How should I manage a patient presenting with acute neurological deficits that may require surgical intervention?

Initial management of a patient presenting with acute neurological deficits potentially requiring surgical intervention involves urgent assessment and imaging. Immediate brain imaging (CT or MRI) is essential to identify the cause, such as infarction, haemorrhage, or hydrocephalus, and to guide further management ¹,².

For acute ischaemic stroke with large middle cerebral artery infarction and decreased consciousness, consider decompressive hemicraniectomy within 48 hours if the patient meets specific clinical and radiological criteria, including NIHSS score above 15, decreased level of consciousness, and infarct size involving at least 50% of the MCA territory or infarct volume >145 cm3 on diffusion-weighted MRI ¹.

Discuss the risks and benefits of decompressive hemicraniectomy with the patient or their family, considering pre-stroke functional status and preferences, and ensure monitoring by professionals skilled in neurological assessment ¹.

For patients with intracerebral haemorrhage, monitor closely for neurological deterioration and refer immediately for brain imaging if deterioration occurs. Surgical intervention should be considered especially if hydrocephalus is present and the patient was previously fit ¹.

In cases of subarachnoid haemorrhage caused by a ruptured aneurysm, management options including endovascular coiling or neurosurgical clipping should be discussed by a neuroradiologist and neurosurgeon, with treatment carried out urgently to prevent rebleeding, ideally within 24 hours of symptom onset ².

Consider drainage or diversion of cerebrospinal fluid in patients with neurological deterioration due to acute hydrocephalus ².

Throughout, ensure multidisciplinary involvement, including specialist stroke or neurosurgical teams, and provide supportive care such as hydration, nutrition, and prevention of complications like aspiration pneumonia ¹,².