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neuro.sah-grade4-5.v1

Aneurysmal SAH — Poor Grade (Hunt-Hess IV–V)

neurologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase C shard-3 neuro wave-14 (2026-05-15): authored at SCAFFOLDED — poor-grade aneurysmal SAH (Hunt-Hess IV–V) drill-down dossier; same-commit peers neuro.sah-grade1-3.v1 + neuro.sah-perimesencephalic.v1. Parent neuro.sah.core.v1 encodes HH I–V as severity_triggers; this child deepens HH IV–V pathway with intubation + ICP/EVD + aggressive critical care with parallel goals-of-care + early palliative integration + brain-death/donor workup if trajectory toward death. 5 setting playbooks — ICU is primary: home (airway-first transport) → ed (intubation + ICP + multidisciplinary trajectory huddle) → icu (aggressive critical care + securing if salvageable + palliative parallel + donor BD workup) → inpatient (severe-disability rehab + tracheostomy/PEG planning) → outpatient (long-term survivor follow-up + caregiver support). 9 severity_triggers: HH_IV_stupor_hemiparesis_decerebrate, HH_V_deep_coma_decerebrate_rigidity, rapid_re-bleeding_pre-securing, poor_outcome_anchor, ULTRA_TXA_NOT_routine, IGNUS_aggressive_vs_palliative, transplant_donor_eligibility_BD_workup, neurogenic_stunned_myocardium_severe, refractory_intracranial_hypertension. 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), 24837690 (STASH Kirkpatrick 2014). Nimodipine dose-reduced 30 mg q2h to avoid hypotension in HH IV–V. ULTRA TXA NOT routine per NCS 2023 (no benefit, thrombotic risk). STASH negative — NO statin for DCI prevention. Abandon triple-H — use euvolemic induced HTN. HH V prognosis ~80% mortality drives early palliative integration; multidisciplinary trajectory huddle (neurosurgery + neurointerventional + critical care + palliative) within 24 h. Brain-death determination + organ-donor coordination is standard of care for HH V brain-death trajectory. Schema-blocked: calc.sahit, protocol.sah, brain-death workup atom, organ-donor referral protocol — shard-3 cannot edit clinical-tools-registry.ts. Siblings: neuro.sah.core.v1 (parent PRODUCTION), neuro.sah-grade1-3.v1 (same-commit), neuro.sah-perimesencephalic.v1 (same-commit), neuro.ich.core.v1 (real PRODUCTION).

Entry points (5)

  • symptom
    Stupor + moderate-to-severe hemiparesis + early decerebrate posturing (HH IV) [Hunt-Hess 1968]
    stupor_hemiparesis_decerebrate_HH_IV
  • symptom
    Deep coma + decerebrate rigidity + moribund appearance (HH V) [Hunt-Hess 1968]
    deep_coma_decerebrate_rigidity_HH_V
  • symptom
    Acute neurologic deterioration pre-securing → rebleed (mortality ~50–70%) [AHA/ASA 2023]
    rapid_re-bleeding_pre-securing
  • imaging
    CT showing thick diffuse SAH ± IVH (modified Fisher IV) in stuporous/comatose patient [Frontera 2006]
    ct_thick_diffuse_sah_with_ivh
  • imaging
    CTA demonstrates aneurysm in HH IV–V patient — securing decision pending goals-of-care [AHA/ASA 2023]
    cta_demonstrates_aneurysm_in_unresponsive_patient

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Age + frailty + premorbid function inform aggressive vs palliative decision [AHA/ASA 2023]
  • gcsrequired
    symptom • used at RED_FLAGS
    GCS ≤8 mandates intubation; GCS 3–6 = HH V trajectory [Hunt-Hess 1968; AHA/ASA 2023]
  • hunt_hess_graderequired
    symptom • used at RISK_STRATIFICATION
    HH IV (~30–45% mortality) vs HH V (~50–80% mortality) drives aggressive vs palliative tilt [Hunt-Hess 1968; AHA/ASA 2023]
  • pupil_examrequired
    symptom • used at RED_FLAGS
    Fixed/dilated pupils + decerebrate posturing + apnea trajectory toward brain death (NCS 2023)
  • ct_head_noncontrastrequired
    imaging • used at INITIAL_WORKUP
    Confirms SAH + modified Fisher (mFS III–IV in HH IV–V; high DCI risk) + IVH/hydrocephalus [Fisher 1980; AHA/ASA 2023]
  • cta_headrequired
    imaging • used at INITIAL_WORKUP
    Identifies aneurysm for securing decision (if salvageable) [AHA/ASA 2023]
  • sbprequired
    vital • used at TREATMENT
    Pre-secure SBP <160 (Class IIa); HH IV–V may have hemodynamic instability + neurogenic stunned myocardium [Hoh 2023]
  • sodiumrequired
    lab • used at MONITORING
    q6–8 h Na for SIADH vs CSWS (NCS 2023)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Neurogenic stunned myocardium / Takotsubo common in HH IV–V (AHA/ASA 2023)
  • current_anticoagulantrequired
    medication • used at TREATMENT
    Reversal required if securing pursued (AHA/ASA 2023)
  • advance_directives_premorbid_functionrequired
    history • used at DISPOSITION
    Premorbid function + advance directives critical for goals-of-care discussion in HH IV–V (AHA/ASA 2023)

12-phase flow (12)

  1. 1FRAME
    Poor-grade aSAH (HH IV–V) — stuporous or comatose with decerebrate posturing; high mortality; aggressive vs palliative decision dominant [AHA/ASA 2023 PMID 37212182]
    advance: HH IV or V stratum confirmed
  2. 2ENTRY
    Severe AMS + thunderclap onset OR found-down with imaging-confirmed thick SAH ± IVH [AHA/ASA 2023]
    inputs: age, gcs
    advance: Airway secured if GCS ≤8; STAT CT + CTA ordered
  3. 3CONTEXT
    Premorbid function, advance directives, family contact, frailty, anticoagulation [AHA/ASA 2023]
    inputs: gcs, sbp, current_anticoagulant, advance_directives_premorbid_function
    advance: Goals-of-care substrate captured
  4. 4RED_FLAGS
    GCS ≤8 → intubate; rebleed (~50–70% mortality); hydrocephalus → STAT EVD; herniation; fixed pupils signal brain-death trajectory [AHA/ASA 2023; NCS 2023]
    inputs: gcs, pupil_exam
    actions: workup.sah
    advance: Airway + ICP control + EVD considered
  5. 5INITIAL_WORKUP
    Non-contrast CT + CTA head; CBC/CMP/coags; ECG + troponin (neurogenic stunned myocardium); type & screen; HCG if reproductive-age female [AHA/ASA 2023]
    inputs: ct_head_noncontrast, cta_head, troponin
    actions: panel.cbc, panel.renal, panel.lft, panel.coag
    advance: Imaging + labs + ECG returned
  6. 6BRANCHING_WORKUP
    DSA if CTA inconclusive; aneurysm anatomy guides securing if pursued; multidisciplinary trajectory huddle (neurosurgery + neurointerventional + critical care + palliative) [AHA/ASA 2023]
    advance: Aneurysm characterised + multidisciplinary plan
  7. 7DIFFERENTIAL
    Aneurysmal HH IV–V vs traumatic SAH vs massive ICH with IVH vs anoxic brain injury post-arrest [AHA/ASA 2023]
    advance: Aneurysmal pattern confirmed
  8. 8RISK_STRATIFICATION
    Hunt-Hess IV–V; WFNS IV–V; modified Fisher III–IV; SAHIT prognostic model; ICH-score adjunct if parenchymal extension [Hunt-Hess 1968; WFNS 1988; Frontera 2006; AHA/ASA 2023]
    inputs: hunt_hess_grade, gcs
    actions: calc.hunt_hess, calc.wfns, calc.modified_fisher, calc.ich_score
    advance: Severity + prognosis documented
  9. 9TREATMENT
    Intubation + ICP monitoring + EVD; aggressive critical-care; aneurysm securing if salvageable (coil preferred posterior, individualised anterior); nimodipine 30 mg q2h (dose-reduced to avoid hypotension); BP <160 pre-secure; AVOID long-course TXA per ULTRA + NCS 2023 in HH IV–V (no benefit, thrombotic risk); STASH negative — NO statin for DCI [Hoh 2023; Treggiari 2023; ULTRA; BRANT; ISAT; STASH]
    inputs: sbp, current_anticoagulant
    advance: Treatment trajectory set (aggressive vs withdrawal)
  10. 10DISPOSITION
    Neuro-ICU at comprehensive aneurysm centre; early goals-of-care meeting; palliative care consult parallel; transplant donor eligibility brain-death workup if trajectory toward death [AHA/ASA 2023]
    inputs: advance_directives_premorbid_function
    advance: ICU + goals-of-care decision
  11. 11MONITORING
    Continuous ICP + CPP; q1 h GCS + pupil exam; daily TCD days 3–14; q6–8 h Na; cEEG (NCSE common); CT perfusion if decline; brain-death exam protocol if trajectory clear [NCS 2023]
    inputs: sodium
    advance: Monitoring bundle active
  12. 12FOLLOWUP
    If survivor — IRF/SNF rehab + long-term cognitive + family support; if death — donor coordination + bereavement [AHA/ASA 2023]
    advance: Disposition realized