Intracranial bleeding


  • Can be classified as
    • Extradural (epidural)
    • Subdural
    • Intracerebral
    • Subarachnoid
  • Intracranial bleeding can act as a mass lesion (associated with rise in ICP and focal deficits)
    • If left untreated can cause ‘coning’, which can often be fatal


  • Epidemiology/Aetiology
    • Occurs in ~2% of head injury- but up to 15% of fatal cases
    • Around 30% are acute, 30% subacute and 10% chronic
    • More common in males
    • Most commonly due to damage to the middle meningeal artery, often with fractured temporal/parietal bones (lateral blow to the head)
  • Presentation immediately after injury can be normal but later develops worsening headache and then change in conscious level, third nerve palsy, and nausea/vomiting (i.e. raised ICP)
  • Appearance on CT (Immediate CT in these patients is the investigation of choice in patients with altered conscious level, focal neurological signs or suspected fracture)
    • Lentiform (convex) shaped ‘bleed’ (/lesion)
  • Management
    • ABCDE with C-spine and full injury assessment
    • Surgical decompression (burr holes or craniotomy) should be considered in patients with impaired conscious level
    • Any patients with evidence of a fracture should be considered for surgery
    • Even in patients who appear normal, close observation is required to watch for any deterioration


  • Epidemiology/Aetiology
    • Occurs in 1-2% of head injury
    • More common in older patients
    • Most commonly due to damage of bridging veins between the cortex and venous sinuses
      • these are fragile and can tear easily
      • alternatively from vessel of the brain cortex which run along the surface of the brain
    • Can be acute or chronic (after injury)
  • Appears as a crescent shaped bleed on CT
  • Acute SDH
    • Usually present after trauma (lucid period is relatively less common than with EDH); loss of consciousness is probably most common
  • Chronic SDH
    • Can present weeks after trauma (which may be trivial, particularly in the elderly on blood thinning drugs including aspirin)
    • usually presents with focal neurological signs, chronic headache or impaired consciousness
  • Again, the management is principally surgical, although this is difficult in acute cases (mini-burr holes/mini craniotomy; success rate is less than in EDH)
    • Other management to consider (as with all ICBs) include mannitol (diuretic) and hyperventilation (to reduce osmotic pressure in the head)
    • Conservative management

Intracerebral haemorrhage and Contusions

  • Bleeding/bruising within the cerebrum itself
  • Not uncommon to complicate SDH


  • Late signs include
    • An enlarging, unresponsive pupil
    • Central respiratory depression
    • Cushing’s reflex :  Falling pulse rate and rising blood pressure

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