REVIEW
C URRENT
OPINION Timely delivery of care in neurological emergencies:
can standardized management protocols help?
Menglu Ouyang a, Ma. Ignacia Allende a and Craig S. Anderson a,b
Purpose of review
To review the evidence that supports the implementation of goal-directed care bundle protocols to improve
outcomes from neurocritical conditions, and of the possible advantage of specific over generalized
protocols.
Recent findings
Articles from January 1, 2023 to July 31, 2024 were searched to evaluate the effectiveness of
standardized management in neurological emergencies. The use of care bundles and standardized
protocols with time- and target-related metrics has shown benefit in patients with acute stroke and traumatic
brain injury.
Summary
A goal-directed care protocol to guide standard management implemented by a multidisciplinary team can
improve outcomes from neurological emergencies. However, implementation challenges need to be
addressed before wide adoption of protocolized care for maximum benefit to populations.
Keywords
acute stroke, neurocritical care, standardized protocol, traumatic brain injury
INTRODUCTION an inconsistent manner [2]. Being similar to a stand-
Neurocritical care is focused on optimizing outcomes ardized protocol involving several distinct elements,
for patients with life-threatening conditions of the a care bundle is a tool to guide the delivery of evi-
nervous system through early diagnosis, prevention dence-based care to improve care processes and
and management to avoid secondary brain injury patient outcomes in a structured manner. The care
and complications. Key neurocritical conditions bundle approach is also recognized as a valuable tool
include intracerebral hemorrhage, ischemic stroke, for audit and quality assurance in clinical manage-
subarachnoid hemorrhage, traumatic brain injury, ment [3]. The choice of intervention for inclusion in a
and cerebral hypoxia following cardiac arrest. The care bundle is often based on expert opinion, but it
prompt initiation of interventions can significantly should be widely accepted as being applicable for
improve the chances of survival and quality of life enhancing practice and outcomes.
of affected patients. Delays in treatment can lead Care bundles were first developed in the late
to permanent neurological impairment, increased 1990s as an early goal-directed therapy in the treat-
mortality, and poor long-term outcomes. The man- ment of severe sepsis and septic shock, in order to
agement of neurological emergencies involves inter- reduce variations in care within intensive care units
disciplinary teamwork, evidence-based protocols, [4]. With the delivery of a minimum standard of
and standardized approaches [1].
a
The George Institute for Global Health, Faculty of Medicine, University of
New South Wales, Sydney, NSW, Australia and bInstitute of Science
CARE BUNDLES and Technology for Brain-Inspired Intelligence, Fudan University,
Shanghai, China
Care bundles are a set of evidence-informed practices Correspondence to Prof. Craig S. Anderson, The George Institute for
or interventions (usually three to five) that are per- Global Health, Faculty of Medicine, University of New South Wales,
formed collectively and consistently to improve the Sydney, NSW 2050, Australia. Tel: +61 410476311;
quality of care. The expectation is that the care bun- e-mail:
[email protected]dle leads to greater treatment effect from combined Curr Opin Crit Care 2025, 31:149–154
interventions over the use of single interventions in DOI:10.1097/MCC.0000000000001240
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Acute neurological problems
warfarin-related anticoagulation, improves the
KEY POINTS functional recovery of a broad range of patients with
acute spontaneous ICH. In this study, the likelihood
Protocolization of care processes improves outcomes
of a poor functional outcome, as measured on the
for neurological emergencies.
modified Rankin scale assessed at 6 months after
Implementation and scale up of strategies should the acute illness, was significantly less in the care
considerer contextual factors in which individuals are bundle group [common odds ratio 0.86, 95% con-
embedded, and to allow flexibility in the use of fidence interval (CI) 0.76–0.97; P ¼ 0.02]. Patients in
interventions according to the availability of resources.
the care bundle group also had significantly
Future research should include evaluations of improved survival and health-related quality of life,
implementation with clinical trial designs. shorter time in hospital and fewer serious adverse
&
events, than those in the usual care group [8 ].
Real-world clinical registry data has shown that
strict adherence to care bundle treatment achieving
care, the care bundle approach has been shown to and maintaining therapeutic ranges for systolic BP
improve survival from severe sepsis by as much as (110–160 mmHg), glucose (80–180 mg/dL or 4.4–
25% [4]. Such success of the care bundle approach 10 mmol/L), and body temperature (35.5–37.58C)
has generated enthusiasm to evaluate them in a wide over the first 72 h is associated with improved func-
range of healthcare conditions [2]. To date, care tional outcome at 12 months, with the treatment
bundle have shown greatest applicability in critical effect driven by BP control and the maintenance of
care, acute kidney injury, and infection control [5]. normothermia [9]. Evidence-based bundled care
reduces unwarranted variations in care and stand-
ardizes management in acute stroke, thereby pro-
BUNDLED CARE FOR ACUTE STROKE moting beneficial outcomes over usual standard
The bundled care approach with time and target of care.
goals presents a most promising approach to
improving outcomes for patients presenting with
acute stroke (Table 1). The Australian Quality in STANDARDIZED PROTOCOLS IN
Acute Stroke Care (QASC) study, a multicenter, par- TRAUMATIC BRAIN INJURY
allel-group, cluster clinical trial, was the first to show In traumatic brain injury (TBI), management is
that implementing a nursing protocol for the man- aimed at the prevention and prompt treatment of
agement of fever and hyperglycemia, and the assess- raised intracranial pressure (ICP) and secondary
ment of swallowing ability, improves functional brain injury, the maintenance of cerebral perfusion
recovery for patients acute stroke, including those pressure, and ensuring there is adequate oxygen
with either ischemic stroke or intracerebral hemor- delivery to patients. Management is ideally based
rhage (ICH) [6]. Subsequently, the single-center, on protocol-based guidelines provided by the Brain
before-after, Acute Bundle of Care for Intracerebral Trauma Foundation (BTF) published in 2016 [10].
Hemorrhage (ABC-ICH) study, showed that the When ICP is unable to be monitored, an imaging
implementation of a care bundle involving time- and clinical examination (ICE) protocol was devel-
based targets for anticoagulation reversal and blood oped based upon the Treatment of Intracranial
pressure (BP) control, and immediate access to neu- Pressure (BEST:TRIP) trial, which showed that main-
rosurgical and critical care services for patients with taining an ICP at 20 mmHg or less was not superior
spontaneous ICH, was associated with a 10.8% to care based on imaging and clinical examination
reduction in 30-day case fatality [7]. alone [11]. Although the ICE protocol was less effi-
Arguably the most influential evidence pertain- cient due to significantly more intensive care unit
ing to the benefit of a care bundle has come from the days compared to the ICP monitoring protocol,
third Intensive Care Bundle with Blood Pressure there were no differences in frequencies of serious
Reduction in Acute Cerebral Hemorrhage Trial adverse events, neurosurgical procedures, or neuro-
(INTERACT3). In an international, multicenter, logical worsening. The ICE protocol was tested in a
prospective, stepped wedge, cluster randomized, prospective cohort study at 19 South American hos-
blinded outcome assessed design, INTERACT3 show pitals to show that patients who received standar-
that compared to usual standard of care, implemen- dized management using the ICE protocol had
tation of a goal-directed care bundle protocol that significantly better function and overall outcome
comprised early intensive BP lowering combined compared to the nonprotocol group (59% vs. 43%
with other management protocols for abnormal with favorable outcome according to the Glasgow
physiological variables and early reversal of Outcome Scale-Extended 5 or higher; P ¼ 0.02).
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Timely delivery of care in neurological emergencies Ouyang et al.
Table 1. Care bundles
Care bundle Components Outcomes
QASC Nurse-initiated Fever, Sugar, Swallowing (FeSS) protocol: Less death or dependent (mRS 2) at 90 days:
-monitoring the patients’ temperature at least four times a day adjusted absolute difference 157% [95% CI
and the prompt treatment of a temperature 37.58C or greater 5.8–25.4], P ¼ 0.0002)
in the first 72 h, following stroke unit admission
-Monitoring the patient’s blood glucose levels at least four times a
day for the first 48 h following stroke unit admission (continue
for 72 h if blood glucose levels unstable), and the prompt
treatment of a blood glucose level >10 mmol/l (180 mg/dl) in
the first 48 h following stroke unit admission
-Keeping patients nil by mouth (including no oral medications)
until they have been screened for dysphagia by a nurse that
has demonstrated competency using an approved dysphagia
screening tool or assessed by a speech pathologist/speech
and language therapist
ICH-ABC Rapid anticoagulant reversal, intensive BP lowering, immediate Lower 30-day case fatality: odds ratio 0.62
neurosurgical referral protocol: (95% CI ¼ 0.38–0.97), P ¼ 0.03
-Rapid anticoagulant reversal, with delivery of 4-factor
prothrombin complex concentrate (PCC) for vitamin-K
antagonists and anti-Xa antagonists or idarucizumab for
dabigatran within 90 min of arrival
-Delivery of intensive BP lowering to an SBP target of 130–140
mmHg for patients arriving within 6 h of onset with an
SBP>150 mmHg. We aimed for a needle-to-target time (NTT;
time from the first dose of an intravenous antihypertensive to
achieving target SBP) of <60 min
-Adherence to a care pathway prompting immediate
neurosurgical referral of all patients with good premorbid
function (modified Rankin Scale [mRS] score 2) and any of
the following: GCS < 9, posterior fossa ICH, an obstructed
3rd/4th ventricle, or hematoma volume >30 ml (measured by
the ABC/2 method)
INTERACT3 Goal-directed intensive blood pressure lowering and other Shift of unfavorable ordinal mRS: odds ratio
management algorithms for physiological control: 0.86 (95% CI 0.76–0.97,) P ¼ 0.015
-Early intensive blood pressure management with the goal of
achieving a target systolic blood pressure of <140 mmHg
within 1 h of the initiation of treatment, with a systolic blood
pressure of 130 mmHg being the threshold for the cessation of
treatment
-Intensive control of elevated blood glucose with the goal of
achieving a glucose target of 6.1–7.8 mmol/l for patients
without diabetes and 7.8–10.0 mmol/l for patients with
diabetes as soon as possible after the initiation of treatment, as
recommended in guidelines for minimal risk of harm from
hypoglycemia
-Treatment of pyrexia with the goal of achieving a body
temperature of <37.58C within 1 h of initiation
-and the reversal of abnormal anticoagulation in those taking
warfarin using fresh frozen plasma or prothrombin concentrate
complex with the goal of reaching an international normalized
ratio of <1.5 within 1 h of treatment
All target concentrations within the care bundle were to be
maintained in patients for 7 days (or until discharge or death,
should these events occur earlier)
However, there was no significant between-group patients with TBI, which resulted in a trend towards
difference in the 6-month mortality (hazard ratio better treatment efficiency over management with-
0.69, 95% CI 0.43–1.10; P ¼ 0.12) [12]. Use of the ICE out a protocol. Even so, uncertainties persist in
protocol led to lower practice variability and man- differentiating causality from the use of specific
agement uncertainty after the management of components or of the protocol in general. A second
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Acute neurological problems
phase of this study aims to address this question, Similar issues related to the use of protocols for
with both groups adopting a detailed Consensus the management of TBI. Since computed tomogra-
REVised Imaging and Clinical Examination (CREV- phy (CT) imaging is central to the CREVICE
ICE) protocol developed through a Delphi-method approach, it is critical that there should be unre-
consensus development process and considering the stricted access to CT for effective implementation of
availability of variable resources to allow a broader the CREVICE protocol. What to do when there is
applicability to neuromonitoring modalities in low- limited or no access to CT remains an unresolved
&&
and middle- income country (LMIC) settings [13 ]. question [19]. In the Delphi study, generating
locally developed protocols with a streamlined
workflow aligned to available resources was viewed
IMPLEMENTATION CHALLENGES OF as being key to implementing complex strategies.
PROTOCOLIZED MANAGEMENT This ensures the delivery of care is customized to
Protocolization of process of care and care bundles meet the need of the target population.
have been shown to improve clinical outcomes and The CREVICE protocol emphasizes the need for
reduce associated care costs, particularly for neuro- configuring interventions where there are limited
critical care [14]. However, the implementation of resources and staffing capacity. Although the results
complex strategies requires an understanding of the do not promote the management of TBI without ICP
delivery of care in the context in which individuals monitoring, they do highlight the relevance of rela-
are nested, and the underlying mechanisms at play tively simple, target-based protocols with dedicated
to achieve clinical effectiveness [15]. A process eval- care pathways that match the available infrastruc-
uation was embedded in INTERACT3 using the ture. Investigators in stroke studies have come to
Medical Research Council guidance and normaliza- similar conclusions. For example, a population-based
tion process theory as theoretical framework, to cohort in Spain showed no difference in 3-month
capture key barriers to achieving the target param- functional outcome for patients with ICH being
eters in the intervention at the organizational level, managed in a primary care center/telestroke center
such as delayed processes, lack of staffing, and poor vs. management in a comprehensive stroke center
medication supply. The study showed that there (OR 1.13, 95%CI 0.93 to 1.38) [20].
were challenges for BP and glycemic control, with Care bundles facilitate the standardization of
targets achieved in 45% and 40%, respectively [16]. processes, assists clinicians in making complex deci-
Nonetheless, the care bundle was found to be sions, and reduces unnecessary variation in care
acceptable and feasible at the study sites. Similarly, [21]. However, incorporating care bundles into rou-
a mixed methods evaluation of the QASC study tine practice may be perceived as compromising
through pre and postimplementation workshops, autonomy and expertise of clinicians, especially in
found that the lack of familiarity with insulin infu- areas of medicine where the limited amount of
sions and the requirement for written orders randomized evidence may have led to an atmos-
were found to be actual barriers. Interestingly, the phere of nihilism over management [22]. These
availability of insulin infusion equipment was issues have been well described by investigators of
not a postimplementation barrier [17]. In both stud- the INTERACT3 and QASC studies, where clinicians
ies, interdisciplinary staff collaboration and contin- were more inclined to rely on their training and
uous training arose as key enablers for an efficient experience rather than shift over to the goal-
implementation. directed care bundle. One way of moving forward
Although implementation of the INTERACT3 is to reshape attitudes toward early prognostication
care bundle was found to be feasible and acceptable, [23]. For example, secondary analysis of the ABC-
various contextual factors raised concerns over rep- ICH study found a 11% reduction in early do-not-
licability of the findings to other settings, especially resuscitate (DNR) orders following implementation
in regional areas with resource constraints. To this of the care bundle [24], and a mixed-method eval-
end, a Delphi study was undertaken in the Latin uation for planning a scale up of intervention cap-
American region to evaluate the potential for wider tured a shift in the attitudes of clinicians towards
implementation of the INTERACT3 care bundle. prognostication and urgency in ICH management
Several strategies were identified that placed partic- [25]. While both bundled care and protocolized
ular emphasis on ensuring the availability of min- management improve outcomes, their level of suc-
imal resources at hospitals, in particular those of cess is dependent upon the implementation proc-
antihypertensive drugs and anticoagulation reversal esses to support application into practice, such as in
agents, and for continuous training of healthcare facilitating ‘knowledge-action’ change in healthcare
professionals and to foster a collaborative approach workers. Thus, strategies to support behavior
within and across healthcare institutions [18]. change, such as shaping knowledge, monitoring,
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Timely delivery of care in neurological emergencies Ouyang et al.
audit and feedback, will facilitate the impact of the management of neurological emergencies is the
research evidence generated of the benefit of care need to evaluate specific implementations strategies
bundles across healthcare settings. that are customized to local practice settings and
populations.
FUTURE DIRECTIONS
Many components of INTERACT3 care bundle have CONCLUSION
already been endorsed in expert consensus reports Standardizing the care of patients with neurological
(it takes time for guidelines to be updated), but emergencies is critical to ensuring there is access to
knowledge of the effectiveness of their translation consistent and high-quality treatments for patients
into practice is limited. One effort to facilitate trans- across different settings and providers. The goal is
lation to improve outcomes for patients with ICH always to ensure optimal patient outcomes, efficient
is the International Care Bundle Evaluation in use of resources, and enhanced patient, caregiver
Cerebral Hemorrhage Research (I-CATCHER) study, and provider safety.
an international, multicenter, batched, parallel,
cluster-randomized trial with a baseline period Acknowledgements
[26]. I-CATCHER aims to assess the effectiveness None.
of an expanded care bundle, comprising the com-
ponents of the INTERACT3 care bundle along with Financial support and sponsorship
rapid (<30 min) referral to neurosurgery and inten- None.
sive care according to prespecified criteria, and for
the use of withdrawal of care directive to be with- Conflicts of interest
held for 48-h. This 8-item care bundle will be com-
C.S.A. reports grants from the National Health and Med-
pared to usual standard care, and the primary
ical Research Council (NHMRC) and Medical Research
outcome evaluated at 6 months in spontaneous
Futures Fund (MRFF) of Australia, the Medical Research
ICH patients [26]. I CATCHER has a clear focus on
Council (MRC) and Medical Research Foundation (MRF)
implementation so that the various participating
of the UK, and Penumbra, Takeda and Astra Zeneca.
stakeholders receive feedback on the effectiveness
He also reports Advisory Board fees for Astra Zeneca. The
of their efforts. As is common with health services
other authors declare no competing interests.
research, clinical trials of care bundles need to
include assessments of the effectiveness of imple-
mentation as complex interventions undergo REFERENCES AND RECOMMENDED
dynamic changes within a local context. READING
Scaling up complex interventions requires con- Papers of particular interest, published within the annual period of review, have
been highlighted as:
sideration of local context and setting, and for per- & of special interest
&& of outstanding interest
formance measures to be simple and straightforward
to allow an institutional framework to evaluate the 1. Kollmar R, De Georgia M. Milestones in the history of neurocritical care.
impact of the intervention on patient care [27]. The Neurol Res Pract 2023; 5:43.
2. Horner DL, Bellamy MC. Care bundles in intensive care. Contin Educ Anaesth
Neurocritical Care Society has already taken the Crit Care Pain 2012; 12:199–202.
initiative of publishing a neurocritical care perform- 3. Lavallee JF, Gray TA, Dumville J, et al. The effects of care bundles on patient
outcomes: a systematic review and meta-analysis. Implement Sci 2017;
ance metric [28] comprised of 21 components, with 12:142.
future plans for feasibility, validity and reliability 4. McCannon CJ, Hackbarth AD, Griffin FA. Miles to go: an introduction to the 5
million lives campaign. Jt Comm J Qual Patient Saf 2007; 33:477–484.
testing [27]. 5. Gilhooly D, Green SA, McCann C, et al. Barriers and facilitators to the
Any residual concerns over the effectiveness of successful development, implementation and evaluation of care bundles in
acute care in hospital: a scoping review. Implementation Sci 2019; 14:47.
intensive BP lowering for ICH patients that have 6. Middleton S, McElduff P, Ward J, et al. Implementation of evidence-based
arisen from the conflicting results of conventional treatment protocols to manage fever, hyperglycaemia, and swallowing dys-
function in acute stroke (QASC): a cluster randomised controlled trial. Lancet
individual participant intervention trials [29,30] 2011; 378:1699–1706.
have been resolved by the results of the fourth 7. Parry-Jones AR, Sammut-Powell C, Paroutoglou K, et al. An intracerebral
hemorrhage care bundle is associated with lower case fatality. Ann Neurol
Intensive ambulance-delivered blood pressure 2019; 86:495–503.
reduction in hyper-acute stroke trial (INTERACT4) 8. Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure
& Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an interna-
[31]. In this prehospital ambulance conducted trial tional, stepped wedge cluster randomised controlled trial. Lancet 2023;
in China, INTERACT4 showed that rapid BP low- 402:27–40.
This study evaluated a care bundle approach to the acute management of patients
ering within the first 2 h after symptom onset with acute intracerebral hemorrhage (ICH). The trial demonstrated that a com-
improved the odds of death and disability in ICH. prehensive care bundle improves the functional recovery of patients with ICH.
9. Mrochen A, Song Y, Harders V, et al. Influence of bundled care treatment on
Thus, in parallel with making updates to processes functional outcome in patients with intracerebral hemorrhage. Front Neurol
and outcome as new evidence emerges for the 2024; 15:1357815.
1070-5295 Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com 153
Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.
Acute neurological problems
10. Dash HH, Chavali S. Management of traumatic brain injury patients. Korean J 20. Seiffge DJ. Good treatment of hyperacute intracerebral hemorrhage is as easy
Anesthesiol 2018; 71:12. as ABC. Neurology 2024; 103:e209614.
11. Chesnut RM, Temkin N, Carney N, et al. A trial of intracranial-pressure 21. Dimmer A, Baird R, Puligandla P. Role of practice standardization in outcome
monitoring in traumatic brain injury. N Engl J Med 2012; 367:2471–2481. optimization for CDH. World J Pediatr Surg 2024; 7:e000783.
12. Chesnut RM, Temkin N, Videtta W, et al. Testing the impact of protocolized 22. Hemphill JC, White DB. Clinical nihilism in neuroemergencies. Emerg Med
care of patients with severe traumatic brain injury without intracranial pressure Clin North Am 2009; 27:27–37.
monitoring: the imaging and clinical examination protocol. Neurosurgery 23. Shafi S, Collinsworth AW, Richter KM, et al. Bundles of care for resuscita-
2023; 92:472–480. tion from hemorrhagic shock and severe brain injury in trauma patients—
13. Chesnut RM, Temkin N, Videtta W, et al. The roles of protocols and proto- translating knowledge into practice. J Trauma Acute Care Surg 2016;
&& colization in improving outcome from severe traumatic brain injury. Neurosur- 81:780–794.
gery 2023; 94:966–982. 24. Minhas JS, Sammut-Powell C, Birleson E, et al. Are do-not-resuscitate orders
This study investigated the impact of a systematic protocolization of the manage- associated with limitations of care beyond their intended purpose in patients
ment of severe traumatic brain injury. The finding suggests adherence to protocols with acute intracerebral haemorrhage? Analysis of the ABC-ICH study. BMJ
improves patients outcomes, without the need for intracranial pressure monitoring. Open Qual 2021; 10:e001113.
14. Sevransky JE, Agarwal A, Jabaley CS, Rochwerg B. Standardized care is 25. Brunton L, Sammut-Powell C, Birleson E, et al. Scale-up of ABC care bundle
better than individualized care for the majority of critically ill patients. Crit Care for intracerebral haemorrhage across two hyperacute stroke units in one
Med 2021; 49:151–155. region in England: a mixed methods evaluation of a quality improvement
15. Raine R, Fitzpatrick R, Barratt H, et al. Randomised controlled trials of complex project. BMJ Open Qual 2022; 11:e001601.
interventions and large-scale transformation of services. Chall Solut Future Dir 26. International Care Bundle Evaluation in Cerebral Hemorrhage Research (I-
Eval Serv Innov Healthcare Public Health. Health Serv Deliv Res. CATCHER) [Internet]. Report No.: Identifier: NCT06429332. Available at:
16. Ouyang M, Anderson CS, Song L, et al. Implementing a goal-directed care https://clinicaltrials.gov/study/NCT06429332?cond=intracerebral%20he-
bundle after acute intracerebral haemorrhage: process evaluation for the Third morrhage&intr=Care%20bundle&rank=1.
INTEnsive Care Bundle with Blood Pressure Reduction in Acute Cerebral 27. Moheet AM, Livesay SL. Quality improvement in neurocritical care: current
Haemorrhage Trial Study in China. Cerebrovasc Dis 2022; 51:373–383. state and looking to the future. Curr Opin Crit Care 2020; 26:97–102.
17. Dale S, Levi C, Ward J, et al. Barriers and enablers to implementing clinical 28. Moheet AM, Livesay SL, Abdelhak T, et al. Standards for neurologic critical
treatment protocols for fever, hyperglycaemia, and swallowing dysfunction in care units: a statement for healthcare professionals from the Neurocritical
the Quality in Acute Stroke Care (QASC) project—a mixed methods study. Care Society. Neurocrit Care 2018; 29:145–160.
Worldviews Evid Based Nurs 2015; 12:41–50. 29. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive blood-pressure lowering
18. Allende MaI, Mu~ noz-Venturelli P, Gonzalez F, et al. Recommendations for in patients with acute cerebral hemorrhage. N Engl J Med 2016; 375:
implementing the INTERACT3 care bundle for intracerebral hemorrhage in 1033–1043.
latin america: results of a Delphi method. Cerebrovasc Dis 2024; 1–8. [Online 30. Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in
ahead of print]. patients with acute intracerebral hemorrhage. N Engl J Med 2013; 368:
19. Maas AIR, Menon DK, Manley GT, et al. Traumatic brain injury: progress and 2355–2365.
challenges in prevention, clinical care, and research. Lancet Neurol 2022; 31. Li G, Lin Y, Yang J, et al. Intensive ambulance-delivered blood-pressure
21:1004–1060. reduction in hyperacute stroke. N Engl J Med 2024; 390:1862–1872.
154 www.co-criticalcare.com Volume 31 Number 2 April 2025
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