What are the next steps for a patient with a history of a fall from a golf cart, diagnosed with a cerebral hematoma, now complaining of a tight feeling in the eyebrow area?

Urgent Evaluation for Compartment Syndrome and Neurosurgical Consultation

This patient requires immediate assessment for orbital compartment syndrome, which is a vision-threatening emergency that can occur after head trauma with cerebral hematoma, and urgent neurosurgical consultation to evaluate for expanding hematoma or increased intracranial pressure.

Immediate Assessment Required

Evaluate for Orbital Compartment Syndrome

• Perform urgent ophthalmologic examination checking for proptosis, decreased visual acuity, relative afferent pupillary defect (RAPD), restricted extraocular movements, and increased intraocular pressure 1, 2
• The "tight feeling" in the eyebrow area could represent:
  • Orbital compartment syndrome from retrobulbar hemorrhage
  • Frontal sinus fracture with associated soft tissue swelling
  • Supraorbital nerve compression from expanding hematoma or edema
  • Early sign of increased intracranial pressure with periorbital edema 1, 3

Assess for Neurological Deterioration

• Perform immediate neurological examination using Glasgow Coma Scale and pupillary assessment to compare against baseline 1, 2
• Repeat neurological assessments at least hourly, as 15% of patients with cerebral hematoma deteriorate within the first hour and 30-40% experience hematoma expansion in the first few hours 1, 2
• Document any focal neurological deficits, changes in level of consciousness, or signs of herniation 1, 3

Urgent Imaging

Obtain Immediate CT Imaging

• Order non-contrast head CT immediately to assess for hematoma expansion, new hemorrhage, or mass effect 4, 1, 2
• The high rate of early neurological deterioration following cerebral hematoma is related to active bleeding that may proceed for hours after symptom onset 4
• Consider CT angiography to identify patients at high risk for hematoma expansion based on contrast extravasation 4, 1

Evaluate Orbital and Facial Structures

• Include dedicated orbital and facial bone windows on CT to assess for:
  • Orbital fractures
  • Retrobulbar hemorrhage
  • Frontal sinus fractures
  • Supraorbital rim fractures 1

Neurosurgical Consultation

Contact Neurosurgery Immediately

• Obtain urgent neurosurgical consultation regardless of imaging findings, given the patient's existing cerebral hematoma and new symptoms 4, 1, 2
• Do not delay consultation or transfer - cerebral hematomas can expand rapidly and cause herniation within hours 1, 3
• Lack of critical care beds should never be a reason for refusing admission for patients requiring emergency evaluation 4, 1

Specific Indications for Urgent Intervention

• New onset of acute hydrocephalus requires urgent neurosurgical consultation for possible external ventricular drain placement 4
• Cerebellar hemorrhage with altered level of consciousness or new brainstem symptoms requires urgent neurosurgical referral 4, 5
• Evidence of hematoma expansion or deteriorating neurological status may require surgical evacuation 4, 1, 2

Maintain Cerebral Perfusion

Hemodynamic Management

• Maintain systolic blood pressure >100 mmHg to ensure adequate cerebral perfusion 4, 1, 2, 3
• Establish large-bore IV access if not already present 1
• Avoid hypotension, which is a critical cause of secondary brain injury 1, 3

Airway and Oxygenation

• Maintain oxygen saturation above 94% to prevent cerebral hypoxia 1, 3
• Consider intubation if GCS ≤8 or signs of neurological deterioration develop 1, 2, 3

Critical Pitfalls to Avoid

• Never delay surgical consultation or ophthalmologic evaluation - new symptoms in a patient with known cerebral hematoma represent potential emergency until proven otherwise 1, 2
• Do not assume the eyebrow tightness is simply soft tissue swelling without ruling out vision-threatening orbital compartment syndrome 1
• Do not wait for neurological deterioration to occur before arranging transfer or consultation - proactive evaluation improves outcomes 1, 2
• Avoid performing lumbar puncture, as it can precipitate herniation in patients with intracranial hemorrhage 1