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neuro.ich-cerebellar.v1

Intracerebral Hemorrhage — Cerebellar (emergent decompression)

neurologyacuteadultpediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase C shard-3 neuro-sym wave-14 ICH location triplet (2026-05-15): authored at SCAFFOLDED — uses generic workup.ich; no cerebellar-specific surgical cascade in clinical-tools-registry.ts. Same-commit peers: neuro.ich-lobar.v1 + neuro.ich-deep.v1. AHA/ASA 2022 Class I emergent decompression for cerebellar ≥3 cm OR brainstem compression OR obstructive hydrocephalus — life-saving suboccipital decompressive craniectomy; posterior fossa is non-compliant (Cushing reflex = late sign). ICU is the PRIMARY setting — LOW threshold even for small <3 cm because of delayed-deterioration arm. 5 setting playbooks: home (HINTS-positive central → bypass community ED, route to CSC) → ed (STAT NSurg + CT volumetrics + INTERACT3 if stable + reversal) → icu (post-decompression OR observation arm; q1h Cushing reflex × 24 h) → inpatient (cerebellar rehab + AVM management if applicable + phenotype-specific 2° prevention) → outpatient (BP <130/80 + cerebellar rehab continuity + driving eval). 10 severity_triggers: small_cerebellar_lt_3cm_no_brainstem_compression, cerebellar_ge_3cm_or_brainstem_compression_STAT_decompression, cerebellar_with_obstructive_hydrocephalus_EVD, cerebellar_with_GCS_decline_post_admission_STAT_surgery, ataxia_vertigo_predominant (HINTS pivot), cerebellar_AVM_associated, cerebellar_amyloid_overlap, oral_anticoag_associated_cerebellar, SVC_overlap, pediatric_cerebellar_AVM. 6 PMID anchor: AHA/ASA 2022 (35579034), INTERACT3 (37245517), HINTS Newman-Toker 2009 (19762709), ANNEXA-I (38749032), PATCH (27178479), ENRICH (38598795 — explicit non-applicability for cerebellar). Regimen 4-step bundle: STAT decompression Class I; EVD if hydrocephalus; INTERACT3 BP <140 if stable; reversal per anticoag (4F-PCC + vit K for VKA; idarucizumab for dabigatran; andexanet ANNEXA-I low/high for FXa-DOAC). KEY contrast vs lobar/deep: cerebellar is the ONLY ICH phenotype with Class I emergent decompression; ENRICH MIE benefits lobar (NOT cerebellar); supratentorial deep NOT routinely evacuated. Sibling siblings (3, all resolving): neuro.ich.core.v1 (parent PRODUCTION), neuro.ischaemic-stroke.v1 (real PRODUCTION), symptom.vertigo.v1 (real PRODUCTION; HINTS pivot for vestibular presentations). Promotion to INTEGRATED requires cerebellar suboccipital decompressive craniectomy cascade + EVD cascade in clinical-tools-registry.

Entry points (4)

  • imaging
    Non-contrast CT head showing cerebellar intraparenchymal blood (AHA/ASA 2022 PMID 35579034)
    ct_head_cerebellar_blood
  • symptom
    Sudden ataxia + vertigo + vomiting + occipital headache (often mistaken for benign vertigo — HINTS pivot; Newman-Toker Stroke 2009 PMID 19762709)
    sudden_ataxia_vertigo_vomiting_headache
  • symptom
    Altered consciousness from brainstem compression / hydrocephalus (AHA/ASA 2022)
    altered_consciousness
  • medication
    On VKA / DOAC / heparin at presentation (ANNEXA-I PMID 38749032)
    current_anticoagulant

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Pediatric cerebellar ICH often AVM rupture; adult often hypertensive (AHA/ASA 2022)
  • sbprequired
    vital • used at TREATMENT
    INTERACT3 (PMID 37245517) target SBP <140 within 1 h if hemodynamically stable; avoid <110 (ATACH-2)
  • gcsrequired
    vital • used at RED_FLAGS
    GCS drives ICH score (Hemphill 2001) + intubation + Cushing-reflex monitoring (AHA/ASA 2022)
  • ct_head_noncontrastrequired
    imaging • used at INITIAL_WORKUP
    Volume measurement (≥3 cm = STAT surgical indication per AHA/ASA 2022 Class I); brainstem compression; 4th-ventricle compression; obstructive hydrocephalus
  • cta_head_spot_sign
    imaging • used at INITIAL_WORKUP
    Spot sign within 6 h predicts hematoma expansion (AHA/ASA 2022)
  • mri_for_underlying_lesion
    imaging • used at BRANCHING_WORKUP
    AVM / cavernous malformation / amyloid overlap workup, especially in young / atypical patients
  • inrrequired
    lab • used at RED_FLAGS
    VKA reversal threshold; STAT 4F-PCC if INR ≥1.4 (INCH PMID 27302126)
  • platelet_countrequired
    lab • used at RED_FLAGS
    Coagulopathy assessment; PATCH (PMID 27178479) — do NOT routinely transfuse
  • creatininerequired
    lab • used at CONTEXT
    Contrast + dosing decisions; andexanet (ANNEXA-I PMID 38749032)
  • current_anticoagulantrequired
    medication • used at TREATMENT
    VKA → 4F-PCC + vit K (INCH); dabigatran → idarucizumab; FXa-DOAC → andexanet (ANNEXA-I PMID 38749032)
  • cerebellar_signs_ataxia_dysmetria
    symptom • used at CONTEXT
    Cerebellar dysfunction signs anchor diagnosis when CT preceded by vestibular pivot (HINTS Newman-Toker Stroke 2009 PMID 19762709)

12-phase flow (12)

  1. 1FRAME
    Cerebellar bleed on CT; assess volume + brainstem compression + 4th-ventricle compression + obstructive hydrocephalus (AHA/ASA 2022 PMID 35579034)
    advance: Cerebellar ICH confirmed on imaging
  2. 2ENTRY
    Sudden ataxia / vertigo / vomiting / occipital headache (HINTS pivot — central pattern: ipsilateral vertical or torsional nystagmus, normal head impulse, vertical skew; Newman-Toker Stroke 2009 PMID 19762709)
    inputs: age
    advance: Cerebellar entry trigger captured; CT ordered
  3. 3CONTEXT
    HTN history, anticoag exposure, age, baseline function, AVM history, creatinine (AHA/ASA 2022)
    inputs: sbp, gcs, creatinine, current_anticoagulant, cerebellar_signs_ataxia_dysmetria
    advance: Context captured + reversal decision-tree primed
  4. 4RED_FLAGS
    Volume ≥3 cm OR brainstem compression OR obstructive hydrocephalus → STAT surgical decompression (AHA/ASA 2022 Class I); Cushing reflex; GCS decline post-admission (AHA/ASA 2022)
    inputs: gcs, inr, platelet_count
    actions: workup.ich
    advance: Surgical decision documented or low-risk observation initiated
  5. 5INITIAL_WORKUP
    Non-contrast CT + CTA spot sign; CBC, CMP, coags, type & screen; STAT neurosurgical consult; INTERACT3 BP bundle if otherwise stable (AHA/ASA 2022; PMID 37245517)
    inputs: ct_head_noncontrast, cta_head_spot_sign, inr, platelet_count
    actions: panel.renal
    advance: Volume + brainstem-compression + 4th-vent + hydrocephalus status documented
  6. 6BRANCHING_WORKUP
    MRI for underlying AVM / cavernous malformation / amyloid overlap; DSA if young or atypical (AHA/ASA 2022)
    inputs: mri_for_underlying_lesion
    advance: Mechanism confirmed (chronic HTN vs AVM vs amyloid overlap vs anticoag)
  7. 7DIFFERENTIAL
    Spontaneous hypertensive cerebellar (most common) vs AVM-associated vs amyloid-overlap (rare cerebellar CAA) vs anticoag-associated vs pediatric AVM rupture (AHA/ASA 2022)
    advance: Cerebellar mechanism assigned
  8. 8RISK_STRATIFICATION
    Volume ≥3 cm = Class I emergent decompression; brainstem compression markers; ICH score (Hemphill 2001) with infratentorial +1 component (AHA/ASA 2022)
    inputs: gcs
    actions: calc.ich_score, calc.func
    advance: Severity + decompression decision documented
  9. 9TREATMENT
    STAT neurosurgery (suboccipital decompressive craniectomy ± evacuation) if ≥3 cm OR brainstem compression OR hydrocephalus (AHA/ASA 2022 Class I); EVD for obstructive hydrocephalus; INTERACT3 BP <140 if hemodynamically stable; reversal per anticoag; observe <3 cm without compression in ICU (AHA/ASA 2022)
    inputs: sbp, current_anticoagulant
    advance: BP at target + reversal complete + surgical disposition decided
  10. 10DISPOSITION
    Neuro-ICU at NSurg-capable centre — LOW threshold even for small <3 cm (posterior fossa non-compliance); transfer if not available (AHA/ASA 2022)
    inputs: gcs
    advance: NCCU bed allocated at NSurg-capable centre
  11. 11MONITORING
    q1h GCS + pupil + Cushing-reflex check × 24 h; continuous arterial BP; repeat CT 6 h or with decline; post-op craniectomy site assessment (AHA/ASA 2022)
    inputs: gcs, sbp, inr
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Long-term BP <130/80 (SPRINT-MIND); MRI for underlying vascular cause in young / atypical; phenotype-specific secondary prevention; cerebellar rehab; PHQ-9 + MoCA; driving evaluation (cerebellar ataxia affects driving) (AHA/ASA 2022)
    advance: Rehab + outpatient stroke clinic + BP plan + driving eval set