Timeliness to Early Medical Intervention in Intracerebral Hemorrhage Among Rural vs Urban Emergency Department Populations

Intracerebral hemorrhage (ICH) represents ~10% of strokes in the US yearly, with mortality of ~30-40%. Acute interventions, such as blood pressure (BP) control, anticoagulation reversal, and timely transfer to a comprehensive stroke center (CSC) are vital to early ICH management. Prior studies suggest higher mortality rates of ICH patients hospitalized in rural vs urban sites, but few have compared timeliness to interventions and overall impact on ICH mortality in these two populations. Here we assessed time to medical interventions and overall impact on ICH disease severity in rural vs urban populations within our health network.

All spontaneous ICH patients (n=205) presenting to any of our 10 network emergency departments (9 community/rural sites (n=102) and 1 tertiary center/CSC (n=103)) were reviewed for diagnosis verification between 1/1/2024 and 11/11/2025 and included in this cohort study. Time to first antihypertensive medications, anticoagulation reversal, neuroimaging order and read time, hemorrhage expansion, and length of ICU stay were compared amongst rural and urban populations using unpaired, two-tailed Mann-Whitney analyses.

Time to first antihypertensive medication was statistically shorter at our CSS compared to our rural hospitals (p = 0.0003), as was time to first CT order and read (p = 0.0001; p= 0.0256). There was no statistical significance between time to anticoagulation reversal (p= 0.9279), ICH expansion (p = > 0.99), or ICU length of stay (p = 0.7427).

Our CSC demonstrated faster times to neuroimaging and BP control, likely related to increased frequency of patient exposure though this did not lead affect rate of hemorrhage expansion, in-hospital mortality, or ICU LOS. Future Directions We recently implemented a system-wide ED ICH orderset to standardize/streamline medical management in this low frequency/high-risk patient population with the goal of improving time to medical management, transfer, and overall outcomes.