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neuro.ich-lobar.v1

Intracerebral Hemorrhage — Lobar (CAA-suspected)

neurologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase C shard-3 neuro-sym wave-14 ICH location triplet (2026-05-15): authored at SCAFFOLDED — no lobar-CAA-specific cascade in clinical-tools-registry.ts (only generic workup.ich registered; calc.boston_caa is schema-blocked). Same-commit peers: neuro.ich-deep.v1 + neuro.ich-cerebellar.v1. 5 setting playbooks: home (EMS + anticoag pre-alert) → ed (CT + MRI GRE/SWI + STAT NSurg + ENRICH eligibility + INTERACT3) → icu (BP + reversal + ENRICH bridging + CAA-RI immunotherapy + EVD) → inpatient (Boston v2.0 + INDEFINITE anticoag-hold + LAA closure plan) → outpatient (4-8 wk INDEFINITE hold + 6-mo repeat MRI + PHQ-9 + MoCA). 9 severity_triggers: classic_lobar_CAA_age_gt_55, APOL1_amyloid_associated, cerebral_amyloid_inflammation_CAA-RI, recurrent_lobar_high_risk, anticoag_restart_4-8wk_decision_CAA_AVOID, MRI_GRE_microbleeds_required_for_dx, PET_amyloid_PiB, familial_HCHWA_Dutch_or_Icelandic, mixed_amyloid_HTN. 6 PMID anchor: AHA/ASA 2022 (35579034), INTERACT3 (37245517), Boston v2.0 (35841910), ENRICH (38598795), PATCH (27178479), ANNEXA-I (38749032). Regimen 5-step bundle: INTERACT3 BP <140 in 1 h; ANNEXA-I FXa-DOAC reversal (low/high dose) + INCH 4F-PCC + vit K (VKA) + idarucizumab (dabigatran); PATCH — NO routine platelet transfusion (DDAVP optional); ENRICH MIE for supratentorial lobar 30-80 mL <24 h; CAA-RI methylprednisolone + cyclophosphamide. Schema-blocked: calc.boston_caa (Boston v2.0 CAA criteria) NOT in registry — surfaced as cross-shard ticket; encoded as plain-English required_assessment + severity_trigger fire. Sibling siblings (3, all resolving): neuro.ich.core.v1 (parent PRODUCTION), neuro.ischaemic-stroke.v1 (real PRODUCTION), neuro.tia.v1 (real PRODUCTION). Promotion to INTEGRATED requires registered CAA-specific cascade OR shared workup.ich + ENRICH MIE cascade in clinical-tools-registry.

Entry points (4)

  • imaging
    Non-contrast CT head showing lobar (cortico-subcortical) intraparenchymal blood (AHA/ASA 2022 PMID 35579034)
    ct_head_lobar_blood
  • symptom
    Sudden focal deficit in patient age >55 (lobar CAA suspect; Boston v2.0 PMID 35841910)
    sudden_focal_deficit_age_gt_55
  • history
    Pre-ICH cognitive impairment (CAA-associated dementia) (AHA/ASA 2022)
    cognitive_baseline_pre_ich
  • medication
    On VKA / DOAC / heparin at presentation (ANNEXA-I PMID 38749032; INCH PMID 27302126)
    current_anticoagulant

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Age >55 anchors CAA suspicion (Boston v2.0 PMID 35841910)
  • sbprequired
    vital • used at TREATMENT
    INTERACT3 (PMID 37245517) target SBP <140 within 1 h; avoid <110 (ATACH-2)
  • gcsrequired
    vital • used at RED_FLAGS
    GCS drives ICH score (Hemphill 2001), intubation, EVD decisions (AHA/ASA 2022)
  • ct_head_noncontrastrequired
    imaging • used at INITIAL_WORKUP
    Volume + lobar location + IVH; ENRICH MIE candidate if 30-80 mL <24 h (Pradilla NEJM 2024 PMID 38598795)
  • cta_head_spot_sign
    imaging • used at INITIAL_WORKUP
    Spot sign within 6 h predicts hematoma expansion (AHA/ASA 2022)
  • mri_gre_swirequired
    imaging • used at BRANCHING_WORKUP
    Boston v2.0 (PMID 35841910) — required for probable/possible CAA classification; multiple cortical microbleeds + cortical superficial siderosis
  • 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 for antiplatelet ICH
  • creatininerequired
    lab • used at CONTEXT
    Contrast + dosing decisions for nicardipine, clevidipine, andexanet (ANNEXA-I PMID 38749032)
  • current_anticoagulantrequired
    medication • used at TREATMENT
    VKA → 4F-PCC + vit K (INCH PMID 27302126); dabigatran → idarucizumab; FXa-DOAC → andexanet (ANNEXA-I PMID 38749032)
  • current_antiplatelet
    medication • used at TREATMENT
    PATCH (PMID 27178479) — do NOT routinely transfuse platelets; consider DDAVP
  • family_history_caa
    history • used at DIFFERENTIAL
    Familial HCHWA-Dutch/Icelandic APP mutation suspicion if young + recurrent lobar

12-phase flow (12)

  1. 1FRAME
    Spontaneous lobar (cortico-subcortical) IPH on imaging in age >55; rule out trauma + hemorrhagic transformation (AHA/ASA 2022 PMID 35579034)
    advance: Lobar ICH confirmed on imaging
  2. 2ENTRY
    Lobar bleed on CT + age >55 + antithrombotic exposure (AHA/ASA 2022)
    inputs: age
    advance: Lobar phenotype entry trigger captured
  3. 3CONTEXT
    Age + cognitive baseline + family history + anticoag exposure + creatinine (AHA/ASA 2022; Boston v2.0 PMID 35841910)
    inputs: sbp, gcs, creatinine, current_anticoagulant, current_antiplatelet
    advance: Context captured + reversal decision-tree primed
  4. 4RED_FLAGS
    Herniation, GCS ≤8, hematoma expansion >33%, hydrocephalus, CAA-RI inflammatory edema → STAT NSurg (AHA/ASA 2022)
    inputs: gcs, inr, platelet_count
    actions: workup.ich
    advance: No immediate surgical/airway need or escalated
  5. 5INITIAL_WORKUP
    Non-contrast CT + CTA spot sign; CBC, coags, BMP, type & screen; INTERACT3 care-bundle initiation (PMID 37245517)
    inputs: ct_head_noncontrast, cta_head_spot_sign, inr, platelet_count
    actions: panel.renal
    advance: Volume + location + IVH + spot-sign documented
  6. 6BRANCHING_WORKUP
    STAT MRI GRE/SWI for Boston v2.0 (PMID 35841910) — multiple cortical microbleeds + cortical superficial siderosis; CAA-RI evaluation (T2 white-matter edema + meningeal enhancement); PET amyloid (PiB) in select; DSA if <55 / atypical
    inputs: mri_gre_swi, family_history_caa
    advance: CAA Boston v2.0 probable/possible/inflammatory classification assigned
  7. 7DIFFERENTIAL
    Lobar CAA (this engine) vs deep hypertensive (route ich-deep) vs cerebellar (route ich-cerebellar) vs anticoag-associated vs vascular malformation vs tumor with hemorrhage vs CAA-RI (AHA/ASA 2022)
    advance: Phenotype assigned (probable/possible CAA vs alternative)
  8. 8RISK_STRATIFICATION
    ICH score (Hemphill 2001) → 30-d mortality; FUNC score (Rost 2008) → 90-d independence; CAA-specific recurrence ≈7%/yr (AHA/ASA 2022)
    inputs: gcs
    actions: calc.ich_score, calc.func
    advance: Severity score + CAA recurrence-risk documented
  9. 9TREATMENT
    INTERACT3 bundle (SBP <140 in 1 h via nicardipine/clevidipine; reversal); ANNEXA-I andexanet for FXa-DOAC; ENRICH MIE if supratentorial lobar 30-80 mL <24 h (Pradilla NEJM 2024 PMID 38598795); CAA-RI → methylprednisolone pulse + cyclophosphamide; PATCH — NO routine platelet transfusion
    inputs: sbp, current_anticoagulant
    advance: BP at target + reversal complete + surgical consult dispositioned
  10. 10DISPOSITION
    Neuro-ICU admission; 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; q6h INR until <1.3 (VKA-ICH); MRI GRE/SWI for definitive CAA classification (AHA/ASA 2022)
    inputs: gcs, sbp, inr
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Long-term BP <130/80 (SPRINT-MIND); INDEFINITE anticoag-hold (CAA recurrence ≈7%/yr); LAA closure if AF; repeat MRI 6 mo for microbleed burden tracking; CAA family counselling; PHQ-9 + MoCA (AHA/ASA 2022)
    advance: Rehab + outpatient stroke clinic + indefinite-hold + LAA-closure plan set