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neuro.ich.core.v1

Intracerebral Hemorrhage

neurologyacuteadult
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Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Acute spontaneous intraparenchymal hemorrhage; exclude trauma + ischemic transformation (AHA/ASA 2022)

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Advance rule
Set
Advance when

spontaneous ICH confirmed on imaging

Patient inputs (12)

Age informs CAA likelihood (lobar, >55) and reversal risk/benefit (AHA/ASA 2022, Greenberg Stroke 2022)

Contrast/dosing decisions for nicardipine/clevidipine + andexanet (ANNEXA-I Connolly NEJM 2024 PMID 38749032)

Hematoma volume + location + IVH; serves as trigger for surgical decision (AHA/ASA 2022)

GCS drives ICH score (Hemphill Stroke 2001), intubation, EVD decisions (AHA/ASA 2022)

VKA reversal threshold; STAT 4F-PCC if INR ≥1.4 (INCH Steiner Lancet Neurol 2016 PMID 27302126)

Heparin/dabigatran assessment (AHA/ASA 2022)

Coagulopathy assessment; PATCH (Baharoglu Lancet 2016 PMID 27178479) — do NOT routinely transfuse for antiplatelet ICH

INTERACT2 (Anderson NEJM 2013) / INTERACT3 (Ma Lancet 2023 PMID 37245517) / ATACH-2 (Qureshi NEJM 2016) — target SBP <140 within 1h; avoid <110

VKA → 4F-PCC + vit K (INCH Steiner Lancet Neurol 2016 PMID 27302126); dabigatran → idarucizumab; Xa-DOAC → andexanet (ANNEXA-I Connolly NEJM 2024 PMID 38749032)

Distinguishes hypertensive deep vs lobar/CAA phenotype (AHA/ASA 2022)

Spot sign within 6h predicts hematoma expansion; identifies vascular cause (AHA/ASA 2022)

PATCH (Baharoglu Lancet 2016 PMID 27178479): do NOT transfuse platelets routinely; consider DDAVP

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

Severity triggers (13)

13 need judgement
  • informationallife_threateningcerebellar_ich_>=3cm (AHA/ASA 2022)
    Cerebellar ICH ≥3 cm OR brainstem compression OR hydrocephalus (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningherniation_signs (AHA/ASA 2022)
    Cushing reflex, anisocoria, GCS decline ≥2, posturing (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninggcs_<=8 (AHA/ASA 2022; Hemphill Stroke 2001)
    GCS ≤8 at presentation or decline (Hemphill Stroke 2001)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningphenotype_cerebellar_>=3cm_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_threateningphenotype_infratentorial_pons_brainstem
    Pontine or brainstem ICH on CT (typically hypertensive); GCS often ≤8; quadriparesis + cranial nerve deficits
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehematoma_expansion_>33pct (AHA/ASA 2022)
    Hematoma volume increase >33% on repeat CT (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereivh_with_hydrocephalus (AHA/ASA 2022)
    IVH on CT with ventricular enlargement + GCS decline (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereanticoagulated_at_presentation (AHA/ASA 2022)
    Patient on VKA / DOAC / heparin with confirmed ICH (AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresbp_not_at_target_within_1h (INTERACT3)
    SBP not at <140 within 1 h of ED arrival despite first-line IV antihypertensive (INTERACT3 Ma Lancet 2023 PMID 37245517)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverephenotype_lobar_caa
    Lobar ICH (cortico-subcortical) on CT; age >55; multiple cortical/subcortical microbleeds on MRI GRE/SWI per Boston v2.0; absence of hypertensive history
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverephenotype_deep_basal_ganglia_hypertensive
    Deep ICH in basal ganglia / thalamus / internal capsule on CT; long-standing hypertension; absence of lobar microbleed burden on MRI
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverephenotype_ivh_predominant
    Predominant IVH on CT with or without small parenchymal source; obstructive hydrocephalus common
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredepth2_quantitative_and_special_pop_2026_05_18
    Effect-size + special-population matrix (data, not a runtime gate): INTERACT2 ordinal mRS OR 0.87 (95% CI 0.77-1.00; p=0.04), mortality 11.9% vs 12.0% (Anderson NEJM 2013 PMID 23713578); INTERACT3 goal-directed care bundle (SBP 130-150 within 1 h + glucose + pyrexia + anticoagulation algorithms) improved 6-mo functional outcome (Ma Lancet 2023 PMID 37245517); ATACH-2 intensive (SBP 110-139) vs standard death/disability 38.7% vs 37.7%, renal AE 9.0% vs 4.0% (p=0.002) → avoid SBP <110 (Qureshi NEJM 2016 PMID 27276234); ANNEXA-I andexanet vs usual care superior haemostatic efficacy for FXa-DOAC ICH, n=263 vs 267 (Connolly NEJM 2024 PMID 38749032); INCH INR ≤1.2 within 3 h 4F-PCC 67% vs FFP 9% (adjusted OR 30.6, 95% CI 4.7-197.9; p=0.0003) (Steiner Lancet Neurol 2016 PMID 27302126); PATCH platelet transfusion in antiplatelet ICH death/dependence adjusted common OR 2.05 (95% CI 1.18-3.56; p=0.0114) — HARM (Baharoglu Lancet 2016 PMID 27178479); ENRICH minimally invasive evacuation (lobar/anterior-BG 30-80 mL <24 h) superior mean utility-weighted mRS at 180 d, posterior probability >0.975 (Pradilla NEJM 2024 PMID 38598795); ICH Score → 30-d mortality 0→0%, 1→13%, 2→26%, 3→72%, 4→97%, 5→100% (Hemphill Stroke 2001 PMID 11283388); FUNC score ≤4 → 0% vs 11 → >80% 90-d functional independence, n=629 (Rost Stroke 2008 PMID 18556582); CTA spot sign first-pass sens 53% spec 88%, LR+ 4.70 (3.28-6.74) LR- 0.44 (0.34-0.58); combined modalities LR+ 6.76 LR- 0.17 (Du PLoS One 2014 PMID 25541717); spot-sign frequency 39% (<2 h) → 13% (>8 h) and PPV 53%→33% with onset-to-CTA time (Dowlatshahi Stroke 2016 PMID 26846857) — spot-sign LR is time-conditional; lobar/CAA annual recurrent-ICH risk ≈7%/yr; brainstem ICH 90-d mortality ≈50-80% (AHA/ASA 2022 PMID 35579034).
    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

INTERACT3 (Ma Lancet 2023 PMID 37245517) acute care bundle — BP, reversal, glucose, temp, surgery
axis: ich_acute_bundlestep 1 - Step 1 — Aggressive BP control within 1 hour (INTERACT2 2013 / INTERACT3 Ma Lancet 2023 PMID 37245517 / ATACH-2 Qureshi NEJM 2016)
Selected step "Step 1 — Aggressive BP control within 1 hour (INTERACT2 2013 / INTERACT3 Ma Lancet 2023 PMID 37245517 / ATACH-2 Qureshi NEJM 2016)" — Spontaneous ICH on CT; 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 infusion (max: 15 mg/h)
    triggers: SBP_>150_target_130-150
    INTERACT3 (Ma Lancet 2023) / ATACH-2 (Qureshi NEJM 2016) — target SBP 130–150 within 1 h reduces hematoma growth + improves functional outcome
    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; useful when frequent titration needed (AHA/ASA 2022)
    rxcui 233603
  • labetalol
    add on
    beta_alpha_blocker
    10–20 mg IV bolus q10 min; or 2–8 mg/min infusion • IV • PRN / infusion (max: 300 mg cumulative)
    triggers: SBP_persistent_>150
    Adjunct for resistant HTN or when CCBs contraindicated (AHA/ASA 2022)
    rxcui 6185

outpatient playbook — drug actions (5)

  1. 1. ACEI/ARB + thiazide
    Lisinopril 10–40 mg PO daily; chlorthalidone 12.5–25 mg PO daily; titrate to BP <130/80 • PO • daily
    trigger: BP ≥130/80 long-term
    2025 AHA/ACC HTN; SPRINT-MIND — intensive BP control reduces dementia + recurrent stroke
  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 + non-CAA phenotype + stable hematoma
    AHA/ASA 2022 — individualised restart; ENRICH-AF + ELAN trials; left-atrial-appendage closure alternative if CAA
  3. 3. HOLD anticoagulation if CAA
    — • — • indefinite
    trigger: Lobar ICH + CAA per Boston v2.0
    CAA annual recurrent-ICH risk ≈7%/yr > stroke risk from AF in most patients; consider LAA closure (AHA/ASA 2022)
  4. 4. varenicline OR NRT OR bupropion
    Per agent • PO / patch / lozenge • per agent
    trigger: Active tobacco use
    Smoking cessation reduces recurrent stroke (AHA/ASA 2022)
  5. 5. sertraline OR escitalopram
    Sertraline 50 mg PO daily; escitalopram 10 mg PO daily • PO • daily
    trigger: PHQ-9 ≥10 post-ICH
    Post-ICH depression 25-40%; SSRI first-line; avoid concomitant antiplatelet if possible (AHA/ASA 2022)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute focal deficit with sudden severe headache (AHA/ASA 2022); Altered consciousness / GCS drop (Hemphill Stroke 2001); New seizure with focal deficit (AHA/ASA 2022).

Objective

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

Assessment

**Intracerebral Hemorrhage** (neuro.ich.core.v1).
Phenotype framing: Phenotype by location: lobar (CAA) / deep basal-ganglia (hypertensive) / cerebellar ≥3 cm / infratentorial pons-brainstem / IVH-predominant / anticoagulant-associated / vascular malformation (AHA/ASA 2022)
Scope: Acute spontaneous intraparenchymal hemorrhage; exclude trauma + ischemic transformation (AHA/ASA 2022)

No severity triggers fired against current inputs.

Plan

Regimen axis: **INTERACT3 (Ma Lancet 2023 PMID 37245517) acute care bundle — BP, reversal, glucose, temp, surgery** — step "Step 1 — Aggressive BP control within 1 hour (INTERACT2 2013 / INTERACT3 Ma Lancet 2023 PMID 37245517 / ATACH-2 Qureshi NEJM 2016)".
1. nicardipine 5 mg/h IV; titrate by 2.5 mg/h q5–15 min IV continuous infusion (CCB_dihydropyridine, first line) — INTERACT3 (Ma Lancet 2023) / ATACH-2 (Qureshi NEJM 2016) — target SBP 130–150 within 1 h reduces hematoma growth + improves functional outcome
2. clevidipine 1–2 mg/h IV; double q90 sec IV continuous (CCB_dihydropyridine, first line) — Ultra-short acting; useful when frequent titration needed (AHA/ASA 2022)
3. labetalol 10–20 mg IV bolus q10 min; or 2–8 mg/min infusion IV PRN / infusion (beta_alpha_blocker, add on) — Adjunct for resistant HTN or when CCBs contraindicated (AHA/ASA 2022)

Setting playbook (outpatient) — Stroke clinic 4-8 wk + 90 d + 6 mo + 12 mo: anticoag-restart decision (AF high-stroke-risk vs CAA contraindication), BP <130/80 long-term (SPRINT-MIND / RESPECT-ESUS), depression + cognition screen, rehab progress, repeat MRI for CAA at 6 mo (Boston v2.0), recurrence counselling (AHA/ASA 2022)
4. ACEI/ARB + thiazide Lisinopril 10–40 mg PO daily; chlorthalidone 12.5–25 mg PO daily; titrate to BP <130/80 PO daily — BP ≥130/80 long-term (2025 AHA/ACC HTN; SPRINT-MIND — intensive BP control reduces dementia + recurrent stroke)
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 + non-CAA phenotype + stable hematoma (AHA/ASA 2022 — individualised restart; ENRICH-AF + ELAN trials; left-atrial-appendage closure alternative if CAA)
6. HOLD anticoagulation if CAA — — indefinite — Lobar ICH + CAA per Boston v2.0 (CAA annual recurrent-ICH risk ≈7%/yr > stroke risk from AF in most patients; consider LAA closure (AHA/ASA 2022))
7. varenicline OR NRT OR bupropion Per agent PO / patch / lozenge per agent — Active tobacco use (Smoking cessation reduces recurrent stroke (AHA/ASA 2022))
8. sertraline OR escitalopram Sertraline 50 mg PO daily; escitalopram 10 mg PO daily PO daily — PHQ-9 ≥10 post-ICH (Post-ICH depression 25-40%; SSRI first-line; avoid concomitant antiplatelet if possible (AHA/ASA 2022))

Non-pharmacologic actions:
- Recurrent-stroke counselling — symptom recognition, when to call 911 (AHA/ASA 2022)
- Advance directives + power-of-attorney discussion (AHA/ASA 2022)
- Mediterranean diet counselling
- Aerobic exercise prescription 150 min/wk moderate intensity (AHA/ASA 2022)
- Home BP monitor + log review at each visit (AHA/ASA 2022)
- Outpatient rehab continuation through 12 mo per functional progress (AHA/ASA 2022)
- Genetic counselling for hereditary CAA (rare; Dutch/Iceland-type APP mutations) if young + recurrent lobar ICH (AHA/ASA 2022)

AVOID / contraindication checks:
- No_thrombolysis_in_hemorrhagic_stroke (AHA/ASA 2022)
- No_routine_platelet_transfusion_for_antiplatelet_ICH (PATCH Baharoglu Lancet 2016 PMID 27178479)
- Avoid_SBP_<110_hypoperfusion_risk (ATACH 2 Qureshi NEJM 2016)
- No_routine_seizure_prophylaxis_unless_seizure_documented (AHA/ASA 2022)
- No_intraventricular_tPA_routinely_CLEAR_III_negative (Hanley Lancet 2017 PMID 28081952)
- No_routine_tranexamic_acid_TICH 2_neutral (Sprigg Lancet 2018 PMID 29778325)

Monitoring

Regimen monitoring:
- GCS q1h x 24h (AHA/ASA 2022)
- BP continuous arterial target SBP 130-150 (INTERACT3 Ma Lancet 2023 PMID 37245517)
- INR q6h until <1.3 for VKA reversal (INCH Steiner Lancet Neurol 2016 PMID 27302126)
- repeat CT at 6h or with decline (AHA/ASA 2022)
- serum osm q6h during osmotic therapy (AHA/ASA 2022)
- serum Na q4-6h during HTS (AHA/ASA 2022)

Setting (outpatient) monitoring:
- Clinic visit at 7–14 d post-discharge for medication reconciliation (AHA/ASA 2022)
- Stroke clinic at 4-8 wk (anticoag-restart decision), 90 d (mRS + secondary prevention audit), 6 mo (repeat MRI for CAA), 12 mo (long-term outcome)
- BP home log + clinic check q3 mo until at goal then q6 mo (2025 AHA/ACC HTN)
- PHQ-9 + MoCA at 90 d, 6 mo, 12 mo (AHA/ASA 2022)
- INR weekly until stable then q4 wk if warfarin re-introduced (ACCP 2018) — rare in ICH survivors
- Renal function q6 mo if on DOAC; q3 mo if CrCl 30–50 (2024 ESC AF)

Follow-up plan: Long-term BP <130/80 (SPRINT-MIND); anticoag-restart 4–8 wk decision (AF high CHA2DS2-VASc favours restart; CAA contraindicates restart); CAA family + amyloid counselling; rehab; PHQ-9 depression screen at 90 d (AHA/ASA 2022)
- Close-out criterion: rehab + outpatient stroke clinic + BP plan set

Monitoring phase: GCS q1h × 24h, repeat CT at 6h or with decline, q6h INR until <1.3 (VKA-ICH), continuous arterial BP (AHA/ASA 2022)

Disposition

Current setting: outpatient — Stroke clinic 4-8 wk + 90 d + 6 mo + 12 mo: anticoag-restart decision (AF high-stroke-risk vs CAA contraindication), BP <130/80 long-term (SPRINT-MIND / RESPECT-ESUS), depression + cognition screen, rehab progress, repeat MRI for CAA at 6 mo (Boston v2.0), recurrence counselling (AHA/ASA 2022)

Disposition criteria:
- Continue indefinite BP <130/80 secondary-prevention regimen — no de-escalation (AHA/ASA 2022)
- Transition from rehab to community-based exercise programs at 6–12 mo per functional status (AHA/ASA 2022)
- CAA phenotype: lifelong anticoag-hold + LAA closure if AF + recurrence-risk counselling (AHA/ASA 2022)

Escalation triggers (move to higher acuity):
- Any new TIA-spectrum or stroke-like event → ED (AHA/ASA 2022)
- BP persistently >140/90 despite 3-drug regimen → resistant HTN workup (AHA/ASA 2022)
- PHQ-9 ≥15 OR suicidal ideation → urgent psych referral (AHA/ASA 2022)
- MoCA <26 OR cognitive decline noted by family → neurocognitive workup (AHA/ASA 2022)
- Recurrent ICH → re-image, hold any antithrombotic, escalate to vascular neurology (AHA/ASA 2022)
- New CAA microbleeds on 6-mo MRI → reinforce anticoag-hold; consider LAA closure if AF (AHA/ASA 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Cerebellar ICH ≥3 cm OR brainstem compression OR hydrocephalus (AHA/ASA 2022)
- [LIFE_THREATENING] Cushing reflex, anisocoria, GCS decline ≥2, posturing (AHA/ASA 2022)
- [LIFE_THREATENING] GCS ≤8 at presentation or decline (Hemphill Stroke 2001)

Citations

- 2022 AHA/ASA Guideline for Spontaneous ICH (Greenberg Stroke 2022) + INTERACT3 care bundle + ANNEXA-I + ENRICH evacuation [PMID:35579034](https://pubmed.ncbi.nlm.nih.gov/35579034/)
- Cited evidence (PMID 38749032) [PMID:38749032](https://pubmed.ncbi.nlm.nih.gov/38749032/)
- 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/)

Last reconciled with current guidelines: 2026-05-18.
References
  • 2022 AHA/ASA Guideline for Spontaneous ICH (Greenberg Stroke 2022) + INTERACT3 care bundle + ANNEXA-I + ENRICH evacuation — PMID:35579034
  • Cited evidence (PMID 38749032) — PMID:38749032
  • Cited evidence (PMID 37245517) — PMID:37245517
  • Cited evidence (PMID 38598795) — PMID:38598795
  • Cited evidence (PMID 27178479) — PMID:27178479