Ms. Patterson is a 68-year-old woman with a history of hypertension who was at home when she developed a sudden-onset severe headache with vomiting. She called 911 but was obtunded on arrival of emergency medical services and could give no further history. She was brought to the emergency department (ED) within 40 minutes of the onset of headache. On arrival to the ED, her blood pressure is 205/110 mmHg and her heart rate is 90; she is taking shallow breaths with a respiratory rate of 32 breaths per minute with an oxygen saturation of 94%. She has a fixed pupil on the left and does not withdraw from painful stimulus on the right. Her family arrives 20 minutes later, and by then a computed tomography (CT) scan has been performed, showing a 7-cm intracerebral hemorrhage (ICH) with a “spot sign” on the CT angiogram. The spot sign describes an area of contrast enhancement within a hemorrhage that serves as an independent predictor of ICH expansion and poor outcome. On return from the CT, she has a Glasgow Coma Scale of 7.