To assess institutional adherence to key 2022 AHA/ASA guidelines in the acute management of intraparenchymal hemorrhage (IPH) and to identify opportunities for quality improvement.

Adherence to 2022 AHA/ASA time-sensitive IPH guidelines improves outcomes, yet real-world compliance remains inconsistent.

We retrospectively analyzed patients admitted with IPH to a comprehensive stroke center from January–December 2024. Inclusion criteria: IPH on CT head, presenting SBP >160 mmHg, and evaluation via code stroke or neurology consult. Exclusion criteria: interfacility transfer, initial SBP <160 mmHg, or non-IPH.

Quality metrics (per 2022 AHA/ASA Class I/II): time to neuroimaging, time to BP medication (≤1 hr of CTH), SBP <160 mmHg within 3 hrs of arrival, repeat CTH ≤6 hrs to assess hematoma expansion, ICH score documentation, and discharge mRS.

Of 119 patients, 77 met inclusion criteria; 61 arrived as code stroke and 16 were evaluated for AMS. Quality metric adherence was inconsistent. Only 28%(17/61) code stroke patients had imaging within 15 min. Among non-code strokes, 50% had >3 hr imaging delays.

Among 77 patients, compliance was: BP therapy within 1 hr of CTH in 60(77%); SBP <160 mmHg within 3 hrs of arrival in 56(73%); repeat CTH ≤6 hrs in 32(41%); ICH score in 72(93%).

24 had hematoma expansion; delayed BP initiation and BP control was seen in only 4 and 3 cases respectively, suggesting limited association. Severe functional decline (≥2-point mRS worsening) occurred in 57%(44/77), and this occurred in all patients with hematoma expansion. Most of the 10 deaths involved anticoagulation or delayed BP control.

AHA/ASA guidelines were generally adhered to, but time-sensitive ICH care was delayed. AMS with severe hypertension should prompt rapid CTH. Targeted interventions (order sets, education, audit-feedback, real-time alerts) are needed to optimize care. Limitations include small sample size and lack of 3-month mRS, which may show outcome benefits of early BP control.