Intracranial Bleeds

Around 10-20% of strokes are caused by intracranial bleeds.

Risk Factors

  • Head injury
  • Hypertension
  • Aneurysms
  • Ischaemic stroke can progress to haemorrhage
  • Brain tumours
  • Anticoagulants such as warfarin



Sudden onset headache is a key feature. They can also present with:

  • Seizures
  • Weakness
  • Vomiting
  • Reduced consciousness
  • Other sudden onset neurological symptoms


Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is a universal assessment tool for assessing the level of consciousness. It is worth learning for your exams and every day practice as it frequently appears.

It is scored based on eyes, verbal response and motor response. The maximum score is 15/15, minimum is 3/15. When someone has a score of 8/15 or below then you need to consider securing their airway as there is a risk they are not able to maintaining it on their own.


  • Spontaneous = 4
  • Speech = 3
  • Pain = 2
  • None = 1

Verbal response

  • Orientated = 5
  • Confused conversation = 4
  • Inappropriate words = 3
  • Incomprehensible sounds = 2
  • None = 1

Motor response

  • Obeys commands = 6
  • Localises pain = 5
  • Normal flexion = 4
  • Abnormal flexion = 3
  • Extends = 2
  • None = 1


Subdural Haemorrhage

Subdural haemorrhage is caused by rupture of the bridging veins in the outermost meningeal layer. They occur between the dura mater and arachnoid mater. On a CT scan they have a crescent shape and are not limited by the cranial sutures (they can cross over the sutures).

Subdural haemorrhages occur more frequently in elderly or alcoholic patients. These patients have more atrophy in their brains making vessels more likely to rupture.


Extradural Haemorrhage

Extradural haemorrhage is usually caused by rupture of the middle meningeal artery in the temporo-parietal region. It can be associated with a fracture of the temporal bone. It occurs between the skull and dura mater. On a CT scan they have a bi-convex shape and are limited by the cranial sutures (they can’t cross over the sutures).

The typical history is a young patient with a traumatic head injury that has an ongoing headache. They have a period of improved neurological symptoms and consciousness followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents.


Intracerebral Haemorrhage

Intracerebral haemorrhage involves bleeding into the brain tissue. It presents similarly to an ischaemic stroke.

These can be anywhere in the brain tissue:

  • Lobar intracerebral haemorrhage
  • Deep intracerebral haemorrhage
  • Intraventricular haemorrhage
  • Basal ganglia haemorrhage
  • Cerebellar haemorrhage

They can occur spontaneously or as the result of bleeding into an ischaemic infarct or tumour or rupture of an aneurysm.


Subarachnoid Haemorrhage

Subarachnoid haemorrhage involves bleeding in to the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane. This is usually the result of a ruptured cerebral aneurysm.

The typical history is a sudden onset occipital headache that occurs during strenuous activity such as weight lifting or sex. This occurs so suddenly and severely that it is known as a “thunderclap headache”.

They are particularly associated with cocaine and sickle cell anaemia.


Principles of Management

  • Immediate CT head to establish the diagnosis
  • Check FBC and clotting
  • Admit to a specialist stroke unit
  • Discuss with a specialist neurosurgical centre to consider surgical treatment
  • Consider intubation, ventilation and ICU care if they have reduced consciousness
  • Correct any clotting abnormality
  • Correct severe hypertension but avoid hypotension


Last updated April 2019