Can a patient still have an intracranial (within the skull) injury 2 weeks after the initial incident, especially if they are experiencing symptoms such as headache, confusion, or neurological deficits?

Can Intracranial Injury Still Be Present 2 Weeks After Head Trauma?

Yes, intracranial injury can absolutely still be present 2 weeks after the initial incident, and patients experiencing symptoms at this timepoint require immediate emergency department evaluation and neuroimaging. 1

Critical Time Windows for Delayed Complications

The evidence demonstrates multiple temporal patterns for intracranial pathology after head trauma:

• Delayed neurological deterioration occurs in approximately 4.1% of patients with mild head injury and intracranial hemorrhage, with 87% deteriorating within the first 24 hours 2
• However, late increases in intracranial pressure can begin after 72 hours post-injury in 17% of patients with severe traumatic brain injury, with peak swelling occurring as late as day 7 3
• Delayed hematomas are a recognized complication that can develop hours to days after the initial injury 4

Red Flag Symptoms Requiring Immediate ED Evaluation at 2 Weeks

Patients must return to the emergency department immediately if experiencing any of the following symptoms at 2 weeks post-injury 5, 1:

• Repeated vomiting or new onset vomiting
• Worsening or persistent headache beyond 24 hours
• Problems with memory or concentration
• Confusion or disorientation
• Focal neurologic deficits (weakness, sensory changes, vision problems)
• Abnormal behavior or personality changes
• Increased sleepiness or difficulty arousing
• Seizures

Distinguishing Acute Injury from Post-Concussive Syndrome

At 2 weeks post-injury, the clinical picture becomes more nuanced:

Acute intracranial pathology (subdural hematoma, delayed hemorrhage, hydrocephalus) remains possible and requires urgent imaging if symptoms suggest deterioration 5, 1, 4. The American College of Radiology recommends MRI as the most useful imaging modality for subacute or chronic head trauma (beyond the acute phase) when evaluating unexplained cognitive or neurologic deficits, as it is more sensitive than CT for subtle findings adjacent to the calvarium, small white matter lesions, and chronic sequelae of previous injuries 5.

Post-concussive symptoms are expected in approximately 58% of patients at 1 month and 15% at 1 year after mild traumatic brain injury 5. These symptoms include chronic headaches, dizziness, balance problems, nausea, vision problems, sensitivity to noise/light, depression, mood swings, anxiety, irritability, memory problems, difficulty concentrating, and sleep difficulties 5.

Management Algorithm at 2 Weeks Post-Injury

If the patient has any of the red flag symptoms listed above:

• Immediate ED evaluation with neuroimaging (CT or MRI) 1, 5
• Do not attribute symptoms solely to post-concussive syndrome without excluding structural pathology 6

If the patient has persistent but stable post-concussive symptoms without red flags:

• Active management should begin rather than waiting for spontaneous recovery 7
• Implement sub-symptom threshold aerobic exercise with gradual increases 7
• Provide systematic, individualized information about symptom management and expected recovery 7
• Assess specific domains: vestibular, visual, cervical, cognitive 7
• Consider referral to a traumatic brain injury specialist 5, 8

Critical Pitfalls to Avoid

Do not assume all symptoms at 2 weeks are "just post-concussive syndrome" without proper evaluation, especially in high-risk populations 1, 2:

• Patients on anticoagulants or antiplatelet agents (excluding aspirin alone) have significantly higher risk of delayed intracranial hemorrhage 1, 8
• Age greater than 60 years is associated with higher mortality from delayed neurological deterioration 2
• Coagulopathy significantly increases risk of progressive hemorrhage 2

Do not recommend complete rest beyond the first 24-48 hours, as prolonged rest may have negative implications for recovery 7. However, patients should refrain from strenuous mental or physical activity until symptom-free, which may require 2-3 days off work or school initially 5.

Do not rely solely on patient self-report—systematic evaluation of specific symptom domains is essential 7. Problems may persist for at least 6 months and require not only continued medical care but also social assistance with driving support, employment issues, and financial assistance 5, 7.