Brain Bleed

A friend of mine recently experienced a brain bleed. Initially, when his wife shared the news with me, I immediately suspected an auto accident; but the reality was far different. He was slammed by a rogue wave while boogie boarding two weeks prior. He hit his head on the ocean floor, but did not lose consciousness.

His initial symptoms were headache and neck stiffness, which began to resolve a few days later. He does have a history of migraines, which were often relieved by chiropractic adjustments. In fact, for the past 10 years he had been seeing a chiropractor and the adjustments were helping him manage his migraine headaches.

In this case, he was planning to see his chiropractor if his headache and neck stiffness did not resolve, but his symptoms improved over a couple of days. Feeling better, he decided to join his paddling club for a strenuous three-hour, open-ocean practice.

Now, one might assume that he must be a reckless, foolhardy jock, but keep in mind he is a retired ER nurse. Despite his medical background, he didn’t consider his injury serious enough to warrant concern, especially since his symptoms were improving. I must add that he is a very active 62-year-old who regularly cycles, surfs, paddles and hikes. So, strenuous paddle practice is generally no big deal to him.

However, when he got home from paddling practice, he was fatigued, and the headache had returned with a vengeance. All he wanted to do was go to bed and rest.

His wife, also a retired ER nurse, wanted him to go to the ER right away, but he refused. He just wanted to get some rest. Hours later he was awake, but she noticed that he was losing his balance while walking. Against his will she called the paramedics. In brief, a CT scan revealed a brain bleed (see image) and he was medevacked to a trauma center for emergency surgery to relieve the pressure on his brain. Thankfully, he didn’t experience any lasting neurological deficits after the procedure.

Chiropractic Relevance

Generally, I avoid discussing clinical histories that are out of my area of expertise, but I feel this is a problem that could be missed or misdiagnosed, in particular in older adults. Think of this article as a warning to anyone over age 60.

Older adults are at higher risk of traumatic intracranial bleeding because there can be a loss of the elastic integrity of the cerebral bridging veins and brain atrophy, allowing rapid movements of the brain within the cerebral spinal fluid with trauma to tear vessels. Even minor head trauma can cause tearing of blood vessels over the surface of the brain, resulting in a slow “leak” of blood.

Since there is no place for the blood to go, it accumulates and begins to displace the brain. Initially this may not cause significant symptoms, but as the volume of blood accumulates, the most common complaint is headache, seen in up to 80% of patients. Other symptoms include lethargy, memory impairment, confusion, weakness, nausea, vomiting, impaired vision, and seizures. Patients with large hematomas may develop varying degrees of paralysis and coma.

By the time my friend was loaded onto the helicopter, he had lost control of his extremities and was fading into a coma; he doesn’t remember anything that happened to him for a 48-hour period. Things can happen very quickly.

Chronic subdural hematoma may mimic several other brain disorders, including dementia, stroke, encephalitis, and brain lesions such as tumors or abscesses. If the history of trauma is not reported or not known, the patient can be easily misdiagnosed. Older adults may also be less able to withstand intracranial bleeding because of pre-existing comorbidity, frailty, and polypharmacy.

We all are vulnerable to this type of injury even if we are not physically very active. Falling and hitting your head, especially when older, can be catastrophic. My friend was lucky. He had a trained partner who recognized the signs of a brain injury. This incident is interesting because he seemed to be recovering, but there was a slow leakage of blood. Apparently, the exertion from the paddling exacerbated the problem.

I wonder if he were my patient if I would have considered a bleed. He had a history of headaches associated with a stiff neck. Certainly, the key to the diagnosis was knowing he had recent head trauma. Would he have told me about the injury? Would I have asked the question? I certainly hope so.

Falling on level ground is the most common cause of traumatic intracranial bleeding.¹ Falling associated with intracranial bleeding in older adults is increasing. The mortality rate of fall-associated intracranial bleeding is 15%.² One of the biggest problems with older adults ending up in the emergency room is how to triage these patients. Older patients cannot always give a history of what happened. Falls are frequently unwitnessed. The ER is often overcrowded and the CT scanner backed up with patients.

Older patients are at greater risk of developing delirium the longer they stay in the ER. There are clinical decision rules that help identify the patient who needs a CT to rule out intracranial bleeding and those who do not.³ However, these rules are only tools and are still up for debate.⁴

The most common strategies for ruling in / out a possible brain bleed are the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC) and CT in Head Injury Patients rule (CHIP). I am not going to review any of these rules in this article (note the references), but suffice it to say that none is perfect, even along with using the Glasgow Coma Scale (GCS).⁵

Most of the time a CT scan will demonstrate a brain bleed easily, although of course rarely there can be the outlier; the patient who has a negative CT scan initially and then goes on to develop a bleed hours later.⁶ Waiting for further symptoms to develop is never appropriate and can be life threatening.

At the end of the day, determining which patient with minor head trauma should get a CT is difficult. Emergency departments are required to render cost-effective service and at the same time provide the sensitivity and specificity of identifying patients who require imaging and possible neurosurgery. The uncertainty regarding long-term functional outcomes after minor head trauma should justify the routine use of CT in all older patients with minor head trauma.⁷

From what I can discern from reviewing the recent information, my humble opinion is to forget all the different strategies for triaging an older patient presenting with symptoms (especially headache) from minor head trauma; just get the CT scan.

Takeaway Points

• Older adults with a history of minor head trauma should have a CT if they have any symptoms, particularly headache, which is present 80% of the time.
• Even patients with a medical background may not be capable of assessing their condition when they have suffered minor head trauma.
• Emergency departments have been mandated to be cost-effective and still render the appropriate services. When a patient is sent to the ER, they need to be accompanied by an advocate or followed up quickly.

References

1. Chan V, Zagorski B, Parsons D, Colantonio A. Older adults with acquired brain injury: a population-based study. BMC Geriatr, 2013 Sep 23;13:97.
2. Fu WW, Fu TS, Jing R, et al. Predictors of falls and mortality among elderly adults with traumatic brain injury: a nationwide, population-based study. PLoS One, 2017 Apr 21;12(4):e0175868.
3. de Wit K, Mercuri M, Clayton N, et al. Which older emergency patients are at risk of intracranial bleeding after a fall? A protocol to derive a clinical decision rule for the emergency department. BMJ Open, 2021 Jul 2;11(7):e044800.
4. Ibid.
5. https://my.clevelandclinic.org/health/diagnostics/24848-glasgow-coma-scale-gcs
6. Hadjigeorgiou GF, Anagnostopoulos C, Chamilos C, et al. Patients on anticoagulants after a head trauma: is a negative initial CT scan enough? Report of a case of delayed subdural haematoma and review of the literature. J Korean Neurosurg Soc, 2014;55(1):51-53.
7. Smits M, Dippel DW, Nederkoorn PJ, et al. Minor head injury: CT-based strategies for management - a cost-effectiveness analysis. Radiology, 2010 Feb;254(2):532-40.