Clinical Commander

All dossiers
neuro.ich-deep.v1

Intracerebral Hemorrhage — Deep (hypertensive)

neurologyacuteadultacuteinpatient
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 deep-ICH-specific cascade in clinical-tools-registry.ts. Same-commit peers: neuro.ich-lobar.v1 + neuro.ich-cerebellar.v1. Mechanism = chronic uncontrolled HTN (basal ganglia / thalamus / pons); contrast with lobar (amyloid) and cerebellar (anatomy-driven decompression). 5 setting playbooks: home (EMS + anticoag pre-alert + tox screen indication) → ed (INTERACT3 aggressive SBP <140 + reversal + tox screen) → icu (sustained BP + reversal monitoring + EVD if hydrocephalus + 24-48 h pontine observation) → inpatient (strict BP <130/80 + anticoag-restart FAVOURABLE 4-8 wk for AF + non-CAA) → outpatient (SPRINT-MIND BP + secondary-HTN workup if uncontrolled + DOAC restart). 9 severity_triggers: basal_ganglia_putaminal, thalamic_with_hydrocephalus_risk, pontine_brainstem_poor_prognosis_TOC, HTN_predominant_chronic_uncontrolled, cocaine_methamphetamine_induced, secondary_to_pituitary_apoplexy_or_AVM, INTERACT3_bundle_target_<140, spot_sign_hematoma_expansion_risk, rapidly_expanding_30pct_or_6mL_repeat_CT_6h. 7 PMID anchor: AHA/ASA 2022 (35579034), INTERACT3 (37245517), AHA cardiorenal HTN (35579034), ENRICH (38598795), PATCH (27178479), TICH-2 (29778325), MISTIE III (30739747). Regimen 4-step bundle: STAT SBP <140 within 1 h (nicardipine + clevidipine + labetalol adjunct); reversal per anticoag (4F-PCC + vit K for VKA; idarucizumab for dabigatran; andexanet ANNEXA-I low/high for FXa-DOAC); EVD if hydrocephalus (supratentorial deep evac NOT routine); long-term BP <130/80 + statin restart + lifestyle. KEY contrast vs lobar CAA: deep HTN ICH has FAVOURABLE anticoag-restart risk-benefit at 4-8 wk for AF + high CHA2DS2-VASc + non-CAA phenotype (opposite of lobar CAA which holds indefinitely). KEY contrast vs cerebellar: cerebellar Class I emergent decompression; deep supratentorial = NOT a routine MIE candidate (ENRICH benefits lobar 30-80 mL <24 h; PMID 38598795). Sibling siblings (3, all resolving): neuro.ich.core.v1 (parent PRODUCTION), neuro.ischaemic-stroke.v1 (real PRODUCTION), cardio.hypertensive-emergency.core.v1 (real PRODUCTION). Promotion to INTEGRATED requires deep-specific HTN-secondary-screen cascade or shared workup.ich + INTERACT3 cascade in clinical-tools-registry.

Entry points (5)

  • imaging
    Non-contrast CT head showing deep (basal ganglia / thalamus / pons) intraparenchymal blood (AHA/ASA 2022 PMID 35579034)
    ct_head_deep_blood
  • symptom
    Sudden contralateral hemiparesis + sensory loss (putamen/thalamus) or quadriparesis + CN deficits (pons) (AHA/ASA 2022)
    sudden_contralateral_hemiparesis_sensory_loss
  • history
    Long-standing or uncontrolled hypertension (deep ICH mechanism)
    chronic_uncontrolled_hypertension
  • medication
    On VKA / DOAC / heparin at presentation (ANNEXA-I PMID 38749032; INCH PMID 27302126)
    current_anticoagulant
  • history
    Cocaine / methamphetamine use in young patients (sympathomimetic mechanism)
    sympathomimetic_drug_use

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Age <55 + deep bleed without HTN history → tox screen + AVM workup (AHA/ASA 2022)
  • sbprequired
    vital • used at TREATMENT
    INTERACT3 (PMID 37245517) — SBP <140 within 1 h; deep ICH = HTN-driven so aggressive (AHA/ASA 2022)
  • gcsrequired
    vital • used at RED_FLAGS
    GCS drives ICH score (Hemphill 2001); pontine often ≤8; AHA/ASA 2022 cautions against early WLST
  • ct_head_noncontrastrequired
    imaging • used at INITIAL_WORKUP
    Volume + deep location + IVH; pontine = worst prognosis (AHA/ASA 2022)
  • cta_head_spot_sign
    imaging • used at INITIAL_WORKUP
    Spot sign within 6 h predicts hematoma expansion 30%/6mL (AHA/ASA 2022)
  • 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; chronic kidney disease comorbid with chronic HTN (AHA cardiorenal PMID 35579034)
  • urine_tox_screen
    lab • used at BRANCHING_WORKUP
    Cocaine / methamphetamine if <55 or no HTN history (AHA/ASA 2022)
  • current_anticoagulantrequired
    medication • used at TREATMENT
    VKA → 4F-PCC (INCH); dabigatran → idarucizumab; FXa-DOAC → andexanet (ANNEXA-I PMID 38749032)
  • hypertension_duration_control
    history • used at DIFFERENTIAL
    Distinguishes chronic uncontrolled HTN mechanism from secondary causes

12-phase flow (12)

  1. 1FRAME
    Deep (basal ganglia / thalamus / pons) ICH on CT in patient with chronic HTN; rule out trauma + hemorrhagic transformation (AHA/ASA 2022 PMID 35579034)
    advance: Deep ICH confirmed on imaging
  2. 2ENTRY
    Sudden focal deficit pattern (contralateral hemiparesis + sensory for putamen/thalamus; quadriparesis + CN for pons); STAT CT (AHA/ASA 2022)
    inputs: age
    advance: Deep-pattern entry trigger captured
  3. 3CONTEXT
    HTN history + duration + control + sympathomimetic exposure + anticoag exposure + creatinine (AHA/ASA 2022)
    inputs: sbp, gcs, creatinine, current_anticoagulant, hypertension_duration_control
    advance: Context captured + reversal decision-tree primed
  4. 4RED_FLAGS
    Herniation, GCS ≤8 (common pontine), hematoma expansion >33% or 6 mL, hydrocephalus (thalamic-IVH or pontine 4th-vent) → STAT NSurg + intubation (AHA/ASA 2022)
    inputs: gcs, inr, platelet_count
    actions: workup.ich
    advance: Airway secured + ICU dispositioned + reversal initiated if applicable
  5. 5INITIAL_WORKUP
    Non-contrast CT + CTA spot sign; CBC, CMP, coags, troponin, ECG; STAT BP control bundle; INTERACT3 initiation (PMID 37245517)
    inputs: ct_head_noncontrast, cta_head_spot_sign, inr, platelet_count
    actions: panel.renal, panel.cardiac
    advance: Volume + deep location + IVH + spot-sign documented
  6. 6BRANCHING_WORKUP
    MRI to confirm location + exclude underlying AVM / pituitary apoplexy / vascular lesion if young; secondary HTN screen if <55 or resistant; tox screen for sympathomimetic (AHA/ASA 2022)
    inputs: urine_tox_screen
    advance: Mechanism confirmed (chronic HTN vs sympathomimetic vs AVM vs apoplexy)
  7. 7DIFFERENTIAL
    Deep hypertensive (this engine) vs lobar CAA (route ich-lobar) vs cerebellar (route ich-cerebellar) vs anticoag-associated vs sympathomimetic-induced vs vascular malformation vs pituitary apoplexy (AHA/ASA 2022)
    advance: Deep mechanism assigned
  8. 8RISK_STRATIFICATION
    ICH score (Hemphill 2001) — pontine/thalamic carry worst prognosis; FUNC score (Rost 2008); pontine 90-d mortality 50-80% but AHA/ASA 2022 cautions against early WLST first 24-48 h
    inputs: gcs
    actions: calc.ich_score, calc.func
    advance: Severity + sub-anatomic prognosis documented
  9. 9TREATMENT
    STAT SBP <140 within 1 h (INTERACT3 PMID 37245517) — aggressive because deep = HTN-driven; reversal per anticoag (4F-PCC INCH PMID 27302126; idarucizumab; andexanet ANNEXA-I PMID 38749032); EVD if hydrocephalus from IVH; surgical evacuation NOT routine for deep supratentorial; goals-of-care 24-48 h for pontine (AHA/ASA 2022)
    inputs: sbp, current_anticoagulant
    advance: BP at target + reversal complete + surgical disposition decided
  10. 10DISPOSITION
    Neuro-ICU; comprehensive stroke / NSurg transfer if unavailable (AHA/ASA 2022)
    inputs: gcs
    advance: NCCU bed allocated or transfer initiated
  11. 11MONITORING
    GCS q1h × 24 h; continuous arterial BP; repeat CT 6 h or with decline; serial coags during reversal (AHA/ASA 2022)
    inputs: gcs, sbp, inr
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Long-term BP <130/80 STRICT (SPRINT-MIND); secondary-HTN workup if uncontrolled; anticoag restart at 4-8 wk FAVOURABLE for AF + high CHA2DS2-VASc + non-CAA phenotype (opposite of lobar CAA); lifestyle + statin restart (AHA/ASA 2022)
    advance: Rehab + outpatient stroke clinic + BP plan + anticoag-restart decision set