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HomeAnswersNeurosurgerysubdural hemorrhageCan subdural hematoma be cured by medicines alone?

Can subdural hematoma be cured by medicines alone?

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The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.

Medically reviewed by

iCliniq medical review team

Published At December 19, 2017
Reviewed AtJune 30, 2023

Patient's Query

Hello doctor,

Please go through and advise. Acute on chronic subdural hemorrhage in bilateral cerebral convexities measuring 0.7 inches on the right side and 0.5 inches on the left side. The mass effect is noted in the form of effacement of adjacent sulcal spaces and compression of ventricles. A thin rim of subdural hematoma is seen along the lateral convexity of the left cerebellar hemisphere, with maximal thickness measuring about 4 mm. The C.P. Angeles and posterior fossa contents are normal. The basal cisterns and Sylvian fissures are normal. The sella, parasellar and suprasellar regions are normal.' Immediate surgery was recommended by the doctors. The suspected cause is the use of Ecosprin 150 for the last three months. It was prescribed when last admitted for high sugar levels, which caused stroke symptoms. But, the brain CT(Computer Tomography) was normal at that time. The patient has been diabetic for the last 35 years on insulin. Please advise if surgery is needed or if it can be cured with medications. How critical is this condition, and is it risky to delay? Is this a major or minor surgery? How will it be done?

Hello,Welcome to icliniq.com.

Surgery is absolutely indicated in this case. This hematoma cannot be cured with medications. Surgery should not be delayed as there is a possibility of permanent brain damage if the mass effect is not relieved. This is usually a minor surgery. Burr holes and drainage is the usual operation in most cases. In some cases, when there are membranes in the hematoma, a craniotomy may be required to prevent a recurrence. In addition to the surgery, Ecosprin (Aspirin) should be stopped immediately. It can be restarted at a later date, depending on its need.

Patient's Query

Hello doctor,

Thank you for the reply,

Sorry for the delayed reply. Thank you very much for the timely advice, due to which we could take a decision to go ahead and get the surgery done. The patient was discharged from the hospital last Friday. As you anticipated, the burr hole was made on one side, and the craniotomy on the other. The CT report after surgery is attached herewith for your review. The questions on it are:

1. A residual SDH of 7 mm on the left side is present, and we were told this is the best possible with a burr hole. Is this a concern for recurrence?

2. Residual SDF on right side 1.7 cm with a large air pocket. Are there any implications of this in terms of becoming an SDH?

3. Midline shift of 9 mm. I am not sure if there is a concern here.

4. The day after the surgery, the patient became very normal with speech clarity and response, but days after that, he was dull, tired, and not speaking out much. Is this a concern?

I would be grateful if you could let us know your opinion on the above. Aspirin has been stopped until the next review, which is ten days from discharge for stitches removal.

Hello,

Welcome back to icliniq.com.

It depends on the condition of the patient. If the patient is alright, we can wait. If the patient has residual symptoms, we may need to re-explore.

For further queries, consult a neurosurgeon online.

Patient's Query

Hi doctor, Thank you for the reply,

The patient went through craniotomy surgery again for the second time. Since he was unable to move his left hand and left leg. So the CT (Computed Tomography) scan on showed his condition necessitating surgery, and he went through the same. Subsequent to the surgery, a CT scan and MRI( Magnetic Resonance Imaging) was taken, and we were informed that he would do fine (but his recovery would take its time) and hence could be discharged. He was doing fine in terms of food intake and other activities though he had to be supported with assistance. Since then, he had a mild fever and shivering, followed by which he was unconscious for more than 24 hours, but again he opened his eyes and recognized people, and tried to speak. He is taking food and medicine orally in liquid form and is able to swallow the same. But he is falling asleep again, and his left hand has no action. He has a sensation in the left hand but no movement.

Please advise on the next steps.

Hi, Welcome back to icliniq.com.

I have gone through all the attached reports (attachment removed to protect the identity). The CT (computed tomography) scan states that there is still residual subdural hematoma. In view of the change in the neurological status, I suggest that we repeat a CT scan of the brain and evaluate the patient for any abnormalities in metabolic parameters such as sodium and potassium. The CT scan shows significant hematoma with mass effect and midline shift equal to what it was before or more than what it was before. He might need to re-exploration of the craniotomy and evacuation of the hematoma.

Patient's Query

Hi,

Thank you for the reply,

The sodium and potassium were verified after the surgery and found to be normal. CT and MRI were done, after which we were told that he was fine and was discharged. But your point is that there is still hematoma and more than the earlier mid-line shift. Please advise the MRI and CT also indicate that the reexploration of craniotomy and evacuation of hematoma is needed. Thanks in advance for your kind consideration and support.

Hi,

Welcome back to icliniq.com.

I have seen the MRI (magnetic resonance imaging) and a CT (computed tomography) scan (attachment removed to protect the patient's identity). Since there has been a change in consciousness level. I suggest we repeat a CT (computed tomography) scan of the brain to see if there is been any change in the size of the hematoma in the midline shift. The sodium and potassium levels, although normal immediately after surgery, vary from time to time and need to be checked again. We need to identify the causes of unconsciousness or altered consciousness. It could be either an increase in the hematoma and the midline shift or some metabolic disturbance. Only when the cause of altered consciousness is identified can it be treated appropriately.

Patient's Query

Hi doctor, Thank you for the reply,

As per your advice, we admitted the patient again to the hospital, he was taken to the emergency, and it was found that Sodium and Potassium levels were normal. Later he was taken into the ICU(Intensive care unit) to date, he is in ICU, and there has been no change in his status. He remains to be unconsciousness till date. I have attached the MRI (Magnetic Resonance Imaging), CT (Computed Tomography) scan reports, and the doctor’s letter stating his current condition. Please advise on the below: Septic Encephalopathy – What could be the reason for the same? Urosepsis and Pneumonia – Were these two that led to Septic Encephalopathy? SDH – Doctors say that this condition remains the same as what it was when he was discharged. And this is not the reason for his altered consciousness or unconsciousness today. How critical is the residual Sub Dural collection at the right frontal region and thin SDH (Sub Dural Haemorrage) in the right parietal region? Does he have to go for another surgery? But the doctors do not see a need for this. Post-traumatic epilepsy – Why is this caused? What will be the impact of the same on his lifestyle? Continuous EEG (Electroencephalogram) is planned to rule out NCSE(Non Convulsive Status Epilepticus). What will be the impact of Non-Convulsive Status Epileptics on his lifestyle? Meningitis – It is mentioned in the MRI scan as suggestive of Meningitis. How critical is this? And why might this have been caused? Will the current medications resolve the same? Medication: Levera 500mg - Anticonvulsant Artacil - skeletal muscle relaxation Magnex Forte – Bacterial infection Aneket Injection - Anesthetic Trofentyl – 10ml – Anesthetic Acivir Injection - Infection Valprol 100mg – Anti seizure Levipil 500mg – Anti seizure Duolin Respules – Pneumonia Fristum 10mg – Sleeping dose Rexite Plus – Nerve damage Rantac 150mg - Acidity Tracheostomy. We were told that this was to keep the patient from Ventilator. But was this necessary in the current condition? Will this not lead to additional chances for further infection? Will the current treatment regime involving antibiotics and anti-epilepsy medications good enough to resolve the infection, and will he be back to normal once the infection is cleared? How long will this likely take? Is this condition a life threat?

Hi, Welcome back to icliniq.com.

I have gone through all the reports (attachment removed to protect the identity).I have the following observations to make:1) Septic Encephalopathy – What could be the reason for the same? Urosepsis and Pneumonia – Were these two that lead to Septic Encephalopathy? Urosepsis or pneumonia can lead to septic encephalopathy. We have to see the circumstances and reasons that led to these? Was the patient on urinary catheter? if so, were appropriate precautions taken to prevent infection? Was the patient taking oral feed or through the nasogastric (Ryle's) tube? were appropriate precautions taken to prevent aspiration pneumonia? Urosepsis and aspiration pneumonia are the two common causes of infection following surgery in elderly patients. If we do not take appropriate precautions, they can be life threatening. 2) SDH – Doctors say that this condition remains the same as what it was when he was discharged? And this is not the reason for his altered consciousness or unconsciousness today. How critical is the residual sub dural collection at the right frontal region and thin SDH in the right parietal region? Does he have to go for another surgery? But the doctors do not see a need for this. I agree with the treating doctors that the residual subdural seems to not contribute to his current unconscious state. Usually, following surgery for chronic subdural hepatoma, some amount of residual hematoma is expected. The hematoma resolves over a period of two to three months. As long as the residual hepatoma is not infected and not causing any pressure on the underlying brain, it need not be evacuated again. 3) Post traumatic epilepsy – Why is this caused? What will be the impact of the same in his lifestyle? Continuous EEG is planned to rule out NCSE. What will be the impact of Non-Convulsive Status Epileptics on his life style? There are a number of reasons for seizures in this patient. the presence of the residual hematoma itself can be an irritating factor to the underlying brain. sepsis can also contribute to seizures. If controlled appropriately, it usually does not affect the long term outcome 4) Meningitis – It is mentioned in the MRI (magnetic resonance imaging) scan as suggestive of Meningitis. How critical is this? And why this might have been caused? Will the current medications resolve the same? Meningitis is infection of the coverings of the brain. It is a serious condition and can be life threatening. However, one should not believe the MRI blindly. Meningeal enhancement is also seen in chronic subdural hematoma where the hematoma membranes can enhance. So, one needs to correlate the mai findings with the clinical status. In this patient, although one cannot conclusively say, the presence of normal CSF (cerebrospinal fluid) on lumbar puncture indicates that meningitis is unlikely. 5) Medication: Levera 500mg (Levetiracetam) - Anticonvulsant. Artacil (Atracurium Besylate) - skeletal muscle relaxation. Magnex Forte (Sulbactam and Cefaperozone) – Bacterial infection. Aneket Injection (Ketamine Hydrochloride) - Anesthetic. Trofentyl – 10ml – Anesthetic. Acivir (Acyclovir) Injection - Infection. Valprol 100mg (Sodium Valproate) – Anti seizure. Levipil (Levetiracetam) 500mg – Anti seizure.

Duolin (Ipratropium Bromide) Respules – Pneumonia. Fristum 10mg (Clobazam) – Sleeping dose. Rexite Plus (Methylcobalamin) – Nerve damage. Rantac 150mg (Domperidone and Ranitidine) - Acidity. These are appropriate 6) Tracheostomy – We were told that this is to keep the patient from Ventilator? But was this necessary in the current condition? Will this not lead to additional chances for further infection? Tracheostomy helps in tracheal suction and removal of the tracheal secretions. It is absolutely necessary in this patient given his unconscious state. 7) Will the current treatment regime involving antibiotics and anti-epilepsy medications good enough to resolve the infection and will he be back to normal once the infection is cleared? How long will this likely to take? Is this condition a life threat? I believe that the current treatment regime is appropriate. I would want to wean the patient off ventilator as soon as possible so that we can start rehab. It is difficult to predict how long it is going to take and how much the patient will improve. However, we need to continue supportive treatment aggressively.

Patient's Query

Hi doctor, Thank you very much for your review and suggestions.

To answer your questions: We have to see the circumstances and reasons that led to these. Was the patient on a urinary catheter? If so, were appropriate precautions taken to prevent infection? Was the patient taking oral feed or through the nasogastric (Ryle's) tube? Were appropriate precautions taken to prevent aspiration pneumonia? No, the patient was not on the urinary catheter. When he was conscious, he passed urine at night in the bed most time, and when he went unconscious, adult diapers were used. The patient was taking oral feed. But I think the oral feed given even after he went unconscious was the mistake causing the aspiration pneumonia. I believe that the current treatment regime is appropriate. I would want to wean the patient off the ventilator as soon as possible so that we can start rehabilitation. Exactly this is the concern currently as of now. The doctors are saying that he will not be able to survive even five to six hours if he is taken off from a ventilator. I am not worried about him being in rehabilitation for whatever time it is necessary, but the statement that he will not survive without a ventilator is putting us under a lot of stress. Please advise.

Hi doctor,

Welcome back to icliniq.com.

"But I think the oral feed given even after he went unconscious was the mistake done causing the aspiration pneumonia". I believe this could have led to the chest infection. "The doctors are saying that he will not be able to survive even five to six hours if he is taken off from the ventilator." It is difficult to understand why he would be so bad. If the infection is in control, he should gradually be able to come off the ventilator.

Same symptoms don't mean you have the same problem. Consult a doctor now!

Dr. Ambekar Sudheer
Dr. Ambekar Sudheer

Neurosurgery

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