If a TBI patient shows a midline shift on CT, what is a reasonable next step?

• A. Observation and continued monitoring only.
• B. Surgical decompression may be required.
• C. Immediate corticosteroids despite guidelines.
• D. Administer hyperventilation indefinitely.

Answer: (B)

A midline shift on CT signals significant mass effect from bleeding or swelling, meaning the brain is being pushed away from its normal position and the pressure needs to be relieved promptly to prevent damage or herniation.

In this situation, a reasonable next step is neurosurgical evaluation for possible decompression or evacuation of the accumulating lesion. Removing the source of pressure and creating more space for the swollen brain can directly reduce intracranial pressure and improve outcomes.

Corticosteroids are not recommended in adult traumatic brain injury, so giving them immediately would not be appropriate. Hyperventilation can reduce ICP temporarily, but using it indefinitely is dangerous and can lead to reduced cerebral blood flow and ischemia; it should be reserved for short-term, tightly monitored use in specific urgent scenarios, not as a long-term plan. Observation alone would not address the mass effect indicated by the shift.