A 62-year-old woman is brought to the emergency department by her family due to dizziness. She was unable to get out of bed and go to the bathroom this morning and has had headache and nausea. The patient has a history of migraine headaches and hypertension. Six months ago, she had an episode of transient right-sided vision loss and was prescribed aspirin. Other medications include amlodipine and hydrochlorothiazide. Temperature is 36.7 C (98.1 F), blood pressure is 156/72 mm Hg, and pulse is 88/min. BMI is 33 kg/m². On physical examination, the patient moves all extremities, and deep tendon reflexes are symmetric. CT scan of the head is shown in the image. The patient is admitted to the hospital. An hour after admission, she appears lethargic but follows simple commands. She had a single episode of vomiting in the emergency department. Which of the following is the best next step in management of this patient?

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Explanation: 11ec25c8_d82b_3601_bc81_bfe43e0df75e_MD0003_00 This patient with a posterior fossa hyperdensity on CT scan has a cerebellar hemorrhage, which accounts for approximately 10% of cases of intracerebral hemorrhage (ICH). Risk factors for ICH include hypertension, antithrombotic therapy (eg, aspirin), and cerebral amyloid angiopathy. Symptoms of ICH are progressive and worsen over minutes to hours. Headache, nausea, and vomiting are common, and meningismus can occur if the bleed extends into the intraventricular space. Further manifestations depend on the location of the bleed; cerebellar hemorrhage can result in vertigo, dysarthria, nystagmus, and ipsilateral truncal (cerebellar vermis) or limb (cerebellar hemispheres) ataxia. Unlike other locations of stroke, hemiparesis and sensory loss are rare. posterior fossa hyperdensity Management includes stabilization (eg, airway, breathing, cardiovascular system), reversal of anticoagulation, blood pressure management, and elevation of the head of the bed to decrease intracranial pressure (ICP). However, extension of cerebellar hemorrhage can result in obstructive hydrocephalus (due to compression of the fourth ventricle), with elevated ICP or brainstem compression leading to stupor, coma, and death. Therefore, urgent surgical decompression and clot evacuation are indicated in cerebellar hemorrhage with: signs of neurologic deterioration (eg, progressive lethargy, obtundation, coma). radiologic evidence of a bleed >3 cm, brainstem compression, or obstructive hydrocephalus. (Choice A) Anticoagulation is indicated in patients with an uncomplicated ischemic stroke due to embolic disease; however, it is initiated 24-48 hours after the infarction. This patient has evidence of hemorrhagic stroke on CT scan, and anticoagulation would likely worsen the bleed. (Choice B) Glucocorticoids are used to reduce inflammation and peritumor edema due to intracranial malignancy, but tumors are usually less hyperdense and demonstrate peritumor edema with central necrosis. Glucocorticoids are not indicated in ischemic or hemorrhagic stroke. peritumor edema with central necrosis (Choice C) Osmotic diuretics (eg, mannitol) are occasionally used to acutely reduce ICP due to hemorrhage or life-threatening mass effect; however, loop diuretics have no role in the management of either. (Choice D) Cerebrospinal fluid removal via serial lumbar puncture or an external ventricular drain is sometimes needed to reduce ICP due to obstructive hydrocephalus, but this is considered second-line therapy in cerebellar hemorrhage and should be pursued only if decompressive surgery is not possible. Educational objective: Cerebellar hemorrhage presents with progressive headache, nausea, and vomiting; in addition, vertigo, ipsilateral truncal (cerebellar vermis) or limb (cerebellar hemispheres) ataxia, dysarthria, and nystagmus may occur. CT scan demonstrates a posterior fossa hyperdensity. Urgent surgical decompression is indicated in patients with signs of neurologic deterioration or radiologic evidence of a hemorrhage >3 cm, brainstem compression, or obstructive hydrocephalus. References: Current management of spontaneous intracerebral haemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/28959487)

A 62-Year-Old Woman Is Brought to the Emergency Department by Her