Patient handout

Intracerebral Hemorrhage — Lobar (CAA-suspected)

PRODUCTION

1. Your condition

This handout is for intracerebral hemorrhage — lobar (caa-suspected). Your care team identified this based on: non-contrast ct head showing lobar (cortico-subcortical) intraparenchymal blood (aha/asa 2022 pmid 35579034).

Other reasons your team may use this plan: sudden focal deficit in patient age >55 (lobar caa suspect; boston v2.0 pmid 35841910); pre-ich cognitive impairment (caa-associated dementia) (aha/asa 2022); on vka / doac / heparin at presentation (annexa-i pmid 38749032; inch pmid 27302126).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
nicardipine	5 mg/h IV; titrate by 2.5 mg/h q5–15 min	IV	continuous	INTERACT3 (PMID 37245517) — SBP 130-150 within 1 h reduces hematoma growth
clevidipine	1-2 mg/h IV; double q90 sec	IV	continuous	Ultra-short acting; rapid titration (AHA/ASA 2022)
labetalol	10-20 mg IV bolus q10 min	IV	PRN	Adjunct for resistant HTN (AHA/ASA 2022)

Plan: Lobar-CAA bundle — INTERACT3 BP + FXa-DOAC reversal + PATCH + ENRICH MIE + CAA-RI immunotherapy (AHA/ASA 2022 PMID 35579034; INTERACT3 PMID 37245517; ANNEXA-I PMID 38749032; ENRICH PMID 38598795; PATCH PMID 27178479)

3. When to call your provider

Contact your care team if any of the following happen:

Any new TIA-spectrum or stroke-like event → ED
BP persistently >140/90 despite 3-drug regimen → resistant HTN workup
PHQ-9 ≥15 or suicidal ideation → urgent psych referral
Recurrent ICH → re-image, hold all antithrombotics, escalate to vascular neurology
New CAA microbleeds on 6-mo MRI → reinforce anticoag-hold; consider LAA closure if AF

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Classic lobar ICH (cortico-subcortical) in age >55 with multiple cortical/subcortical microbleeds + cortical superficial siderosis on MRI GRE/SWI per Boston v2.0 (Charidimou Lancet Neurol 2022 PMID 35841910)
APOL1 high-risk genotype amyloid mechanism in select populations (research-stage; consider in young recurrent lobar without classic CAA)
CAA-related inflammation — T2 white-matter edema + meningeal enhancement on MRI; steroid-responsive immune variant
Recurrent lobar ICH within 12 mo OR multiple cortical microbleeds + cortical superficial siderosis — high recurrence risk (CAA recurrence ≈7%/yr)
Anticoag-restart decision at 4-8 wk in lobar CAA = HOLD INDEFINITELY (opposite of deep hypertensive ICH which favours restart)
Boston v2.0 requires MRI GRE/SWI for probable/possible CAA classification — multiple cortical microbleeds + cortical superficial siderosis (Charidimou Lancet Neurol 2022 PMID 35841910)
Mixed phenotype — both CAA microbleeds (cortical) AND deep hypertensive bleeds; chronic HTN comorbid with CAA

5. Follow-up

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)

6. Sources

Guideline: 2022 AHA/ASA Guideline for Spontaneous ICH (Greenberg Stroke 2022) + Boston v2.0 (Charidimou Lancet Neurol 2022) + INTERACT3 + ENRICH + ANNEXA-I