Early care limitation after ICH in a population-based study: what drives clinicians' decisions?

Early care limitation (ECL) after ICH is increasingly recognised, but population-based data on time-dependent determinants remain scarce. We aimed to identify influencing factors of ECL within 72 h from admission and explore differences by sex, haematoma location and stroke-centre type.

Prospective population-based study of consecutively recruited adults with spontaneous ICH and pre-stroke mRS 0-3, admitted within the first 24 h to any hospital of the Catalan Stroke Network (HIC-CAT registry, 2020-2022). Early care limitation was recorded at 24 h (ECL-24 h) and 72 h (ECL-72 h). Candidate predictors were selected using all-subsets modelling for each time window. Model performance was assessed overall and in predefined subgroups.

Among 1821 patients, ECL-24 h was applied in 355 (19.5%) and an additional 102 had ECL by 72 h, yielding an overall ECL rate of 25.1%. Strongest predictors of ECL-24 h were age, prior anticoagulant use, baseline NIHSS, ICH volume and intraventricular haemorrhage (AUC 0.88). Predictors of ECL-72 h were age, prior anticoagulant use, pre-stroke mRS, baseline NIHSS and early neurological deterioration within 72 h (AUC 0.90). Across subgroups, AUCs ranged from 0.85 to 0.90, with lower performance in infratentorial ICH for ECL-72 h and in telestroke centres. Among ECL-24 h patients, 39 (11%) achieved 3-month favourable functional outcome, whereas no patients with ECL-72 h achieved this outcome.

Early care limitation after ICH is frequent and its determinants differ by timing. In our study, very early decisions rely mainly on the static severity at admission, whereas later decisions incorporate neurological deterioration and appear to better align with prognosis. These findings support deferring ECL decisions until clinical evolution can be observed.