Intracerebral hemorrhage is the most severe form of stroke and one of the neurological conditions with the highest mortality. It is relatively common for decisions involving early limitation of treatment—that is, not initiating or withdrawing certain therapeutic interventions—to be made within the first hours after admission, generally when the prognosis is considered poor and these measures are not expected to provide real benefit to the patient.
A study led by the Institut de Recerca Sant Pau (IR Sant Pau), published in the European Stroke Journal and based on data from the entire stroke care network in Catalonia, shows that these decisions are often made at very early stages. They may not accurately reflect the true prognosis of some patients.
The study, which analyzes more than 1,800 cases included in the population-based HIC-CAT registry, which prospectively collects all cases of intracerebral hemorrhage treated within the Catalan stroke network, shows that approximately one in four patients with intracerebral hemorrhage receives some form of care limitation within the first 72 hours (25.1% of cases). Nearly one in five already receives it within the first 24 hours (19.5%). This finding contrasts with clinical guideline recommendations, which advise waiting at least 48 to 72 hours before establishing a prognosis and making such decisions.
The study demonstrates that decisions made within the first 24 hours are primarily based on the patient’s initial clinical condition—that is, a static snapshot taken at the time of admission. Factors such as advanced age, neurological severity, hemorrhage volume, or the presence of intraventricular bleeding carry decisive weight at this stage. However, this approach has an important limitation: it does not yet incorporate the patient’s clinical course or response to initial therapeutic measures.
“The decision is not neutral,” states Dr. Anna Ramos-Pachón, researcher in the Cerebrovascular Diseases group at IR Sant Pau and corresponding author of the study. “When we limit treatment intensity at very early stages, we are not only describing a prognosis—we are directly influencing the patient’s course, because we stop applying interventions that may be decisive in those first hours”.
In this regard, the authors emphasize that intracerebral hemorrhage is a dynamic condition in its early phase, in which outcomes may be influenced by initial clinical management. Measures such as strict blood pressure control, metabolic stabilization, or intensive monitoring in specialized units may help prevent complications and allow patients to overcome the most critical phase.
When the decision is delayed until 72 hours, the scenario changes. At that point, clinicians already have information about the patient’s neurological evolution, particularly regarding early deterioration, allowing them to refine the prognosis and make decisions more closely aligned with clinical reality. “At 72 hours, if the patient has worsened, the likelihood of recovery is very low; but in the first hours, that evolution has not yet occurred and cannot be predicted with the same precision,” adds Dr. Ramos-Pachón.
One of the most relevant findings of the study is that 11% of patients whose care was limited within the first 24 hours achieved a good functional outcome at three months—that is, approximately one in ten patients. This finding suggests that the course of some patients may not be fully determined in the early hours and that there is a potential for recovery that may not be evident in the initial assessment.
The study also indicates that a relevant proportion of these patients correspond to cases in which treatment was initially limited but later resumed with active management, which is associated with better clinical outcomes. “We cannot know with certainty what would have happened if care had not been limited, but we have observed that some patients ultimately have a good outcome after an initial limitation of treatment,” notes Dr. Álvaro Lambea-Gil, researcher in the Cerebrovascular Diseases group at IR Sant Pau and first author of the study. “This suggests that we may be underestimating the recovery potential in some cases and reinforces the importance of not making definitive decisions at very early stages.”
The study’s results align with a broader shift in the management of hemorrhagic stroke. Traditionally, this condition has been associated with a more pessimistic outlook than ischemic stroke, partly due to the absence of highly visible immediate treatments such as thrombolysis or thrombectomy. However, the authors emphasize that active management—based on physiological control, close monitoring, and complication prevention—can be decisive in patient outcomes.
In this sense, the study’s findings are consistent with previous work conducted at IR Sant Pau, which has shown that early, protocolized management—including control of hemodynamic and metabolic parameters—can improve outcomes in patients with intracerebral hemorrhage. These findings reinforce the idea that, despite the absence of immediate treatments comparable to those for ischemic stroke, active intervention in the first hours can be decisive for prognosis.
“Maintaining the patient in optimal conditions during the first hours can make the difference,” notes Dr. Anna Ramos-Pachón. “This allows some patients to overcome the most critical phase and retain a margin for recovery.” In this context, the researchers warn of the risk of a “self-fulfilling prophecy,” in which an expectation of poor prognosis leads to treatment limitation and, consequently, confirms that outcome.
The study also highlights the key role of healthcare professionals in decision-making during the first hours after admission, especially in a context where advance directives are uncommon. “In numerous instances, the patient cannot decide, and the family makes decisions based on the information they receive,” explains Dr. Anna Ramos-Pachón. “If we convey a very negative message from the outset, it is more likely that care limitation will be chosen.” In this context, the authors stress the importance of appropriately communicating uncertainty to support decisions better aligned with the patient’s actual situation.
The population-based nature of the study, which includes all hospitals in the Catalan stroke network—from tertiary centers to hospitals supported by tele-stroke systems—provides a representative view of real-world clinical practice and allows exploration of how these decisions are made across different care settings. In this regard, the results indicate that, although there is some variability between centers, the observed pattern is consistent across the network, reinforcing the robustness of the findings. “Studies like this are rare and help us better understand what is happening in real-world practice,” notes Dr. Anna Ramos-Pachón.
Overall, the results convey a clear message: whenever possible, decisions to limit care should be delayed until information on the patient’s clinical course is available. “This is not about maintaining treatments indefinitely but about avoiding decisions that are made too early,” concludes Dr. Álvaro Lambea-Gil. “Allowing a 48–72-hour window may help identify patients who, despite a severe initial condition, have a real chance of recovery.”
Lambea-Gil Á, Camps-Renom P, Martí-Fàbregas J, Guasch-Jiménez M, Ezcurra-Díaz G, Fernández-Vidal JM, Prats-Sanchez L, Martínez-Domeño A, de la Ossa NP, Ramos-Pachón A. Early care limitation after ICH in a population-based study: what drives clinicians’ decisions? Eur Stroke J 2026;11. https://doi.org/10.1093/esj/aakag028.
