Abstract Background and aims Spontaneous Intracerebral haemorrhage (ICH) has high morbidity and mortality. We aimed to identify prognostic factors in clinical practice and to assess whether an intensive management care bundle protocol (CBP) improves outcomes. Methods Retrospective observational study included patients admitted with ICH between 2022-2025. Clinical and radiological variables and ICHMAX score were analysed. Outcomes were mortality and modified Rankin Scale (mRS) at 90 days. Results were compared before and after CBP implementation in 2024. Results 321 patients (201 before, 120 after CBP), mean age 69.45 years, 56.4% male. Median baseline stroke severity was: NIHSS 10, ICHMAX score 3, pre-ICH mRS 1. No baseline differences between periods. Women had higher mortality (22.9% vs 13.3%; p=0.02) and worse functional outcome (p=0.02). Hypertension, diabetes and admission hyperglycaemia were associated with poor functional outcome (p0.05). Radiological markers (spot, blend, black hole and island signs) and hematoma size were strongly associated with higher mortality and poor outcome (p0.001). A linear association existed between ICHMAX and both mortality and 90-day mRS (p0.001). Following CBP implementation, a trend towards improved blood pressure control (p=0.08) and better glycaemic control (p=0.046) was observed. Overall outcome and mortality showed limited improvement (14.2% vs 19.5%; p=0.28), but mortality decreased in ICHs with radiological poor-prognosis signs (23.3% vs 37.8%; p=0.075) and ICHMAX size-positive haemorrhages (21.4% vs 45.3%; p=0.016) Conclusions Our protocol appears to benefit patients with worse prognosis. Initial severity, ICHMAX and radiological poor-prognosis features are strong determinants of outcome. Future prognostic improvement will likely require complementary strategies, including brain injury biomarkers and novel therapeutic approaches. Conflict of interest Nothing to disclose
García et al. (2026) studied this question.