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neuro.sah-grade1-3.v1

Aneurysmal SAH — Good Grade (Hunt-Hess I–III)

neurologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase C shard-3 neuro wave-14 (2026-05-15): authored at SCAFFOLDED — good-grade aneurysmal SAH (Hunt-Hess I–III) drill-down dossier; same-commit peers neuro.sah-grade4-5.v1 + neuro.sah-perimesencephalic.v1. Parent neuro.sah.core.v1 encodes broader SAH framework + HH I–V + perimesencephalic as severity_triggers; this child deepens HH I–III pathway with early-securing-≤24-h, ISAT coil-first posterior, BRAT individualised anterior. 5 setting playbooks: home (EMS triage CT centre) → ed (Hunt-Hess/WFNS/mFisher + CTA + transfer) → icu (securing ≤24 h + DCI surveillance days 3–14 + nimodipine + euvolemic induced HTN) → inpatient (rehab + cognitive eval + family screen) → outpatient (cerebrovascular clinic 6 wk/3/6/12 mo; BP <130/80; smoking cessation; repeat MRA 6 mo). 11 severity_triggers: HH_I_asymp_minimal_HA, HH_II_mod_HA_no_focal, HH_III_drowsy_mild_focal, ACommA_aneurysm_predominant, PComm_aneurysm, MCA_bifurcation, basilar_tip_aneurysm, vertebral_PICA, coiling_vs_clipping (ISAT), pregnancy_with_aneurysmal_SAH, family_history_screening_indication. 6 PMID anchor (all NEEDS_SOURCE_REVIEW): 37212182 (AHA/ASA 2023 Hoh), 37202712 (NCS 2023 Treggiari), 33357465 (ULTRA Post 2021), 2496789 (BRANT Pickard 1989), 16139655 (ISAT Molyneux 2005), 29158449 (HIMALAIA). Nimodipine PO/NG only — NEVER IV (FDA boxed warning). Routine seizure prophylaxis NOT recommended. Long-course TXA NOT recommended (ULTRA negative). Abandon triple-H — use euvolemic induced HTN (HIMALAIA). Schema-blocked: calc.ottawa_sah, calc.sahit, protocol.sah — shard-3 cannot edit clinical-tools-registry.ts. Siblings: neuro.sah.core.v1 (parent PRODUCTION), neuro.sah-grade4-5.v1 (same-commit), neuro.sah-perimesencephalic.v1 (same-commit), neuro.ich.core.v1 (real PRODUCTION), neuro.ischaemic-stroke.v1 (real PRODUCTION).

Entry points (6)

  • symptom
    Thunderclap headache, GCS 15, no/minimal focal deficit (HH I–II) [AHA/ASA 2023 Hoh PMID 37212182]
    thunderclap_headache_HH_I_II_alert
  • symptom
    Drowsiness OR mild focal deficit (HH III) with thunderclap [Hunt-Hess 1968; AHA/ASA 2023]
    drowsy_or_mild_focal_HH_III
  • imaging
    CT showing subarachnoid blood in alert patient (Fisher I–IV) [AHA/ASA 2023]
    ct_subarachnoid_blood_alert_patient
  • imaging
    CTA demonstrates saccular aneurysm — entry to coiling/clipping pathway [AHA/ASA 2023; ISAT 2005]
    cta_demonstrates_aneurysm
  • history
    Family history aneurysm/SAH OR ADPKD presenting for screening (HH 0 effectively but warrants SAH workup if symptomatic) [AHA/ASA 2023]
    family_history_aneurysm_or_adpkd_screen_entry
  • demographic
    Pregnancy + good-grade aSAH — securing strategy modified by trimester [AHA/ASA 2023]
    pregnancy_with_aSAH_HH_I_III

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Age + comorbidity shape coil vs clip decision; older patients trend toward coiling [AHA/ASA 2023; ISAT 2005]
  • gcsrequired
    symptom • used at RED_FLAGS
    GCS confirms HH I–III stratum (good grade); GCS drop redirects to HH IV–V engine [Hunt-Hess 1968]
  • hunt_hess_graderequired
    symptom • used at RISK_STRATIFICATION
    HH I–III drives early-securing-within-24h pathway; HH I/II low DCI risk, HH III higher DCI risk + cEEG threshold [Hunt-Hess 1968; AHA/ASA 2023]
  • ct_head_noncontrastrequired
    imaging • used at INITIAL_WORKUP
    Confirms SAH + modified Fisher grade (vasospasm risk) [Fisher 1980; AHA/ASA 2023]
  • cta_headrequired
    imaging • used at INITIAL_WORKUP
    Identifies aneurysm + location (AComm/PComm/MCA/basilar tip/vertebral-PICA); drives coil-vs-clip ladder [AHA/ASA 2023; ISAT 2005]
  • dsa_if_cta_inconclusive
    imaging • used at BRANCHING_WORKUP
    DSA gold standard for aneurysm anatomy when CTA equivocal [AHA/ASA 2023]
  • sbprequired
    vital • used at TREATMENT
    2023 AHA/ASA Class IIa — SBP <160 pre-secure with nicardipine first-line [Hoh Stroke 2023]
  • sodiumrequired
    lab • used at MONITORING
    q6–8h Na for SIADH vs CSWS [NCS 2023 PMID 37202712]
  • current_anticoagulantrequired
    medication • used at TREATMENT
    Reverse before aneurysm securing [AHA/ASA 2023]
  • family_history_aneurysm_adpkd
    history • used at FOLLOWUP
    Family aneurysm screening indication if ≥2 first-degree relatives OR ADPKD [AHA/ASA 2023]
  • pregnancy_status
    history • used at CONTEXT
    Pregnancy alters securing strategy + delivery planning [AHA/ASA 2023]

12-phase flow (12)

  1. 1FRAME
    Good-grade aneurysmal SAH (HH I–III) — alert/drowsy patient with thunderclap + subarachnoid blood [AHA/ASA 2023 PMID 37212182]
    advance: HH I–III stratum confirmed
  2. 2ENTRY
    Thunderclap + GCS ≥13 ± minor focal deficit (HH I–III); CTA confirms aneurysm [AHA/ASA 2023]
    inputs: age, gcs
    advance: STAT CT + CTA ordered
  3. 3CONTEXT
    HTN, smoking, family aneurysm/ADPKD, pregnancy, anticoagulation, baseline function [AHA/ASA 2023]
    inputs: gcs, sbp, current_anticoagulant, family_history_aneurysm_adpkd, pregnancy_status
    advance: Context captured
  4. 4RED_FLAGS
    GCS decline → escalate to HH IV–V engine; rebleed signs; hydrocephalus → STAT EVD [AHA/ASA 2023; NCS 2023]
    inputs: gcs
    actions: workup.sah
    advance: No immediate escalation
  5. 5INITIAL_WORKUP
    Non-contrast CT + CTA head; LP for xanthochromia if CT-negative >6 h; CBC/CMP/coags; ECG + troponin (NSM); type & screen [AHA/ASA 2023]
    inputs: ct_head_noncontrast, cta_head
    actions: panel.cbc, panel.renal, panel.lft, panel.coag
    advance: Imaging + labs returned
  6. 6BRANCHING_WORKUP
    DSA if CTA inconclusive; aneurysm location characterised (AComm/PComm/MCA/basilar tip/vertebral-PICA) drives coil-vs-clip [ISAT 2005 PMID 16139655; AHA/ASA 2023]
    inputs: dsa_if_cta_inconclusive
    advance: Aneurysm anatomy + location confirmed
  7. 7DIFFERENTIAL
    Aneurysmal vs perimesencephalic (route to neuro.sah-perimesencephalic.v1) vs AVM vs RCVS vs dissection [AHA/ASA 2023]
    advance: Aneurysmal pattern assigned
  8. 8RISK_STRATIFICATION
    Hunt-Hess + WFNS + modified Fisher (HH I/II low DCI; HH III moderate DCI); SAHIT prognostic model [Hunt-Hess 1968; WFNS 1988; AHA/ASA 2023]
    inputs: hunt_hess_grade, gcs
    actions: calc.hunt_hess, calc.wfns, calc.modified_fisher
    advance: Severity scores documented
  9. 9TREATMENT
    Early securing ≤24 h (coil preferred posterior — ISAT; individualised anterior — BRAT) [AHA/ASA 2023 Class I; ISAT 2005 PMID 16139655]; nimodipine 60 mg PO/NG q4h × 21 d [BRANT 1989 PMID 2496789; AHA/ASA 2023 Class I]; SBP <160 pre-secure (nicardipine) [AHA/ASA 2023 Class IIa]; EVD if hydrocephalus; AVOID long-course TXA [ULTRA 2021 PMID 33357465]; abandon triple-H [HIMALAIA PMID 29158449]
    inputs: sbp, current_anticoagulant
    advance: Aneurysm secured + nimodipine started
  10. 10DISPOSITION
    Neuro-ICU at comprehensive aneurysm centre; step-down at day 21 nimodipine completion + stable DCI window [AHA/ASA 2023]
    advance: NCCU bed or transfer arranged
  11. 11MONITORING
    Daily TCD days 3–14 (vasospasm screen) [AHA/ASA 2023]; q1–2 h neuro checks; CT perfusion if clinical decline; q6–8 h Na [NCS 2023]; cEEG if HH III with persistent AMS [NCS 2023]; DCI rescue → euvolemic induced HTN with norepi (target MAP 100–110); IA verapamil for refractory [AHA/ASA 2023; NCS 2023]
    inputs: sodium
    advance: DCI surveillance bundle active
  12. 12FOLLOWUP
    Cerebrovascular clinic 6 wk / 3 / 6 / 12 mo; BP <130/80 (2025 AHA/ACC HTN); smoking cessation; family aneurysm screening if ≥2 first-degree relatives or ADPKD; rehab; cognitive eval (MoCA + PHQ-9); repeat MRA at 6 mo [AHA/ASA 2023]
    inputs: family_history_aneurysm_adpkd
    advance: Long-term plan set