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neuro.ich-cerebellar.v1PRODUCTION
neuro.ich-cerebellar.v1

Intracerebral Hemorrhage — Cerebellar (emergent decompression)

neurologyacuteadultpediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Cerebellar bleed on CT; assess volume + brainstem compression + 4th-ventricle compression + obstructive hydrocephalus (AHA/ASA 2022 PMID 35579034)

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Cerebellar ICH confirmed on imaging

Patient inputs (11)

Pediatric cerebellar ICH often AVM rupture; adult often hypertensive (AHA/ASA 2022)

Contrast + dosing decisions; andexanet (ANNEXA-I PMID 38749032)

Volume measurement (≥3 cm = STAT surgical indication per AHA/ASA 2022 Class I); brainstem compression; 4th-ventricle compression; obstructive hydrocephalus

GCS drives ICH score (Hemphill 2001) + intubation + Cushing-reflex monitoring (AHA/ASA 2022)

VKA reversal threshold; STAT 4F-PCC if INR ≥1.4 (INCH PMID 27302126)

Coagulopathy assessment; PATCH (PMID 27178479) — do NOT routinely transfuse

INTERACT3 (PMID 37245517) target SBP <140 within 1 h if hemodynamically stable; avoid <110 (ATACH-2)

VKA → 4F-PCC + vit K (INCH); dabigatran → idarucizumab; FXa-DOAC → andexanet (ANNEXA-I PMID 38749032)

AVM / cavernous malformation / amyloid overlap workup, especially in young / atypical patients

Cerebellar dysfunction signs anchor diagnosis when CT preceded by vestibular pivot (HINTS Newman-Toker Stroke 2009 PMID 19762709)

Spot sign within 6 h predicts hematoma expansion (AHA/ASA 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningcerebellar_ge_3cm_or_brainstem_compression_STAT_decompression
    Cerebellar ICH ≥3 cm OR brainstem compression OR obstructive hydrocephalus from cerebellar mass effect (AHA/ASA 2022 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcerebellar_with_obstructive_hydrocephalus_EVD
    Cerebellar ICH with 4th-ventricle compression → obstructive hydrocephalus → STAT EVD (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcerebellar_with_GCS_decline_post_admission_STAT_surgery
    Cerebellar ICH (any volume) with GCS decline post-admission → STAT decompressive craniectomy even if initial volume <3 cm (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereataxia_vertigo_predominant
    Cerebellar ICH presenting with predominant ataxia / vertigo / vomiting / headache — often mistaken for benign vestibular disorder (HINTS pivot; Newman-Toker Stroke 2009 PMID 19762709)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecerebellar_AVM_associated
    Cerebellar ICH from underlying AVM rupture — MRI / DSA for vascular lesion workup (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereoral_anticoag_associated_cerebellar
    Cerebellar ICH on VKA / DOAC at presentation — STAT reversal regardless of dose timing (AHA/ASA 2022; ANNEXA-I PMID 38749032; INCH PMID 27302126)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_cerebellar_AVM
    Pediatric cerebellar ICH — AVM rupture is the leading cause; MRI + DSA mandatory; STAT pediatric neurosurgery (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesmall_cerebellar_lt_3cm_no_brainstem_compression
    Cerebellar ICH <3 cm without brainstem compression, 4th-ventricle compression, or obstructive hydrocephalus — ICU observation arm (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecerebellar_amyloid_overlap
    Rare cerebellar CAA overlap — MRI GRE/SWI for cortical microbleeds elsewhere supports CAA (Boston v2.0)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateSVC_overlap
    Superficial venous cerebellar drainage anatomy overlap with bleed pattern — radiographic mimic of cerebellar ICH; MRV / DSA to differentiate
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Cerebellar ICH bundle — STAT decompression (Class I) + EVD + INTERACT3 BP + reversal (AHA/ASA 2022 PMID 35579034; INTERACT3 PMID 37245517; INCH PMID 27302126; ANNEXA-I PMID 38749032)
axis: ich_cerebellar_bundlestep 1 - Step 1 — STAT neurosurgery (suboccipital decompressive craniectomy ± evacuation) if ≥3 cm OR brainstem compression OR hydrocephalus (AHA/ASA 2022 Class I)
Selected step "Step 1 — STAT neurosurgery (suboccipital decompressive craniectomy ± evacuation) if ≥3 cm OR brainstem compression OR hydrocephalus (AHA/ASA 2022 Class I)" — Volume ≥3 cm OR 4th-ventricle compression OR obstructive hydrocephalus OR GCS decline

outpatient playbook — drug actions (3)

  1. 1. ACEI/ARB + thiazide
    Lisinopril 10-40 mg PO daily; chlorthalidone 12.5-25 mg PO daily • PO • daily
    trigger: BP ≥130/80
    SPRINT-MIND + 2025 AHA/ACC HTN
  2. 2. DOAC restart if AF + non-CAA + non-AVM
    Apixaban 5 mg PO BID • PO • BID
    trigger: 4-8 wk post-ICH + AF + CHA2DS2-VASc ≥4 + stable hematoma + non-CAA + AVM not implicated
    AHA/ASA 2022 — individualised by mechanism
  3. 3. sertraline OR escitalopram
    Sertraline 50 mg daily; escitalopram 10 mg daily • PO • daily
    trigger: PHQ-9 ≥10
    Post-ICH depression 25-40%

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Non-contrast CT head showing cerebellar intraparenchymal blood (AHA/ASA 2022 PMID 35579034); Sudden ataxia + vertigo + vomiting + occipital headache (often mistaken for benign vertigo — HINTS pivot; Newman-Toker Stroke 2009 PMID 19762709); Altered consciousness from brainstem compression / hydrocephalus (AHA/ASA 2022).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Intracerebral Hemorrhage — Cerebellar (emergent decompression)** (neuro.ich-cerebellar.v1).
Phenotype framing: Spontaneous hypertensive cerebellar (most common) vs AVM-associated vs amyloid-overlap (rare cerebellar CAA) vs anticoag-associated vs pediatric AVM rupture (AHA/ASA 2022)
Scope: Cerebellar bleed on CT; assess volume + brainstem compression + 4th-ventricle compression + obstructive hydrocephalus (AHA/ASA 2022 PMID 35579034)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cerebellar ICH bundle — STAT decompression (Class I) + EVD + INTERACT3 BP + reversal (AHA/ASA 2022 PMID 35579034; INTERACT3 PMID 37245517; INCH PMID 27302126; ANNEXA-I PMID 38749032)** — step "Step 1 — STAT neurosurgery (suboccipital decompressive craniectomy ± evacuation) if ≥3 cm OR brainstem compression OR hydrocephalus (AHA/ASA 2022 Class I)".

Setting playbook (outpatient) — Stroke clinic with BP <130/80 (SPRINT-MIND) + cerebellar rehab continuity + driving evaluation (cerebellar ataxia affects driving more than hemiparesis) + PHQ-9 + MoCA + AVM-management coordination if underlying lesion (AHA/ASA 2022)
1. ACEI/ARB + thiazide Lisinopril 10-40 mg PO daily; chlorthalidone 12.5-25 mg PO daily PO daily — BP ≥130/80 (SPRINT-MIND + 2025 AHA/ACC HTN)
2. DOAC restart if AF + non-CAA + non-AVM Apixaban 5 mg PO BID PO BID — 4-8 wk post-ICH + AF + CHA2DS2-VASc ≥4 + stable hematoma + non-CAA + AVM not implicated (AHA/ASA 2022 — individualised by mechanism)
3. sertraline OR escitalopram Sertraline 50 mg daily; escitalopram 10 mg daily PO daily — PHQ-9 ≥10 (Post-ICH depression 25-40%)

Non-pharmacologic actions:
- Recurrent-stroke counselling
- Advance directives + power-of-attorney
- Mediterranean diet + adapted exercise (cerebellar-rehab-compatible)
- Home BP monitor + log review
- AVM follow-up if underlying lesion
- Driving evaluation with cerebellar-rehab specialist

AVOID / contraindication checks:
- No_thrombolysis_in_hemorrhagic_stroke (AHA/ASA 2022)
- No_routine_platelet_transfusion_for_antiplatelet_ICH (PATCH PMID 27178479)
- No_supratentorial_evacuation_protocol_for_cerebellar_use_suboccipital_decompression_only (AHA/ASA 2022)
- Cerebellar_is_NOT_an_ENRICH_MIE_candidate_ENRICH_benefits_supratentorial_lobar (PMID 38598795)
- Avoid_SBP_<110_hypoperfusion (ATACH 2)

Monitoring

Regimen monitoring:
- GCS q1h x 24h (AHA/ASA 2022)
- Cushing reflex q1h HTN bradycardia irregular respirations (AHA/ASA 2022)
- BP continuous arterial target SBP 130-150 if stable (INTERACT3 PMID 37245517)
- repeat CT at 6h or with decline (AHA/ASA 2022)
- INR q6h until <1.3 for VKA reversal (INCH PMID 27302126)
- post op craniectomy site assessment q-shift (AHA/ASA 2022)

Setting (outpatient) monitoring:
- Clinic 7-14 d post-discharge for medication reconciliation
- Stroke clinic 4-8 wk (anticoag-restart decision), 90 d (mRS + ataxia trajectory), 6 mo (repeat MRI for underlying lesion), 12 mo
- BP home log + clinic q3 mo until at goal then q6 mo
- PHQ-9 + MoCA at 90 d, 6 mo, 12 mo
- Cerebellar exam q-visit

Follow-up plan: Long-term BP <130/80 (SPRINT-MIND); MRI for underlying vascular cause in young / atypical; phenotype-specific secondary prevention; cerebellar rehab; PHQ-9 + MoCA; driving evaluation (cerebellar ataxia affects driving) (AHA/ASA 2022)
- Close-out criterion: Rehab + outpatient stroke clinic + BP plan + driving eval set

Monitoring phase: q1h GCS + pupil + Cushing-reflex check × 24 h; continuous arterial BP; repeat CT 6 h or with decline; post-op craniectomy site assessment (AHA/ASA 2022)

Disposition

Current setting: outpatient — Stroke clinic with BP <130/80 (SPRINT-MIND) + cerebellar rehab continuity + driving evaluation (cerebellar ataxia affects driving more than hemiparesis) + PHQ-9 + MoCA + AVM-management coordination if underlying lesion (AHA/ASA 2022)

Disposition criteria:
- Continue indefinite BP <130/80 secondary-prevention regimen
- Cerebellar rehab continuity through 12 mo per ataxia trajectory

Escalation triggers (move to higher acuity):
- Any new neurologic event → ED
- Worsening ataxia → MRI for recurrent bleed / progressive lesion
- BP persistently >140/90 → resistant HTN workup
- PHQ-9 ≥15 or SI → urgent psych referral
- AVM-related recurrence → re-image, escalate to vascular neurosurgery

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Cerebellar ICH ≥3 cm OR brainstem compression OR obstructive hydrocephalus from cerebellar mass effect (AHA/ASA 2022 Class I)
- [LIFE_THREATENING] Cerebellar ICH with 4th-ventricle compression → obstructive hydrocephalus → STAT EVD (AHA/ASA 2022)
- [LIFE_THREATENING] Cerebellar ICH (any volume) with GCS decline post-admission → STAT decompressive craniectomy even if initial volume <3 cm (AHA/ASA 2022)

Citations

- 2022 AHA/ASA Guideline for Spontaneous ICH (Greenberg Stroke 2022) — Class I cerebellar ≥3 cm decompression + INTERACT3 + HINTS pivot + ANNEXA-I reversal [PMID:35579034](https://pubmed.ncbi.nlm.nih.gov/35579034/)
- Cited evidence (PMID 37245517) [PMID:37245517](https://pubmed.ncbi.nlm.nih.gov/37245517/)
- Cited evidence (PMID 19762709) [PMID:19762709](https://pubmed.ncbi.nlm.nih.gov/19762709/)
- Cited evidence (PMID 38749032) [PMID:38749032](https://pubmed.ncbi.nlm.nih.gov/38749032/)
- Cited evidence (PMID 27178479) [PMID:27178479](https://pubmed.ncbi.nlm.nih.gov/27178479/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2022 AHA/ASA Guideline for Spontaneous ICH (Greenberg Stroke 2022) — Class I cerebellar ≥3 cm decompression + INTERACT3 + HINTS pivot + ANNEXA-I reversal — PMID:35579034
  • Cited evidence (PMID 37245517) — PMID:37245517
  • Cited evidence (PMID 19762709) — PMID:19762709
  • Cited evidence (PMID 38749032) — PMID:38749032
  • Cited evidence (PMID 27178479) — PMID:27178479