A 72-year-old woman with atrial fibrillation (not on anticoagulation) presents with acute focal neurological deficit. Non-contrast CT head shows a 4 cm hyperdense lesion in the right basal ganglia with surrounding hypodensity and midline shift. What is the most appropriate immediate next step in management?

Explanation

## Clinical Presentation and Imaging Findings The patient has acute focal neurological deficit with imaging findings consistent with **acute intracerebral hemorrhage (ICH)**: - Hyperdense lesion = acute blood - Surrounding hypodensity = cerebral edema - Midline shift = mass effect and increased intracranial pressure This is NOT an acute ischemic stroke, despite the patient's atrial fibrillation. ## Why Neurosurgical Consultation is the Best Next Step **Key Point:** In acute ICH with significant mass effect (midline shift, 4 cm hematoma volume), neurosurgical evaluation is mandatory to assess candidacy for hematoma evacuation. The goal is to reduce intracranial pressure and prevent herniation. **High-Yield:** Indications for surgical evacuation in ICH include: - Lobar hematomas >30 mL with GCS decline or mass effect - Cerebellar hemorrhage >4 cm or with hydrocephalus/brainstem compression - Significant midline shift and herniation risk ## Management Algorithm for Acute ICH ```mermaid flowchart TD A[Non-contrast CT confirms ICH]:::outcome --> B{Assess severity}:::decision B -->|GCS ≥8, no mass effect| C[Medical management]:::action B -->|GCS <8 or mass effect| D[Urgent neurosurgery consult]:::action D --> E{Candidate for surgery?}:::decision E -->|Yes| F[Hematoma evacuation]:::action E -->|No| G[ICU monitoring, osmotic therapy]:::action C --> H[ICP monitoring, BP control, DVT prophylaxis]:::action ``` ## Why Other Options Are Wrong **Warning:** Thrombolysis is contraindicated in ICH — it will worsen bleeding. Anticoagulation is also contraindicated acutely in ICH and increases risk of hematoma expansion. CTA/CTP are useful in ischemic stroke to assess penumbra; they are not the priority in acute ICH with mass effect. ## Supportive Medical Management **Clinical Pearl:** While awaiting neurosurgery: - Maintain systolic BP <140 mmHg (labetalol, nicardipine) - Elevate head of bed 30° - Avoid hyperthermia, hyperglycemia - Osmotic therapy (mannitol, hypertonic saline) for ICP reduction - DVT prophylaxis with sequential compression devices [cite:Harrison 21e Ch 445; Stroke Council Guidelines on ICH Management]