What criteria should I use to determine whether a patient with an intracerebral haemorrhage requires urgent referral to a neurosurgical unit?

Criteria for urgent referral of a patient with intracerebral haemorrhage to a neurosurgical unit include:

• Presence of hydrocephalus or rapid neurological deterioration associated with lobar haemorrhage.
• Large haemorrhage in a patient without significant comorbidities before the stroke.
• Glasgow Coma Scale (GCS) score of 8 or above, unless a low score is due to hydrocephalus.
• Posterior fossa haemorrhage generally requires urgent neurosurgical assessment.
• Patients with clinical signs suggesting the need for decompressive hemicraniectomy, such as decreased level of consciousness and large infarct volume, should be considered for urgent neurosurgical intervention.

Patients with small deep haemorrhages or lobar haemorrhages without hydrocephalus or rapid deterioration rarely require surgical intervention and usually receive medical treatment initially.

Referral decisions should be made urgently and involve discussion with a specialist neurosurgical centre.

These criteria are based on the NICE guideline on stroke and transient ischaemic attack management, which highlights the importance of neurological status, haemorrhage size and location, and presence of complications such as hydrocephalus in determining the need for neurosurgical referral ³.