated it into the bundle of care, reinforcing the need for effective temperature management to improve outcomes in ICH patients [7].

Our time trends analysis over a 5-year period disclosed SBP and temperature control remained relatively stable, improvements in glycemic measurement, and more selective neurosurgical consultations, leading to better use of neurosurgical resources. We did not observe clear patterns of differences between patients with and without measured parameters at ICH onset.

Additionally, there was an increase in the use of anticoagulation reversal agents, likely driven by better awareness on the potential benefits of this strategy and on the availability of specific antidotes for direct oral anticoagulants. Importantly, this period saw a decrease in 30-day case-fatality, particularly in the years 2021–2022, which coincided with an increase in anticoagulation reversal. These findings suggest that improvements in acute ICH management can lead to better outcomes and reduced mortality.

Our study has several limitations. First, we did not assess therapeutic measures beyond the initial 24 h. Second, we measured key parameters at only two time points, limiting our ability to capture fluctuations within the first hours after onset. Third, the exact time from symptom onset to parameter measurement was not recorded, introducing variability in our data. Fourth, as this was a purely observational study, certain parameters (e.g., blood glucose, body temperature) were not consistently measured across all patients. We were unable to account for the specific reasons behind these omissions, as such decisions were made at the discretion of the treating physicians in the context of usual clinical practice. Fifth, we did not track the specific medications used to control blood pressure or blood glucose, which may have influenced outcomes. Lastly, we collected data solely on 30-day case-fatality, while post-ICH functional status – an essential outcome for evaluating ICH prognosis – was not recorded.