Head injuries can be divided into 2 groups:
Severe and Mild Head Injuries
SEVERE HEAD INJURY
The patients are often in a coma (symptoms include not opening eyes, talking or obeying commands). The primary objective of treatment is to minimize further (secondary) damages to allow the brain to naturally recover (Newspaper 4 and 5). The common causes of secondary
1. bleeding (extradural, subdural, subarachnoid, intracerebral or intraventricular hemorrhage),
2. brain swelling (cerebral oedema),
3. infection in the brain especially when there is leakage of brain water,
4. prolonged epilepsy,
5. low blood pressure (e.g. caused by bleeding in the abdomen or chest) or low oxygen (e.g. caused by lung injury).
Therefore, the blood clot may need to be removed. Drugs may be, needed to reduce brain swelling, treat infection or epilepsy. The blood pressure and oxygen levels in the body need to be well maintained. Recovery often takes a long time. Sometimes, weeks or months after the injury, too much water may accumulate in the brain requiring an operation to drain the water (see Testimonial 1, Waking up from vegetative state after head injury, Manimarium 24 year old Singaporean).
MINOR HEAD INJURY
Patients with minor head injury who have lost consciousness should be admitted to hospital for observation. Sometimes a scan of the brain, usually a CT scan, is needed. In children one should try avoiding unnecessary scans because of the radiation risk to the developing brain.But for the elderly, most of them are scanned because elderly brains are more fragile which may cause them to bleed easily. In addition, they are often on medications such as aspirin,ascardia or plavix, which may cause them to be prone to bleeding. My philosophy is: “If indoubt, scan”. Sometimes minor head injury patients may experience headache, giddiness, poor concentration or poor short term memory. This is called post-concussional syndrome. This will settle with time, occasionally taking several weeks or months. Piracetam (nootropil) may hasten a quicker recovery.
CHRONIC SUBDURAL HAEMATOMA
In older patients, sometimes blood clots develop only several weeks after the injury. In 50% of cases,there may not be even a history of any head injury. The symptoms are often weakness of the limbs,unsteady walking, speech problems or drowsiness. These are often misdiagnosed as strokes until a scan has been done. The treatment is simple and effective. One or two holes are drilled in the head to wash out the blood water (liquefied blood), which solves the problem. Nevertheless, because of the underlying problem of aging shrunken brain (cerebral atrophy), there is a small chance of recurrence (5-10% in the medical literature). To minimize the chance of recurrence, I often ask my patients to lie down and rest for several weeks. This helps the brain to expand and therefore minimizes the chance of recurrence. Patients often recover 100% and return back to their original condition.
Occasionally when the blood clot has not completely liquefied and has solid clot or when there are multiple compartments of the clot, the small hole (burr hole) needs to be extended to ensure complete removal of the clot. The results are usually good and even old patients in their 80’s can undergo this operation successfully (Newspaper 6).
Occasionally when the symptoms or problems from the bleeding are minimal, it may be possible to get away without the need for surgery.