PassFinals
Neurology

Intracranial haemorrhage

Bleeding within the fixed skull can rapidly raise intracranial pressure, reduce cerebral perfusion and cause herniation; the location and mechanism classify extradural, subdural, subarachnoid or intracerebral haemorrhage, but every type needs urgent CT, physiological stabilisation and specialist escalation.

In a nutshell

Intracranial haemorrhage is bleeding inside the fixed skull, causing raised pressure, reduced perfusion and possible herniation. CT identifies the compartment: biconvex extradural, crescentic subdural, cisternal or sulcal subarachnoid, or intraparenchymal intracerebral blood. Resuscitation, urgent CT, anticoagulant reversal and specialist escalation are universal; definitive management is compartment-specific.

Classic presentation

Trauma or thunderclap headache followed by vomiting, focal deficit, seizure, reduced consciousness or pupil change; clinical tempo and CT shape classify the bleed.

Key points

  • Falling GCS or pupil inequality is a brain emergency.
  • Extradural is biconvex and suture-limited; subdural is crescentic and crosses sutures.
  • SAH causes thunderclap headache and needs aneurysm imaging and specialist treatment.
  • Spontaneous ICH needs hyperacute stroke-unit care, urgent reversal when anticoagulated and protocol-guided BP management.
  • Always identify anticoagulant agent and last dose; reversal is agent-specific.
  • Do not treat a deteriorating head injury as uncomplicated concussion or a stroke-like presentation as ischaemic until CT excludes haemorrhage.

First-line investigation

Urgent non-contrast CT head after structured neurological and trauma assessment.

Management

Resuscitate and recognise deterioration

  • Use <C>ABCDE, protect the cervical spine after trauma, maintain oxygenation and cerebral perfusion, record GCS and pupils and treat seizures or hypoglycaemia.1,4

CT and classify the bleed

  • Perform urgent non-contrast CT, apply trauma timing criteria or the SAH pathway, and do not give thrombolysis or antithrombotics until haemorrhage has been excluded where relevant.1,3,7

Reverse and refer

  • Urgently reverse active anticoagulation and transfer or admit to neurosurgical, neurocritical or hyperacute stroke care according to the compartment and clinical state.4,5,2,6

Apply cause-specific treatment

  • Secure aneurysmal SAH, evacuate selected traumatic collections and use specialist ICH BP, surgery and vascular-cause pathways rather than one generic protocol.3,1,2,8

Monitor and rehabilitate

  • Repeat imaging after deterioration, monitor complications, address recurrence risks and arrange rehabilitation, safety-netting and specialist follow-up.1,3,2

Exam traps

  • A lucid interval suggests extradural but does not exclude other traumatic haemorrhage.
  • Subdural crosses sutures; extradural does not.
  • Thrombolysis is harmful if the stroke is haemorrhagic.
  • Anticoagulant reversal must be agent-specific and should not be delayed by a normal INR when DOAC effect is possible.
  • Surgical decisions depend on clinical state and specialist imaging review, not a single memorised threshold.

Illustrations

Acute subdural haematoma on CTAxial non-contrast CT showing a crescentic subdural collection with mass effect.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. NICE NG232: Head injury: assessment and early management (CT, observation, transfer, neurosurgical discussion and anticoagulant-related imaging, 2023)
  2. National Clinical Guideline for Stroke 2023: Management of intracerebral haemorrhage (UK and Ireland stroke guideline, section 3.6 on reversal, BP, hyperacute care and vascular investigation)
  3. NICE NG228: Subarachnoid haemorrhage caused by a ruptured aneurysm (Diagnosis, aneurysm treatment, nimodipine, deterioration and follow-up)
  4. NICE NG39: Major trauma: assessment and initial management (Emergency reversal of anticoagulation and trauma resuscitation)
  5. NICE NG24: Prothrombin complex concentrate transfusion (NICE advice on vitamin K antagonist reversal in intracranial bleeding)
  6. BNF online: anticoagulant reversal (Check current agent-specific reversal, dose, contraindications and monitoring)
  7. NICE NG128: Stroke and transient ischaemic attack in over 16s (Acute stroke imaging and blood-pressure guidance relevant to haemorrhagic stroke)
  8. BNF online: Nimodipine (Check current enteral and specialist intravenous prescribing)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.