Chronic Brain Hemorrhage: Delayed Diagnosis and Treatment Options

Chronic cerebral hemorrhage with hematoma compressing the brain?

Hello Dr.
Zhang, my father (born in 1943) had a severe head injury from a fall down the stairs at the end of August, resulting in significant bleeding that required emergency care.
A CT scan at that time showed only minor intracranial bleeding, so the emergency physician sutured the external wounds and advised us to monitor him at home.
During his recovery, our family noticed that my father exhibited signs of cognitive confusion.
When we followed up with the neurosurgery department, I expressed my concerns and asked if further examinations were necessary.
The neurosurgeon stated that cognitive decline is common in older adults and that if there were serious intracranial issues, there would be noticeable external symptoms, such as sudden inability to walk.
Therefore, we continued to observe him at home.
However, my father's condition deteriorated further; he began to have incontinence and even played with his feces.
In early November, he experienced facial convulsions resembling seizures, prompting another trip to the emergency room.
A CT scan revealed that the intracranial hematoma had expanded to occupy nearly one-third of his brain.
The consulting neurosurgeon explained that if surgery were performed to drain the hematoma, it would only restore his condition to what it was 3-4 days prior.
While the surgery had a high success rate, there were risks involved, but he could not specify what those risks were and advised us to assess the situation ourselves.
We felt unqualified to make such an assessment and, fearing the risks of major brain surgery, ultimately decided against it.
Instead, he was placed in the intensive care unit and treated with anti-hemorrhagic medications.
Today, the neurosurgeon called to inform us that my father's condition is stable and he can be discharged (though the nurse mentioned that he has not shown much awareness).
When I asked the doctor if they had checked for a reduction in the hematoma before deciding on discharge, he said no examination was done and that it was unnecessary, but he would arrange for one if we wanted.
Dr.
Zhang, I would like to ask if we have missed the window for effective treatment and what the best course of action would be moving forward for a hopeful outcome? Thank you for your response.

Qiu Xiansheng, 30~39 year old female. Ask Date: 2022/11/22

Dr. Zhang Junwei reply Neurosurgery

Without detailed CT scans and neurological examinations, it is not possible to determine an accurate treatment plan.
It is recommended to bring the discharge summary and CT scans to an outpatient appointment for discussion with the physician.

Reply Date: 2022/11/22

More Info

Chronic brain hemorrhage, particularly following a traumatic event such as a fall, can lead to significant complications if not diagnosed and treated promptly. In your father's case, the initial CT scan indicated only minor intracranial bleeding, which may have led to a false sense of security. However, the subsequent deterioration in his cognitive function and the eventual discovery of significant hemorrhage occupying a large portion of his brain highlights the complexities involved in diagnosing and managing such conditions.

When a patient experiences a head injury, it is crucial to monitor for symptoms that may indicate worsening conditions, such as confusion, memory loss, changes in behavior, or motor function deficits. In older adults, these symptoms can sometimes be attributed to normal aging or dementia, which can lead to underestimating the severity of a brain injury. This misjudgment can delay necessary interventions, as seen in your father's case.

The delayed diagnosis of chronic brain hemorrhage can occur for several reasons. First, the symptoms may not present immediately after the injury, leading caregivers and medical professionals to overlook the need for further evaluation. Second, the subtlety of cognitive changes can be mistaken for age-related decline, as was suggested by the neurologist in your father's case. It is essential for caregivers to advocate for further imaging or evaluations if they notice significant changes in a patient's condition, especially after a head injury.

In terms of treatment options, surgical intervention, such as decompressive craniectomy or hematoma evacuation, can be necessary to relieve pressure on the brain and restore function. However, as you noted, these procedures carry risks, including infection, bleeding, and neurological deficits. The decision to proceed with surgery should involve a thorough discussion of the potential benefits and risks, ideally with a neurosurgeon who can provide detailed information about the specific circumstances of the case.

If your father is currently stable but not fully conscious, it is crucial to continue monitoring his condition closely. Rehabilitation services, including physical therapy, occupational therapy, and speech therapy, may be beneficial in helping him regain lost functions. Additionally, supportive care in a skilled nursing facility may be necessary if he requires assistance with daily activities.

It is also important to consider follow-up imaging studies to assess the status of the hematoma and any potential changes in his brain condition. If the current medical team is not providing the level of care or information you feel is necessary, seeking a second opinion from a different institution or a specialized neurosurgeon may be warranted.
In summary, the management of chronic brain hemorrhage requires vigilance, timely intervention, and a collaborative approach between caregivers and healthcare providers. Your father's case underscores the importance of advocating for appropriate medical evaluations and treatments, especially in the context of head injuries. Moving forward, ensure that any changes in his condition are communicated clearly to his healthcare team, and do not hesitate to seek further evaluations if you feel they are necessary.

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