Neurology Q45

A 79-year-old man is evaluated for a 2-month history of progressively worsening headaches, nausea, visual disturbance, and difficulty speaking. He also has hypertension and gastroesophageal reflux disease. Medications are lisinopril and omeprazole.

On physical examination, vital signs are normal. Right oculomotor nerve (cranial nerve III) and bilateral abducens nerve (cranial nerve VI) palsies are noted, as is right upper and lower facial weakness.

An MRI of the brain shows a well-demarcated, homogeneously enhancing, hyperintense lesion that is suspicious for primary central nervous system lymphoma in the brainstem extending from the left pons to the medulla. Mass effect but no edema is present. The lesion obstructs the cerebral aqueduct, and hydrocephalus with enlargement of the lateral and third ventricles is noted.

Which of the following is the most appropriate next step in management?

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