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neuro.ich-deep.v1

Intracerebral Hemorrhage — Deep (hypertensive)

neurologyacuteadult
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12/12 authored

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

Current phase

Frame

Detailed

Deep (basal ganglia / thalamus / pons) ICH on CT in patient with chronic HTN; rule out trauma + hemorrhagic transformation (AHA/ASA 2022 PMID 35579034)

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Deep ICH confirmed on imaging

Patient inputs (11)

Age <55 + deep bleed without HTN history → tox screen + AVM workup (AHA/ASA 2022)

Contrast + dosing decisions; chronic kidney disease comorbid with chronic HTN (AHA cardiorenal PMID 35579034)

Volume + deep location + IVH; pontine = worst prognosis (AHA/ASA 2022)

GCS drives ICH score (Hemphill 2001); pontine often ≤8; AHA/ASA 2022 cautions against early WLST

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) — SBP <140 within 1 h; deep ICH = HTN-driven so aggressive (AHA/ASA 2022)

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

Cocaine / methamphetamine if <55 or no HTN history (AHA/ASA 2022)

Distinguishes chronic uncontrolled HTN mechanism from secondary causes

Spot sign within 6 h predicts hematoma expansion 30%/6mL (AHA/ASA 2022)

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

Severity triggers (9)

9 need judgement
  • informationallife_threateningpontine_brainstem_poor_prognosis_TOC
    Pontine / brainstem ICH on CT (typically hypertensive); GCS often ≤8; quadriparesis + cranial nerve deficits; 90-d mortality 50-80% (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebasal_ganglia_putaminal
    Putaminal ICH — most common deep location; classic HTN bleed; contralateral hemiparesis + sensory loss + gaze deviation toward lesion (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverethalamic_with_hydrocephalus_risk
    Thalamic ICH with IVH extension and obstructive hydrocephalus risk; sensory > motor deficit; vertical gaze palsy (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereHTN_predominant_chronic_uncontrolled
    Long-standing or uncontrolled hypertension with deep bleed — chronic-HTN mechanism (AHA cardiorenal PMID 35579034)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecocaine_methamphetamine_induced
    Sympathomimetic-induced deep ICH in young patient or without HTN history (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresecondary_to_pituitary_apoplexy_or_AVM
    Pituitary apoplexy or AVM rupture mimicking deep HTN bleed; warrant MRI + DSA
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereINTERACT3_bundle_target_<140
    INTERACT3 (Ma Lancet 2023 PMID 37245517) care-bundle adherence — SBP <140 within 1 h + reversal + glucose + temp
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverespot_sign_hematoma_expansion_risk
    CTA spot sign within 6 h predicts hematoma expansion 30%/6mL (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapidly_expanding_30pct_or_6mL_repeat_CT_6h
    Hematoma volume increase >33% or >6 mL on repeat CT (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Deep-hypertensive ICH bundle — INTERACT3 aggressive BP + reversal + EVD + secondary prevention (AHA/ASA 2022 PMID 35579034; INTERACT3 PMID 37245517; INCH PMID 27302126; ANNEXA-I PMID 38749032)
axis: ich_deep_hypertensive_bundlestep 1 - Step 1 — STAT SBP <140 within 1 h (INTERACT3) — aggressive because deep = HTN-driven
Selected step "Step 1 — STAT SBP <140 within 1 h (INTERACT3) — aggressive because deep = HTN-driven" — Spontaneous deep ICH; SBP >150 (AHA/ASA 2022)
  • nicardipine
    first line
    CCB_dihydropyridine
    5 mg/h IV; titrate by 2.5 mg/h q5-15 min • IV • continuous (max: 15 mg/h)
    triggers: SBP_>150_target_130-150
    INTERACT3 (PMID 37245517)
    rxcui 7396
  • clevidipine
    first line
    CCB_dihydropyridine
    1-2 mg/h IV; double q90 sec • IV • continuous (max: 21 mg/h)
    triggers: need_rapid_titration
    Ultra-short acting (AHA/ASA 2022)
    rxcui 233603
  • labetalol
    add on
    beta_alpha_blocker
    10-20 mg IV bolus q10 min • IV • PRN (max: 300 mg cumulative)
    triggers: SBP_persistent_>150
    Adjunct for resistant HTN; sympathomimetic-induced cases (AHA/ASA 2022)
    rxcui 6185

outpatient playbook — drug actions (4)

  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
    Apixaban 5 mg PO BID (2.5 mg if 2 of: age ≥80 / weight ≤60 kg / Cr ≥1.5) • PO • BID
    trigger: 4-8 wk post-ICH if AF + CHA2DS2-VASc ≥4 + stable hematoma + non-CAA phenotype
    AHA/ASA 2022 — individualised; deep HTN has favourable risk-benefit vs lobar CAA
  3. 3. atorvastatin
    40 mg PO daily • PO • daily
    trigger: Comorbid ASCVD / diabetes
    Restart post-ICH if indicated (AHA/ASA 2022)
  4. 4. sertraline OR escitalopram
    Sertraline 50 mg daily; escitalopram 10 mg daily • PO • daily
    trigger: PHQ-9 ≥10
    Post-ICH depression 25-40%; SSRI first-line

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Non-contrast CT head showing deep (basal ganglia / thalamus / pons) intraparenchymal blood (AHA/ASA 2022 PMID 35579034); Sudden contralateral hemiparesis + sensory loss (putamen/thalamus) or quadriparesis + CN deficits (pons) (AHA/ASA 2022); Long-standing or uncontrolled hypertension (deep ICH mechanism).

Objective

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

Assessment

**Intracerebral Hemorrhage — Deep (hypertensive)** (neuro.ich-deep.v1).
Phenotype framing: Deep hypertensive (this engine) vs lobar CAA (route ich-lobar) vs cerebellar (route ich-cerebellar) vs anticoag-associated vs sympathomimetic-induced vs vascular malformation vs pituitary apoplexy (AHA/ASA 2022)
Scope: Deep (basal ganglia / thalamus / pons) ICH on CT in patient with chronic HTN; rule out trauma + hemorrhagic transformation (AHA/ASA 2022 PMID 35579034)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Deep-hypertensive ICH bundle — INTERACT3 aggressive BP + reversal + EVD + secondary prevention (AHA/ASA 2022 PMID 35579034; INTERACT3 PMID 37245517; INCH PMID 27302126; ANNEXA-I PMID 38749032)** — step "Step 1 — STAT SBP <140 within 1 h (INTERACT3) — aggressive because deep = HTN-driven".
1. nicardipine 5 mg/h IV; titrate by 2.5 mg/h q5-15 min IV continuous (CCB_dihydropyridine, first line) — INTERACT3 (PMID 37245517)
2. clevidipine 1-2 mg/h IV; double q90 sec IV continuous (CCB_dihydropyridine, first line) — Ultra-short acting (AHA/ASA 2022)
3. labetalol 10-20 mg IV bolus q10 min IV PRN (beta_alpha_blocker, add on) — Adjunct for resistant HTN; sympathomimetic-induced cases (AHA/ASA 2022)

Setting playbook (outpatient) — Stroke clinic with intensive BP <130/80 (SPRINT-MIND) + secondary-HTN workup if uncontrolled + DOAC restart 4-8 wk for AF + PHQ-9 + MoCA + sympathomimetic cessation (AHA/ASA 2022)
4. 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)
5. DOAC restart if AF + non-CAA Apixaban 5 mg PO BID (2.5 mg if 2 of: age ≥80 / weight ≤60 kg / Cr ≥1.5) PO BID — 4-8 wk post-ICH if AF + CHA2DS2-VASc ≥4 + stable hematoma + non-CAA phenotype (AHA/ASA 2022 — individualised; deep HTN has favourable risk-benefit vs lobar CAA)
6. atorvastatin 40 mg PO daily PO daily — Comorbid ASCVD / diabetes (Restart post-ICH if indicated (AHA/ASA 2022))
7. sertraline OR escitalopram Sertraline 50 mg daily; escitalopram 10 mg daily PO daily — PHQ-9 ≥10 (Post-ICH depression 25-40%; SSRI first-line)

Non-pharmacologic actions:
- Recurrent-stroke counselling
- Advance directives + power-of-attorney
- Mediterranean diet + 150 min/wk moderate exercise
- Home BP monitor + log review
- Sympathomimetic cessation referral if applicable

AVOID / contraindication checks:
- No_thrombolysis_in_hemorrhagic_stroke (AHA/ASA 2022)
- No_routine_platelet_transfusion_for_antiplatelet_ICH (PATCH PMID 27178479)
- Avoid_SBP_<110_hypoperfusion (ATACH 2)
- No_routine_supratentorial_deep_evacuation (AHA/ASA 2022; ENRICH benefits lobar PMID 38598795)
- No_routine_TXA_TICH 2_neutral (PMID 29778325)

Monitoring

Regimen monitoring:
- GCS q1h x 24h (AHA/ASA 2022)
- BP continuous arterial target SBP 130-150 (INTERACT3 PMID 37245517)
- INR q6h until <1.3 for VKA reversal (INCH PMID 27302126)
- repeat CT at 6h or with decline (AHA/ASA 2022)
- serum osm q6h during osmotic therapy (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 + secondary-prevention audit), 6 mo, 12 mo
- BP home log + clinic q3 mo until at goal then q6 mo
- PHQ-9 + MoCA at 90 d, 6 mo, 12 mo
- Renal function q6 mo if DOAC; q3 mo if CrCl 30-50

Follow-up plan: Long-term BP <130/80 STRICT (SPRINT-MIND); secondary-HTN workup if uncontrolled; anticoag restart at 4-8 wk FAVOURABLE for AF + high CHA2DS2-VASc + non-CAA phenotype (opposite of lobar CAA); lifestyle + statin restart (AHA/ASA 2022)
- Close-out criterion: Rehab + outpatient stroke clinic + BP plan + anticoag-restart decision set

Monitoring phase: GCS q1h × 24 h; continuous arterial BP; repeat CT 6 h or with decline; serial coags during reversal (AHA/ASA 2022)

Disposition

Current setting: outpatient — Stroke clinic with intensive BP <130/80 (SPRINT-MIND) + secondary-HTN workup if uncontrolled + DOAC restart 4-8 wk for AF + PHQ-9 + MoCA + sympathomimetic cessation (AHA/ASA 2022)

Disposition criteria:
- Continue indefinite BP <130/80 secondary-prevention regimen
- Transition rehab → community exercise at 6-12 mo

Escalation triggers (move to higher acuity):
- Any new TIA-spectrum or stroke-like event → ED
- BP persistently >140/90 despite 3-drug regimen → resistant HTN workup
- PHQ-9 ≥15 or SI → urgent psych referral
- Recurrent ICH → re-image, hold antithrombotic, escalate to vascular neurology

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Pontine / brainstem ICH on CT (typically hypertensive); GCS often ≤8; quadriparesis + cranial nerve deficits; 90-d mortality 50-80% (AHA/ASA 2022)
- [SEVERE] Putaminal ICH — most common deep location; classic HTN bleed; contralateral hemiparesis + sensory loss + gaze deviation toward lesion (AHA/ASA 2022)
- [SEVERE] Thalamic ICH with IVH extension and obstructive hydrocephalus risk; sensory > motor deficit; vertical gaze palsy (AHA/ASA 2022)

Citations

- 2022 AHA/ASA Guideline for Spontaneous ICH (Greenberg Stroke 2022) + INTERACT3 care bundle + INCH 4F-PCC + ANNEXA-I andexanet + SPRINT-MIND long-term BP [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 38598795) [PMID:38598795](https://pubmed.ncbi.nlm.nih.gov/38598795/)
- Cited evidence (PMID 27178479) [PMID:27178479](https://pubmed.ncbi.nlm.nih.gov/27178479/)
- Cited evidence (PMID 29778325) [PMID:29778325](https://pubmed.ncbi.nlm.nih.gov/29778325/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2022 AHA/ASA Guideline for Spontaneous ICH (Greenberg Stroke 2022) + INTERACT3 care bundle + INCH 4F-PCC + ANNEXA-I andexanet + SPRINT-MIND long-term BP — PMID:35579034
  • Cited evidence (PMID 37245517) — PMID:37245517
  • Cited evidence (PMID 38598795) — PMID:38598795
  • Cited evidence (PMID 27178479) — PMID:27178479
  • Cited evidence (PMID 29778325) — PMID:29778325