Dr. Shivam Om Mittal
Neurology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
I am looking for a second opinion on my father's computed tomography (CT) scan (brain). He has been suffering from mild to severe headaches for about two weeks and is now diagnosed with a clot in his head that is causing a midline shift. I am uploading two sets of CT scan images, the first one on the 26th, where the midline shift was 0.48 inch, and the second scan on the 28th, which shows 0.37 inch. Please review the images and advise whether surgery is absolutely required at this stage. How long can they wait before surgery is to be decided? Can it be treated with medications as there is an improvement? He is still in intensive care, and his doctor is going to get another CT scan tomorrow. Meanwhile, I would like to get a second opinion.
Hello,
Welcome to icliniq.com. I am sorry to hear about your father. I have gone through the reports (attachment removed to protect patient identity). If the only symptom he has is this clot in the brain, and no other neurological symptoms such as weakness on the left side of the body or speech changes, then that is reassuring. He has a subdural hematoma, that is, an accumulation of blood outside the brain pushing on the brain tissue. The serial CT (computed tomography) scan shows some improvement, and if it is complemented by a good neurological exam, then I would not recommend surgery, and getting a follow-up CT of the head and a close neurological exam in the ICU (intensive care unit) will suffice. If there is any sudden worsening of symptoms, then he will need surgery. Also, the cause of bleeding should be identified. It could be due to alcohol consumption, blood thinners, or falls.
Patient's Query
Hello doctor,
Thanks for the quick response. He does not remember having any falls or injuries on his head, but he had an open heart surgery done six years ago and has been taking a blood thinner since. No alcohol consumption. The only symptom he has been having over the last two weeks was a headache and his blood pressure raised from 165 to 170. On 26th, he had vomiting and giddiness. So, he was taken to the intensive care unit (ICU). He is still under monitoring, and they temporarily stopped his blood thinners. Please advise what level of improvements in the follow-up computed tomography (CT) scan can be considered safe as compared to the midline shift of 0.48 inch on the 26th.
Hello,
Welcome back to icliniq.com. Yes, blood thinners can make him prone to this type of brain bleed. If he stays stable for the next three to four days with no worsening of bleeding on the computed tomography (CT) scan, then he can be safely discharged. The follow-up scan can be spaced at one month and then six months. With regards to blood thinner, it should be continued to be held until a consultation with a cardiologist is done.
Patient's Query
Thank you doctor,
Please also advise what level of improvements in the follow-up computed tomography (CT) scan can be considered safe as compared to the midline shift of 0.48 inch on the 26th. As per his doctor, they will be doing another scan tomorrow, and surgery will be necessary if the midline shift does not fall below 0.20 inch. In case it is going to be above 0.20 inch but has a significant difference from the previous 0.37 inch level, can they continue the intensive care treatment and monitor for a few more days?
Hello,
Welcome back to icliniq.com. This is my expert opinion, but I do not make decisions for craniotomy just on the basis of midline shift. If he clinically or neurologically has no other signs or symptoms and is improving, then the midline shift is fine. As I recommended earlier, a close follow-up with serial neurological exams and repeat CT of the head for the next few days is needed. If there is any worsening on the computed tomography (CT) head or clinical exam, then make the decision for craniotomy. They can continue the intensive care unit (ICU) monitoring even if the midline shift is 0.20 inch or 0.37 inch, depending on the clinical exam.
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