Intracranial Haemorrhages

Overview – Intracranial Haemorrhages

Intracranial haemorrhages are acute neurological emergencies caused by bleeding within the skull. They can result from trauma, vascular malformations, aneurysmal rupture, or chronic hypertension. The four major types—epidural, subdural, subarachnoid, and intracerebral—have distinct causes, anatomical locations, clinical courses, and imaging findings. Early recognition and targeted management are crucial to reduce morbidity and mortality.

Aetiology

CauseHaemorrhage Type
Skull fracture (trauma)Epidural haemorrhage
Low-force trauma (esp. elderly)Subdural haemorrhage
Congenital berry aneurysmSubarachnoid haemorrhage
AV malformationsIntracerebral haemorrhage
HypertensionIntracerebral haemorrhage (spontaneous)
Types of intracranial hemorrhages
https://www.myupchar.com/en, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

Epidural (Extradural) Haemorrhage

Aetiology & Pathogenesis

  • Caused by arterial rupture (usually middle meningeal artery) due to skull fracture
  • Blood accumulates between dura mater and skull, splitting the dura under high pressure

Morphology

  • Biconvex (lens-shaped) haematoma on CT
  • Bleeding limited by dural attachments
  • Compression of underlying brain

Clinical Course

  • Rapid onset:
    1. Initial LOC
    2. Lucid interval
    3. Sudden deterioration (herniation signs)

Signs & Symptoms

  • Severe headache, vomiting, altered consciousness
  • Ipsilateral fixed/dilated pupil (CN III compression)
  • Contralateral hemiparesis
  • Potential for uncal/tonsillar herniation → coma/death

Investigations

  • CT Head: Hyperdense, biconvex shape (does not cross suture lines)

Management

  • Urgent neurosurgery: Burr hole ± craniotomy
  • Excellent prognosis if treated promptly
  • Untreated → brain herniation and death
intracranial haemorrhages - Extradural
Jpogi, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Subdural Haematoma

Aetiology & Pathogenesis

  • Venous bleed from bridging veins, usually due to low-impact trauma
  • Blood collects between dura mater and arachnoid mater

Morphology

  • Crescent-shaped haematoma on CT
  • Can spread across hemispheres
  • Brain atrophy common (elderly, alcoholics)

Clinical Course

TypePresentationProgression
AcuteImmediate symptoms after traumaRapid deterioration, high mortality
ChronicDays–weeks laterGradual onset headache, confusion, focal signs, seizures

Signs & Symptoms

  • Somnolence, dizziness, ataxia
  • Confusion, amnesia, visual changes
  • Weakness, nausea, seizures
  • More subtle in chronic cases

Investigations

  • CT Head:
    • Acute: Crescent-shaped density
    • Chronic: Hypodense, follows brain contour
  • Midline shift may be present

Management

  • Severe cases: Burr hole drainage
  • Small/chronic cases: Conservative ± serial imaging
  • Prognosis often poorer due to underlying cerebral atrophy
intracranial haemorrhages - SUBDURAL
2007-06-24 17:16 Glitzy queen00, Public domain, via Wikimedia Commons

Subarachnoid Haemorrhage

Aetiology & Pathogenesis

  • Rupture of berry aneurysm in Circle of Willis
  • Common sites: MCA > ACA > PCA
  • Blood enters the subarachnoid space, mixing with CSF
  • May be precipitated by hypertension

Morphology

  • Blood in sulci and basal cisterns
  • Can appear in ventricles if severe
intracranial haemorrhages - SUBARACHNOID
Mikael Häggström, M.D. – Author info – Reusing images- Conflicts of interest: NoneMikael HäggströmConsent Note: Consent from the patient or patient’s relatives is regarded as redundant, because of absence of identifiable features (List of HIPAA identifiers) in the media and case information (See also HIPAA case reports guidance)., CC0, via Wikimedia Commons

Clinical Features

PhaseSymptoms
Pre-ruptureHeadache, balance issues, dysphasia
Post-rupture“Thunderclap headache”, vomiting, meningism, hemiparesis, diplopia, seizures, ALOC

Investigations

  • CT Head: Blood in sulci and fissures
  • Lumbar puncture: Xanthochromia (if CT negative)
  • CT Angiography: To identify aneurysm

Management

  • Stabilise: Airway, breathing, circulation, ICU care
  • Neurosurgical referral (clipping/coiling)
  • Control ICP (mannitol, hyperventilation, corticosteroids)

Prognosis

  • <50% survival
  • High morbidity in survivors (vasospasm, hydrocephalus, seizures)
SUBARACHNOID
Source: http://www.nhlbi.nih.gov/health/dci/Diseases/arm/arm_types.html
intracranial haemorrhages - SUBARACHNOID
https://www.nejm.org/doi/full/10.1056/NEJMcp1605827

Intracerebral Haemorrhage

Aetiology

  • Hypertension (most common)
  • AV malformations, trauma, bleeding diathesis

Pathogenesis

  • Bleeding into brain parenchyma
  • Leads to mass effect, ↑ICP, and ischaemia

Morphology

Clinical Features

  • Acute headache, vomiting, meningism
  • Nystagmus, anisocoria, focal neurological deficits
  • Signs of raised ICP and possible brain herniation
  • Altered consciousness

Investigations

  • CT/MRI Brain: Confirms haemorrhage
  • Transcranial Doppler: Assess AVMs

Management

  • Supportive: Ventilation, BP control
  • Mannitol, corticosteroids for ICP
  • Surgery if >3cm or herniation
  • Correct coagulopathy if present

Prognosis

  • 40% mortality
  • Most survivors have permanent disability
AVM
Source: https://www.rch.org.au/kidsinfo/fact_sheets/Cerebral_Arteriovenous_Malformation_AVM/
intracranial haemorrhages - AVM
Source: https://radiopaedia.org/cases/arteriovenous-malformation-cerebral-3

Summary – Intracranial Haemorrhages

Intracranial haemorrhages are classified by anatomical location into epidural, subdural, subarachnoid, and intracerebral types, each with unique causes, clinical features, and imaging appearances. Rapid diagnosis with CT, close monitoring for signs of raised ICP, and timely neurosurgical intervention are key to improving outcomes. For a broader context, see our Nervous System Overview page.

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