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neuro.ich-lobar.v1PRODUCTION
neuro.ich-lobar.v1

Intracerebral Hemorrhage — Lobar (CAA-suspected)

neurologyacuteadult
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Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Spontaneous lobar (cortico-subcortical) IPH on imaging in age >55; rule out trauma + hemorrhagic transformation (AHA/ASA 2022 PMID 35579034)

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Advance rule
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Lobar ICH confirmed on imaging

Patient inputs (12)

Boston v2.0 (PMID 35841910) — required for probable/possible CAA classification; multiple cortical microbleeds + cortical superficial siderosis

Age >55 anchors CAA suspicion (Boston v2.0 PMID 35841910)

Contrast + dosing decisions for nicardipine, clevidipine, andexanet (ANNEXA-I PMID 38749032)

Volume + lobar location + IVH; ENRICH MIE candidate if 30-80 mL <24 h (Pradilla NEJM 2024 PMID 38598795)

GCS drives ICH score (Hemphill 2001), intubation, EVD decisions (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 for antiplatelet ICH

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

VKA → 4F-PCC + vit K (INCH PMID 27302126); dabigatran → idarucizumab; FXa-DOAC → andexanet (ANNEXA-I PMID 38749032)

Familial HCHWA-Dutch/Icelandic APP mutation suspicion if young + recurrent lobar

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

PATCH (PMID 27178479) — do NOT routinely transfuse platelets; consider DDAVP

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

Severity triggers (9)

9 need judgement
  • informationalsevereclassic_lobar_CAA_age_gt_55
    Classic lobar ICH (cortico-subcortical) in age >55 with multiple cortical/subcortical microbleeds + cortical superficial siderosis on MRI GRE/SWI per Boston v2.0 (Charidimou Lancet Neurol 2022 PMID 35841910)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereAPOL1_amyloid_associated
    APOL1 high-risk genotype amyloid mechanism in select populations (research-stage; consider in young recurrent lobar without classic CAA)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecerebral_amyloid_inflammation_CAA-RI
    CAA-related inflammation — T2 white-matter edema + meningeal enhancement on MRI; steroid-responsive immune variant
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_lobar_high_risk
    Recurrent lobar ICH within 12 mo OR multiple cortical microbleeds + cortical superficial siderosis — high recurrence risk (CAA recurrence ≈7%/yr)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereanticoag_restart_4-8wk_decision_CAA_AVOID
    Anticoag-restart decision at 4-8 wk in lobar CAA = HOLD INDEFINITELY (opposite of deep hypertensive ICH which favours restart)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereMRI_GRE_microbleeds_required_for_dx
    Boston v2.0 requires MRI GRE/SWI for probable/possible CAA classification — multiple cortical microbleeds + cortical superficial siderosis (Charidimou Lancet Neurol 2022 PMID 35841910)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremixed_amyloid_HTN
    Mixed phenotype — both CAA microbleeds (cortical) AND deep hypertensive bleeds; chronic HTN comorbid with CAA
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatePET_amyloid_PiB
    PiB amyloid PET supports CAA when MRI is equivocal (research / specialist use)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefamilial_HCHWA_Dutch_or_Icelandic
    Hereditary cerebral hemorrhage with amyloidosis (HCHWA) Dutch / Icelandic APP mutations — rare familial CAA in young patients
    Trigger could not be auto-evaluated — needs clinician judgement.

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Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Lobar-CAA bundle — INTERACT3 BP + FXa-DOAC reversal + PATCH + ENRICH MIE + CAA-RI immunotherapy (AHA/ASA 2022 PMID 35579034; INTERACT3 PMID 37245517; ANNEXA-I PMID 38749032; ENRICH PMID 38598795; PATCH PMID 27178479)
axis: ich_lobar_caa_bundlestep 1 - Step 1 — Aggressive BP control SBP <140 within 1 h (INTERACT3)
Selected step "Step 1 — Aggressive BP control SBP <140 within 1 h (INTERACT3)" — Spontaneous lobar 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) — SBP 130-150 within 1 h reduces hematoma growth
    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; rapid titration (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 (AHA/ASA 2022)
    rxcui 6185

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. HOLD anticoagulation indefinitely
    — • — • indefinite
    trigger: CAA (Boston v2.0 probable/possible)
    CAA recurrence ≈7%/yr exceeds AF stroke risk; LAA closure preferred
  3. 3. 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 lobar (cortico-subcortical) intraparenchymal blood (AHA/ASA 2022 PMID 35579034); Sudden focal deficit in patient age >55 (lobar CAA suspect; Boston v2.0 PMID 35841910); Pre-ICH cognitive impairment (CAA-associated dementia) (AHA/ASA 2022).

Objective

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

Assessment

**Intracerebral Hemorrhage — Lobar (CAA-suspected)** (neuro.ich-lobar.v1).
Phenotype framing: Lobar CAA (this engine) vs deep hypertensive (route ich-deep) vs cerebellar (route ich-cerebellar) vs anticoag-associated vs vascular malformation vs tumor with hemorrhage vs CAA-RI (AHA/ASA 2022)
Scope: Spontaneous lobar (cortico-subcortical) IPH on imaging in age >55; rule out trauma + hemorrhagic transformation (AHA/ASA 2022 PMID 35579034)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Lobar-CAA bundle — INTERACT3 BP + FXa-DOAC reversal + PATCH + ENRICH MIE + CAA-RI immunotherapy (AHA/ASA 2022 PMID 35579034; INTERACT3 PMID 37245517; ANNEXA-I PMID 38749032; ENRICH PMID 38598795; PATCH PMID 27178479)** — step "Step 1 — Aggressive BP control SBP <140 within 1 h (INTERACT3)".
1. nicardipine 5 mg/h IV; titrate by 2.5 mg/h q5–15 min IV continuous (CCB_dihydropyridine, first line) — INTERACT3 (PMID 37245517) — SBP 130-150 within 1 h reduces hematoma growth
2. clevidipine 1-2 mg/h IV; double q90 sec IV continuous (CCB_dihydropyridine, first line) — Ultra-short acting; rapid titration (AHA/ASA 2022)
3. labetalol 10-20 mg IV bolus q10 min IV PRN (beta_alpha_blocker, add on) — Adjunct for resistant HTN (AHA/ASA 2022)

Setting playbook (outpatient) — Stroke clinic 4-8 wk (anticoag-restart decision = HOLD for CAA) + 90 d (mRS + Boston v2.0 confirmation) + 6 mo (repeat MRI for microbleed burden) + 12 mo; BP <130/80 long-term (SPRINT-MIND); LAA closure if AF (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. HOLD anticoagulation indefinitely — — indefinite — CAA (Boston v2.0 probable/possible) (CAA recurrence ≈7%/yr exceeds AF stroke risk; LAA closure preferred)
6. 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 discussion
- Mediterranean diet + 150 min/wk moderate exercise
- Home BP monitor + log review
- LAA closure if AF + appropriate anatomy
- Genetic counselling for hereditary CAA if young + recurrent lobar

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

Monitoring

Regimen monitoring:
- GCS q1h x 24h (AHA/ASA 2022)
- BP continuous arterial target SBP 130-150 (INTERACT3 PMID 37245517)
- repeat CT at 6h or with decline (AHA/ASA 2022)
- MRI GRE SWI for Boston v2.0 CAA classification (PMID 35841910)
- INR q6h until <1.3 for VKA reversal (INCH PMID 27302126)

Setting (outpatient) monitoring:
- Clinic visit 7-14 d post-discharge for medication reconciliation
- Stroke clinic 4-8 wk (anticoag-hold confirm), 90 d (mRS + Boston v2.0), 6 mo (repeat MRI), 12 mo
- BP home log + clinic check q3 mo until at goal then q6 mo
- PHQ-9 + MoCA at 90 d, 6 mo, 12 mo

Follow-up plan: Long-term BP <130/80 (SPRINT-MIND); INDEFINITE anticoag-hold (CAA recurrence ≈7%/yr); LAA closure if AF; repeat MRI 6 mo for microbleed burden tracking; CAA family counselling; PHQ-9 + MoCA (AHA/ASA 2022)
- Close-out criterion: Rehab + outpatient stroke clinic + indefinite-hold + LAA-closure plan set

Monitoring phase: GCS q1h × 24 h; continuous arterial BP; repeat CT 6 h or with decline; q6h INR until <1.3 (VKA-ICH); MRI GRE/SWI for definitive CAA classification (AHA/ASA 2022)

Disposition

Current setting: outpatient — Stroke clinic 4-8 wk (anticoag-restart decision = HOLD for CAA) + 90 d (mRS + Boston v2.0 confirmation) + 6 mo (repeat MRI for microbleed burden) + 12 mo; BP <130/80 long-term (SPRINT-MIND); LAA closure if AF (AHA/ASA 2022)

Disposition criteria:
- Continue indefinite BP <130/80 + anticoag-hold + LAA closure if AF
- 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 suicidal ideation → urgent psych referral
- Recurrent ICH → re-image, hold all antithrombotics, escalate to vascular neurology
- New CAA microbleeds on 6-mo MRI → reinforce anticoag-hold; consider LAA closure if AF

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Classic lobar ICH (cortico-subcortical) in age >55 with multiple cortical/subcortical microbleeds + cortical superficial siderosis on MRI GRE/SWI per Boston v2.0 (Charidimou Lancet Neurol 2022 PMID 35841910)
- [SEVERE] APOL1 high-risk genotype amyloid mechanism in select populations (research-stage; consider in young recurrent lobar without classic CAA)
- [SEVERE] CAA-related inflammation — T2 white-matter edema + meningeal enhancement on MRI; steroid-responsive immune variant

Citations

- 2022 AHA/ASA Guideline for Spontaneous ICH (Greenberg Stroke 2022) + Boston v2.0 (Charidimou Lancet Neurol 2022) + INTERACT3 + ENRICH + ANNEXA-I [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 35841910) [PMID:35841910](https://pubmed.ncbi.nlm.nih.gov/35841910/)
- 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/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2022 AHA/ASA Guideline for Spontaneous ICH (Greenberg Stroke 2022) + Boston v2.0 (Charidimou Lancet Neurol 2022) + INTERACT3 + ENRICH + ANNEXA-I — PMID:35579034
  • Cited evidence (PMID 37245517) — PMID:37245517
  • Cited evidence (PMID 35841910) — PMID:35841910
  • Cited evidence (PMID 38598795) — PMID:38598795
  • Cited evidence (PMID 27178479) — PMID:27178479