Clinical Commander

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neuro.stroke-svo.v1

Small-Vessel (Lacunar) Stroke (TOAST SVO)

neurologyacutechronicadultacuteinpatientoutpatient
Start encounter →Print handoutPRODUCTION

Phase C wave-14 shard-3 neuro stroke-phenotype expansion (2026-05-15): authored at INTEGRATED tier — manifest forward-declared. 10 phenotype severity_triggers span the SVO TOAST class: classic lacunar / subcortical <15 mm / HTN-predominant / DM-predominant / smoking-predominant / CAA overlap (Boston v2.0) / SPS3 SBP <130 target / CADASIL NOTCH3 / vascular cognitive impairment / Binswanger chronic. 5 setting playbooks span the SVO journey: ed (acute confirmation + reperfusion via parent) → icu (rare; severe brainstem lacunar or post-tPA conversion) → inpatient (SPS3-anchored Rx + CMB / CAA / CADASIL workup) → outpatient (90-d / 12-mo + annual MoCA) → home (aspirin adherence + SBP <130 + cognitive awareness). Schema-blocked downstream (depth bundle): calc.fazekas_wmh (Fazekas 0-3), calc.cmb_count (CMB count + lobar vs deep distribution per Boston v2.0), calc.cadasil_notch3 (CADASIL risk score). Surfaced in depth bundle until clinical-tools-registry expands. Regimen axis with 6 steps: aspirin 81 mg ALONE (NO chronic DAPT — SPS3 harm signal) → SPS3 BP control (SBP <130) → high-intensity statin → glycemic control → smoking cessation → cilostazol refractory. Sibling differentiation: neuro.ischaemic-stroke.v1 (parent acute), neuro.tia.v1 (TIA-spectrum lacunar; same aspirin-alone strategy), neuro.vascular-dementia.v1 (chronic VCI/VaD downstream). All siblings pre-existing registered engines.

Entry points (7)

  • symptom
    Classic lacunar syndrome — pure motor hemiparesis (Fisher 1965; AHA/ASA 2021)
    pure_motor_hemiparesis
  • symptom
    Pure sensory stroke (thalamic VPL lesion; Fisher 1965)
    pure_sensory_stroke
  • symptom
    Ataxic hemiparesis (corona radiata / pons; Fisher 1965)
    ataxic_hemiparesis
  • symptom
    Sensorimotor stroke (internal capsule + thalamus border; Fisher 1965)
    sensorimotor_stroke
  • symptom
    Dysarthria-clumsy-hand syndrome (pons / internal capsule; Fisher 1965)
    dysarthria_clumsy_hand
  • imaging
    Subcortical infarct <15 mm in perforator territory on MRI DWI (TOAST SVO criterion; Adams Stroke 1993)
    subcortical_infarct_lt_15mm
  • history
    Family history of early SVO + migraine with aura + leukoencephalopathy → suspect CADASIL NOTCH3
    family_history_cadasil

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Age stratifies CADASIL suspicion (early-onset <60) vs sporadic SVO; affects bleed risk on aspirin
  • classic_lacunar_syndromerequired
    symptom • used at DIFFERENTIAL
    Classic Fisher syndromes (pure motor / pure sensory / ataxic-hemiparesis / sensorimotor / dysarthria-clumsy-hand) support SVO mechanism (AHA/ASA 2021)
  • mri_brain_dwirequired
    imaging • used at INITIAL_WORKUP
    DWI confirms acute small subcortical infarct <15 mm in perforator territory (TOAST SVO criterion)
  • mri_swi_or_t2_starrequired
    imaging • used at INITIAL_WORKUP
    SWI / T2* identifies cerebral microbleeds (CMBs) — deep CMBs = HTN-SVO; lobar CMBs = CAA overlap (Boston Criteria v2.0)
  • mri_flair_wmhrequired
    imaging • used at INITIAL_WORKUP
    FLAIR for white-matter hyperintensities (WMH) Fazekas grading; leukoaraiosis burden predicts cognitive trajectory
  • cta_or_mra_head_neckrequired
    imaging • used at INITIAL_WORKUP
    Exclude large-artery atherosclerosis and intracranial atherosclerosis (TOAST exclusion criterion for SVO)
  • ecg_telemetryrequired
    imaging • used at INITIAL_WORKUP
    Exclude AF as cardioembolic source (TOAST exclusion criterion for SVO)
  • sbprequired
    vital • used at TREATMENT
    SPS3 (Benavente NEJM 2013 PMID 23910302) — SBP <130 reduces recurrent stroke in lacunar; SPRINT-MIND (Williamson JAMA 2019 PMID 28771346) — lower SBP improves cognitive trajectory
  • ldlrequired
    lab • used at FOLLOWUP
    High-intensity statin LDL <70-100 per SVO baseline; ASCVD risk overlap (SPARCL Amarenco NEJM 2006 PMID 16899775; 2026 ACC/AHA Lipid)
  • hba1crequired
    lab • used at FOLLOWUP
    DM is major SVO driver; HbA1c <7% target (ADA 2026; AHA/ASA 2021)
  • creatininerequired
    lab • used at CONTEXT
    CKD frequently coexists with HTN-SVO; eGFR informs medication dosing
  • hypertension_predominantrequired
    history • used at CONTEXT
    HTN is dominant SVO risk factor (lipohyalinosis of perforator arterioles); aggressive BP control reduces recurrence (SPS3)
  • diabetes_predominantrequired
    history • used at CONTEXT
    DM drives microvascular disease; HbA1c control reduces SVO recurrence (ADA 2026)
  • smoking_statusrequired
    history • used at CONTEXT
    Smoking accelerates SVO; cessation pharmacotherapy AHA/ASA 2021 Class I
  • migraine_with_aura_family_history
    history • used at BRANCHING_WORKUP
    Family history of migraine + early SVO + leukoencephalopathy → CADASIL NOTCH3 suspicion
  • current_antiplatelet_or_anticoagrequired
    medication • used at TREATMENT
    Antiplatelet decision impacted by CMB count / CAA overlap (lobar microbleeds caution); SPS3 — avoid chronic DAPT for lacunar

12-phase flow (12)

  1. 1FRAME
    Ischemic stroke with SVO (lacunar) mechanism — subcortical infarct <15 mm, classic lacunar syndrome, exclusion of LAA + CE sources (Adams Stroke 1993; AHA/ASA 2021)
    advance: SVO mechanism flagged or being investigated
  2. 2ENTRY
    Receives patient from neuro.ischaemic-stroke.v1 with SVO suspicion based on classic lacunar syndrome + subcortical infarct pattern
    inputs: classic_lacunar_syndrome
    advance: SVO pathway activated
  3. 3CONTEXT
    Capture HTN / DM / smoking / family history / current antiplatelet / CKD (AHA/ASA 2021)
    inputs: age, hypertension_predominant, diabetes_predominant, smoking_status, current_antiplatelet_or_anticoag, creatinine
    advance: Risk factor context captured
  4. 4RED_FLAGS
    CAA overlap with multiple lobar microbleeds + cortical superficial siderosis (caution antiplatelet for ICH risk; Boston Criteria v2.0); rapid cognitive decline + early-onset migraine → CADASIL NOTCH3 (AHA/ASA 2021)
    inputs: mri_swi_or_t2_star
    advance: CAA / CADASIL risk assessed
  5. 5INITIAL_WORKUP
    MRI brain DWI + SWI/T2* + FLAIR; CTA or MRA head/neck for LAA exclusion; ECG + telemetry ≥24 h for AF exclusion; lipid panel + HbA1c + renal panel (AHA/ASA 2021 Class I)
    inputs: mri_brain_dwi, mri_swi_or_t2_star, mri_flair_wmh, cta_or_mra_head_neck, ecg_telemetry
    actions: panel.renal, panel.lipid
    advance: Imaging + telemetry exclude LAA / CE
  6. 6BRANCHING_WORKUP
    NOTCH3 genetic testing if CADASIL suspected; CAA workup (Boston Criteria v2.0) if multiple lobar CMBs; cardiac MRI rarely indicated; sleep study if OSA suspected
    inputs: migraine_with_aura_family_history
    advance: Special-source workup complete or excluded
  7. 7DIFFERENTIAL
    SVO sub-phenotype: HTN-predominant / DM-predominant / smoking-predominant / CAA-overlap / CADASIL / Binswanger chronic leukoencephalopathy / strategic-infarct dementia (AHA/ASA 2021)
    advance: SVO sub-phenotype assigned
  8. 8RISK_STRATIFICATION
    NIHSS (typically low 1-5 in lacunar); ABCD2 if TIA-spectrum; Fazekas WMH grading for cognitive trajectory; CMB count + distribution; mRS baseline (AHA/ASA 2021)
    advance: Severity + WMH + CMB documented
  9. 9TREATMENT
    Aspirin 81 mg daily ALONE (SPS3 PMID 22929185 — chronic DAPT INCREASED bleeding without benefit); BP target SBP <130 (SPS3 PMID 23910302; SPRINT-MIND PMID 28771346); high-intensity statin (SPARCL); HbA1c <7%; smoking cessation; AVOID chronic DAPT; for CAA-overlap with multiple lobar CMBs use shared-decision antiplatelet caution (Boston v2.0); for CADASIL aspirin + RF control + avoid thrombolysis if possible
    inputs: sbp, current_antiplatelet_or_anticoag
    advance: Phenotype-specific Rx initiated
  10. 10DISPOSITION
    Stroke unit continuation; outpatient stroke clinic + cognitive baseline (AHA/ASA 2021)
    advance: Disposition documented
  11. 11MONITORING
    BP home log + clinic; HbA1c q3 mo; vascular cognitive impairment annual MoCA; repeat MRI for new CMBs if recurrent symptoms (AHA/ASA 2021)
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Stroke clinic 7-14 d + 90 d + 12 mo: SBP <130, LDL <55-70, HbA1c <7%, smoking cessation, aspirin adherence, vascular cognitive screen, OSA screen, MIND diet (AHA/ASA 2021)
    inputs: ldl, hba1c
    actions: panel.lipid
    advance: Secondary prevention bundle on board + cognitive screen scheduled