Intracranial Hemorrhage: Recovery and Care Insights

Q: Intracranial Hemorrhage: Recovery and Care Insights

Hello： In response to your question, I appreciate your deep concern for this patient. <br>It is rare for someone other than close relatives to observe so attentively, and I am truly touched. <br><br>(1) He has a traumatic brain hemorrhage and has undergone a right craniectomy due

Intracranial hemorrhage

Hello Dr.
Shao: My friend had a motorcycle accident on December 4, 2003, resulting in an intracranial hemorrhage (ICH).
He underwent a craniotomy the next day, and a piece of his skull was preserved in cold storage.
He had an endotracheal tube and a nasogastric tube.
He was in a coma for several days post-surgery and was transferred to a general ward about two weeks later.
He is no longer intubated and is currently on IV fluids only.
He cannot speak but can write, and from what he has written, it seems his memory is intact.

* There is a swollen area on the right side of his head.
When the head of the bed is elevated for about 10 minutes, the swelling appears to shift.
Should we avoid sitting him up to prevent this?
* Since he has sustained an injury to the right side of his brain, the left side of his body is weak and completely immobile, although he can feel when pressure is applied.
Is there a chance for recovery on the left side as the hematoma resolves? What can we do to help improve his condition?
* He has been unable to produce any sounds.
Could this be due to damage to the speech center or a result of having been intubated?
* He tends to fall asleep shortly after we talk to him.
Why does this happen? He wakes up approximately every 30 minutes but falls asleep again within 10 to 20 minutes.

* His right eye is very swollen and difficult to open.
What could be the cause?
* He can eat some soft foods, such as porridge, small pieces of apple, and cake, but he cannot chew on the left side.
If he tries to drink water through a straw, he easily chokes.
Does this indicate a swallowing dysfunction? Why is that?
* In terms of nutrition, what foods would be suitable for him?
* He has a lot of phlegm and cannot cough it up on his own; he ends up swallowing it back down.
Sometimes, suctioning is required about 4 to 5 times a day.
Why is there so much phlegm, and why can't he cough it out?
* After the surgery, he experienced significant body swelling while in the intensive care unit.
What could be the reason for this?
Thank you, Dr.
Shao, for your attentive responses.

Xiao You, 20~29 year old female. Ask Date: 2003/12/22

Dr. Shao Guoning reply Neurosurgery

Hello: In response to your question, I appreciate your deep concern for this patient.
It is rare for someone other than close relatives to observe so attentively, and I am truly touched.

(1) He has a traumatic brain hemorrhage and has undergone a right craniectomy due to injury in the lateral brain region.
This explains the weakness on the left side of his body, which may present as mild hemiparesis.
Rehabilitation can assist with recovery, which is expected to occur within three to six months.

(2) The language center is typically located in the left hemisphere of the brain (the dominant hemisphere), so speech function is likely to recover earlier than motor function.
This will require the assistance of a speech-language pathologist.

(3) The right side of his head is missing a piece of bone, and the contents will shift with changes in position, which is a normal phenomenon.
However, if there is asymmetrical swelling, it may indicate elevated intracranial pressure, and further investigation is needed.
Once his consciousness and neurological functions stabilize, a cranioplasty will be necessary to repair the skull.

(4) Currently, the brain may still be swollen, and his periods of wakefulness will not be very long.
It requires repair and rest.
I recommend starting initial rehabilitation three weeks after Christmas, gradually increasing the intensity, and then incorporating speech therapy.
He still needs plenty of rest at this time.

(5) His ability to cough up phlegm and swallow is intact (as the brainstem is unaffected), but his coordination is poor.
Therefore, attentive nursing care is crucial during this period to prevent choking, which is the most dangerous complication and can lead to aspiration pneumonia.
Eating should be based on his clinical condition; I suggest starting with a straw for water, then trying small pieces of pudding, followed by thin porridge, etc.

In summary, he is somewhat fortunate amidst his misfortune, and significant progress should be expected within three months.
He should be able to walk and speak normally within six months.
As for whether he will regain his pre-injury cognitive abilities, this will depend on the CT scan results, which will show the extent and location of the injury.
Wishing him a speedy recovery.

Reply Date: 2003/12/22

More Info

Understanding intracranial hemorrhage (ICH) and the recovery process can be complex, especially following traumatic events such as motorcycle accidents. Your friend's situation involves several critical aspects that need to be addressed for a comprehensive understanding of recovery and care.

Recovery from Intracranial Hemorrhage
1. Initial Recovery Phase: After a significant event like ICH, patients often undergo surgery to relieve pressure on the brain. In your friend's case, the fact that he underwent craniotomy and had a portion of his skull preserved indicates the severity of his condition. Post-surgery, it is common for patients to remain in a comatose state for several days. The transition from intensive care to a general ward is a positive sign, indicating some stability.

2. Neurological Assessment: The ability to write suggests that his cognitive functions, particularly memory, are intact, which is encouraging. However, the inability to speak and the weakness on the left side of his body are indicative of damage to the right hemisphere of the brain, which is responsible for motor control on the opposite side of the body and may also affect language processing.

3. Physical Rehabilitation: As the hematoma resolves, there is potential for recovery of function on the affected side. Engaging in physical therapy as soon as it is safe can help stimulate recovery. Techniques may include passive range-of-motion exercises, electrical stimulation, and eventually active exercises as strength returns.

4. Speech and Swallowing Issues: The inability to produce sound could stem from damage to the areas of the brain responsible for speech or could be a result of the intubation process. Speech therapy is crucial in such cases to assess and rehabilitate speech and language skills. The swallowing difficulties you mentioned, such as choking on liquids, suggest dysphagia, which is common after brain injuries. A speech therapist can conduct a swallowing evaluation and recommend safe swallowing techniques and dietary modifications.

5. Cognitive and Sensory Recovery: The swelling on the right side of his head could be due to post-surgical edema or hematoma. It’s important to monitor this closely. The fact that he falls asleep quickly after interaction may indicate fatigue, which is common in brain injury patients as their brains work harder to process stimuli.

6. Nutritional Needs: Nutrition plays a vital role in recovery. Soft foods that are easy to swallow, like porridge and mashed fruits, are appropriate. It’s essential to ensure he receives adequate hydration and nutrition, possibly through a feeding tube if swallowing remains a challenge.

7. Respiratory Care: The presence of excessive phlegm and difficulty coughing can be attributed to reduced respiratory function post-intubation. Regular suctioning and respiratory therapy can help manage secretions. Encouraging deep breathing exercises, if possible, can also aid in clearing the airways.

8. Post-Surgical Edema: The swelling observed post-surgery can be attributed to fluid retention and the body’s inflammatory response to trauma. This is typically managed with medications and monitoring fluid intake.

Conclusion
In summary, your friend's recovery from ICH will require a multidisciplinary approach involving neurology, rehabilitation, speech therapy, and nutritional support. Regular assessments by healthcare professionals will be crucial in determining the best course of action as he progresses. Encouraging family involvement in care and rehabilitation can also provide emotional support and motivation for recovery. It’s essential to maintain open communication with the healthcare team to address any concerns and adapt care plans as needed.

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