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What Causes Recurrent Brain Hemorrhage?

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Posted on Sat, 5 Dec 2015
Question: my father is 70-72. he had brain hemorrage and after that undergone for 2 brain surgeries as after first again bleeding has been started. After 12 hr taking out sedative still he is not concious when we can expect pls suggest.
doctor
Answered by Dr. Olsi Taka (1 hour later)
Brief Answer:
Read below.

Detailed Answer:
Hello! I read your question carefully and I am sorry about your father's condition.

It would have been useful to have some more information about the hemorrhage specifics. You see there are several types of brain hemorrhages, like those in the brain surface and its layers (epidural hemorrhage, subdural hemorrhage, arachnoid hemorrhage) or inside the brain matter itself. Also the size matters a lot, a 20 ml hemorrhage doesn't have the same prognosis as a 80 ml one, the location as well as a small hemorrhage can be well tolerated when in the lobes and be catastrophic when in the brain stem. Whether there is blood in the inner ventricles is important as well.
I will stop there as I imagine this might sound confusing for a non professional, what I mean to say is that there are a lot of variables at play for the same diagnosis. If perhaps you could provide some CT report or any other document it would be great.

Judging only by the present info, it seems that the patient is in a coma and it is not related to the use of sedatives. Also I am assuming there are not other medical complications at play such as infections, respiratory failure, metabolic alterations (which also can influence the level of consciousness). The level of consciousness is a strong indicator of gravity and the fact he is in a coma indicates that either there is still residual blood after the surgery, or that the repeat hemorrhages have caused some lasting damage to the brain. So I am afraid that his life is very much threatened and there is a strong likelihood that even if he gradually improves some permanent damage will remain in the form of paralysis or cognitive decline.
If on brain imaging there is no major hemorrhage or destruction left one alternative explanation which should also be considered as a reversible cause of altered consciousness is the possibility of epileptic seizures which should be treated with antiepileptics. If that is not the case though as I said I am afraid there is some permanent damage.

I hope to have been understandable to you, as I said I understand there are many ifs and buts in my answer, but it would be hard I believe for any doctor to be more precise with the current info, it is a complex condition with many possible complications even with all the info at hand.

I remain at your disposal for further questions, possibly including some more details though.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka (1 hour later)
He is slightly responsive at feet and moved feet fingers. After the surgeries(24 hr) the CT scan showed less swelling and no more extra bleeding.
doctor
Answered by Dr. Olsi Taka (32 minutes later)
Brief Answer:
Read below.

Detailed Answer:
Hello again. The fact there is no more bleeding is good. It can be hoped that with the swelling subsiding gradually (doesn't happen overnight, takes several days), some cells which are alive but not functioning well due to the swelling and the compression will resume their function. The bigger the swelling the more the chances that some cells are irreversibly dead and leave some residual damage, I still do not know any info on the size and the location of the swelling.
So some patience is needed as there is no test which can tell us with precision the percentage of affected cells. The fact that you say there is some response, some movements, is positive. It depends also whether these movements are conscious or reflexive, if these movements are conscious ones (in response to verbal stimuli, obeys orders) it is even more heartening and improvement can be hoped.

I hope to have been of help.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka (2 hours later)
It's at left side. And the spot was 6 cm big. The swelling goes down but the movements are reflexive not conscious. Is it possible that it's just time that some patient took long and some recovers fast.
doctor
Answered by Dr. Olsi Taka (57 minutes later)
Brief Answer:
Read below.

Detailed Answer:
Thank you for that additional information. It seems to be the case of a hemorrhage in the brain matter, the parenchyma.

Hemorrhages of this type are often associated with swelling which continues for days, usually reaching its peak in the first week but in some patients it can continue for longer only to gradually subside later. So during these first days the situation is critical and his life at risk, both due to the mass effect of the swelling compressing the brain as well as to the risks of all critically ill immobilized patients (infections, thrombosis and pulmonary embolism, metabolic alterations, bed sores etc).

Gradually if things go well the swelling will gradually subside and some improvement is hoped, as I said before there are brain cells which are dysfunctional due to swelling and compression but still alive and will gradually resume function and try to compensate over time for the lost cells. 6 cm is a considerable size though, some brain cells will be irreversibly lost and chances are that some degree of invalidity will remain, in the form of a right sided paralysis and speech difficulties. The degree of improvement varies among individuals, only time will tell, recovery and rehabilitation will go on for many months. For now though he has to overcome this initial stage with the risks I mentioned above.
As you yourself say there are differences between patients recovery times, each patient has its individual characteristics, but in any case it won't be a long process which requires a lot of patience.

I hope things will work out for the best.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka (11 hours later)
Today they did MRI. In that it showes some spots at critical base area. Thats why they are assuming the delay in conciousness. Today he had reflexive movement in hand and vibration in eyes. There is no new bleeding in scans. But now the conciousness is the most important thing. What you will suggest for theses spots which sre in major functioning area. What can be done for them and conciousness.

Thanks
doctor
Answered by Dr. Olsi Taka (8 hours later)
Brief Answer:
Read below

Detailed Answer:
Thank you for the update.

I assume by critical base area you mean the brain stem. As I mentioned in my first answer it is the most delicate area where there is a dense concentration of nervous structures as well as the consciousness centers so even small lesions there can have dramatic consequences. I don't know whether by spots your doctors mean ischemic or hemorrhagic areas, perhaps more probably they mean ischemic areas due to the previous compression.

In terms of treatment anyhow, unfortunately there is nothing specific which can be done, if there has been prolonged ischemia there is no specific treatment to reverse the cells which are dead, it is not a question of a certain drug or a certain procedure. Management will be limited I am afraid in supporting vital functions, preventing critical illness complications which I mentioned before, in order to put your father's body in the best possible position to recover. How much will the unaffected brain be able to compensate in order to improve and regain consciousness and some other functions unfortunately is something which only time will tell. As I said brain stem is the most critical area, the more extensive these spots are the more difficult it will be to recover, without being able to view it hard to be more precise, hopefully their size is contained.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka (44 hours later)
Thanks for reply....the are taking out the ventilator to check if he is responding for that also they said that they don't know if recovery is possible or not...also they r not sure about time too. They said they even if he is OK without ventilator there is always danger.....today they took out the ventilator only giving oxygen to check it has been 5 hrs and he is doing fine...what u can suggest ...thanks
doctor
Answered by Dr. Olsi Taka (6 hours later)
Brief Answer:
Read below

Detailed Answer:
The fact he is doing fine without a ventilator is certainly good news. Often it is difficult to wean patients out of mechanical ventilation, and the longer they are intubated the harder it becomes to recover.

As for further suggestions as I said there are no major steps to be taken now, it is about monitoring vital functions, giving supportive care and preventing immobilization complications in order to help him recover, but the rest, the degree of recovery, will depend on the scale of damage caused (which again is hard for me to assess with no imaging and no report provided) and its brain response, the individual brain plasticity, which is the ability of the undamaged cells to form new connections to compensate for the lost cells.
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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Olsi Taka

Neurologist

Practicing since :2004

Answered : 3673 Questions

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What Causes Recurrent Brain Hemorrhage?

Brief Answer: Read below. Detailed Answer: Hello! I read your question carefully and I am sorry about your father's condition. It would have been useful to have some more information about the hemorrhage specifics. You see there are several types of brain hemorrhages, like those in the brain surface and its layers (epidural hemorrhage, subdural hemorrhage, arachnoid hemorrhage) or inside the brain matter itself. Also the size matters a lot, a 20 ml hemorrhage doesn't have the same prognosis as a 80 ml one, the location as well as a small hemorrhage can be well tolerated when in the lobes and be catastrophic when in the brain stem. Whether there is blood in the inner ventricles is important as well. I will stop there as I imagine this might sound confusing for a non professional, what I mean to say is that there are a lot of variables at play for the same diagnosis. If perhaps you could provide some CT report or any other document it would be great. Judging only by the present info, it seems that the patient is in a coma and it is not related to the use of sedatives. Also I am assuming there are not other medical complications at play such as infections, respiratory failure, metabolic alterations (which also can influence the level of consciousness). The level of consciousness is a strong indicator of gravity and the fact he is in a coma indicates that either there is still residual blood after the surgery, or that the repeat hemorrhages have caused some lasting damage to the brain. So I am afraid that his life is very much threatened and there is a strong likelihood that even if he gradually improves some permanent damage will remain in the form of paralysis or cognitive decline. If on brain imaging there is no major hemorrhage or destruction left one alternative explanation which should also be considered as a reversible cause of altered consciousness is the possibility of epileptic seizures which should be treated with antiepileptics. If that is not the case though as I said I am afraid there is some permanent damage. I hope to have been understandable to you, as I said I understand there are many ifs and buts in my answer, but it would be hard I believe for any doctor to be more precise with the current info, it is a complex condition with many possible complications even with all the info at hand. I remain at your disposal for further questions, possibly including some more details though.