INTRACRANIAL HAEMORRHAGE

✓ Medically ReviewedDISEASEID: MDBT0124🚨 TRIAGE: EMERGENCYICD-10: I62.9

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Definition

CLINICAL DEFINITION

Intracranial haemorrhage is bleeding inside the cranial vault (bony skull cavity holding the brain). It covers bleeding within brain tissue and into nearby spaces. Spaces include subarachnoid space (fluid area around brain), ventricles (fluid cavities) and extra-axial spaces (areas outside brain but inside skull). Bleeding may be spontaneous (without trauma) or traumatic after head injury. Pooled blood raises intracranial pressure (pressure inside skull) and injures nerve tissue directly.

IN PLAIN ENGLISH

A vessel breaks inside the head. Blood pools inside or around the brain. Pooled blood squeezes healthy brain. Pressure in the head rises fast. This is an emergency needing fast hospital care.

COMMON MISCONCEPTION / WHAT IT DOES NOT MEAN

Intracranial haemorrhage is not ischaemic stroke (blocked artery stroke without bleeding). It is not migraine or tension headache without blood on imaging. It is not scalp bleeding outside the skull. It is not slow degeneration (gradual brain cell loss) alone without bleeding.

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Word Breakdown

intra-

=inside or within

crani-

=skull

-haemorrhage

=escape of blood from vessels

Literal Meaning: bleeding inside the skull cavity

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Abbreviations

ICH=Intracerebral haemorrhage - bleeding within brain tissue itself

SAH=Subarachnoid haemorrhage - bleeding into fluid space around the brain

SDH=Subdural haematoma - blood clot between dura (tough outer cover) and arachnoid (middle cover)

EDH=Extradural haematoma - blood between skull and dura (tough outer cover)

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Synonyms & Variants

Intracranial Hemorrhage›Brain Haemorrhage›Haemorrhagic Stroke›

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Category-Specific Context

Intracranial haemorrhage is a Disease because it is a tissue-injury process with causes and course. It is not a Symptom (patient complaint) such as headache alone. It is not a single Sign (exam finding) such as weakness alone. It spans spontaneous and traumatic origins (no-injury and injury levels). Care targets bleed control with pressure relief rather than symptom cover alone.

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Clinical Context & Usage

CLINICAL SETTINGS

Emergency DepartmentHyperacute Stroke UnitNeurosurgical UnitIntensive Care UnitMajor Trauma Centre

USAGE & DOCUMENTATION NOTES

Use intracranial haemorrhage for any bleeding inside the skull when confirmed or strongly suspected. Specify subtype when known such as intracerebral (within brain), subarachnoid (around brain), subdural or extradural. Do not use it for scalp bleeding outside the skull. Record trauma history, blood thinner use and onset time in every note.

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Primary Causes & Pathophysiology

PATHOPHYSIOLOGY

Vessel rupture spills blood into tissue or nearby spaces. Haematoma (clotted blood collection) acts as a mass and pushes tissue aside. Oedema (swelling from fluid leak) with blocked fluid flow raises pressure further. High pressure cuts cerebral perfusion (blood flow to brain) and risks herniation (brain shift across rigid folds). Breakdown products trigger inflammation (immune activation) with vasospasm (vessel narrowing) and seizures.

PRIMARY CAUSES

Chronic hypertension with small-vessel injury

High pressure damages deep penetrating arteries and weakens walls so they rupture under strain

Cerebral amyloid angiopathy (protein buildup in small vessels)

Amyloid weakens surface vessels in older adults and allows lobar bleeding with minor trauma

Ruptured saccular aneurysm (artery wall bulge)

Thin dome tears and jets arterial blood into fluid spaces around the brain

Arteriovenous malformation (tangled abnormal vessels)

Fragile nidus (central tangle) lacks normal wall layers and bleeds into brain or ventricles

Head trauma with shear injury

Rapid motion tears bridging veins (veins crossing to outer cover) and surface vessels causing subdural, extradural or bruise bleeding

Brain tumour, primary or metastatic

Abnormal tumour vessels with dead areas bleed easily into tumour and nearby brain

Haemorrhagic transformation of infarct (bleeding into dead stroke tissue)

Injured walls in dead tissue leak when flow returns on its own or after flow-restoring treatment

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Drug-Induced Causes

💊 Warfarin ↗

Mechanism: Blocks vitamin K clotting factors and stops stable clot so small leaks expand

→ Stop warfarin at once, give vitamin K with four-factor concentrate (clotting factor mix) and seek neurosurgical input

💊 Direct oral anticoagulants including apixaban and rivaroxaban ↗

Mechanism: Block factor Xa (key clotting protein) or thrombin and prevent firm clot so small bleeds grow fast

→ Stop drug at once, consider specific reversal where available with haematology and neurosurgical review

💊 Antiplatelets including aspirin and clopidogrel ↗

Mechanism: Impair platelet clumping (cell plugging) and prevent early seal at injury sites

→ Stop antiplatelets, control pressure and consider platelet transfusion if emergency surgery is needed

💊 Thrombolytics including alteplase ↗

Mechanism: Dissolve fibrin (clot protein) and deplete clotting reserve so injured tissue bleeds easily

→ Stop infusion at once, give cryoprecipitate (fibrinogen-rich product) per protocol with critical care support

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Epidemiology

Prevalence:Spontaneous brain bleeding forms a minority of all strokes but causes high disability. Traumatic bleeding is common after road collisions and falls. Risk rises with age, hypertension and blood thinner use.

Age Group:All ages can be affected. Traumatic bleeding peaks in young adults after injury. Spontaneous bleeding rises with advancing age from hypertension and vessel fragility. Amyloid-related lobar bleeds cluster in older adults.

Geographic Distribution:Intracranial haemorrhage occurs worldwide in all populations. Burden tracks hypertension detection and treatment patterns. Trauma cases follow road injury patterns. Detection tracks access to CT scanning and neurosurgical care.

Red Flags & Triage ★

TRIAGE LEVEL

🚨 EMERGENCY

DO NOT MISS — LIFE-THREATENING PRESENTATIONS

Aneurysmal bleed needing urgent vessel repair
Expanding extradural clot with brief recovery then decline
Blood thinner bleeding needing rapid reversal
Herniation with unequal pupils and coma

URGENT EVALUATION TRIGGERS

Thunderclap headache peaking within seconds
New coma with unequal pupils or abnormal stiffness
Focal weakness with speech loss or seizure
Vomiting with very high pressure after head injury
Blood thinner use with any new nerve deficit

Contraindications & Precautions

CONTRAINDICATIONS

Do not give blood thinners or antiplatelets during acute bleeding
Do not perform lumbar puncture (spinal fluid test) with mass effect or raised pressure
Do not lower pressure so far that brain blood flow falls
Do not delay imaging for nonurgent tests

SPECIAL PRECAUTIONS

Nurse with head raised to aid vein drainage
Watch neurology with pressure, sugar and salts closely
Prevent seizures with aspiration, clots and pressure sores
Check swallowing before any oral intake
Counsel on driving, work and cause control after recovery

Complications

DOWNSTREAM CLINICAL COMPLICATIONS

Raised pressure with herniation (brain shift) and coma
Hydrocephalus (fluid buildup from blocked flow)
Seizures with aspiration (inhaled stomach contents)
Vasospasm (vessel narrowing) with delayed ischaemia after subarachnoid blood
Pneumonia with clots from immobility
Lasting weakness with thinking and mood change

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Confused With (LASA & DDx) ★

LEXICAL (LASA) — SIMILAR NAMES

Intracranial hypertension

Shares intracranial wording with headache and disc swelling but means high pressure without acute bleeding

Extracranial haemorrhage

Sounds similar but means scalp bleeding outside the skull that does not squeeze brain directly

Ischaemic stroke

Shares sudden weakness but means blocked artery without blood leak and needs opposite clot care

CLINICAL DIFFERENTIAL DIAGNOSES (DDx)

Ischaemic stroke

Key Distinguishing Feature: No blood on plain CT with vessel block on artery imaging and infarct pattern

Migraine with aura

Key Distinguishing Feature: Marching visual symptoms with full recovery and normal emergency imaging

Seizure with postictal drowsiness

Key Distinguishing Feature: Witnessed rhythmic movements then improving confusion without blood on CT

Bacterial meningitis

Key Distinguishing Feature: Fever with stiff neck and cloudy spinal fluid with white cells but no blood

Hypertensive encephalopathy

Key Distinguishing Feature: Severe hypertension with confusion and brain swelling on MRI but no focal blood clot

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Clinical Pearls

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Treat thunderclap headache with vomiting and stiff neck as subarachnoid bleeding until proven otherwise. Arrange emergency CT with artery imaging at once.

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Check clotting in blood thinner users and reverse without waiting for full workup. Small leaks can expand fast in anticoagulated patients.

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Do not trust a brief recovery after trauma to exclude extradural bleeding. Repeat exams with low threshold for rescan when lucid interval (brief improvement) occurs.

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Escalate persistent suspicion even with normal exam because early CT can miss small blood. Arrange spinal fluid test or repeat imaging per protocol.

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Control pressure with head-up nursing and steady vitals while awaiting neurosurgery. Avoid both high pressure spikes and very low pressure that cuts brain flow.

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Example Usage & SOAP

CLINICAL SENTENCE

""68-year-old man on blood thinners with sudden headache and left weakness has intracranial haemorrhage on CT.""

IN A SOAP NOTE

S: 71-year-old woman with sudden severe headache, vomiting and right weakness for 1 hour on apixaban. O: Temp 36.9C, BP 196/110, HR 96, RR 22, SpO2 94 percent on air, drowsy with gaze preference and right weakness. A: Suspected intracranial haemorrhage with hypertension and blood thinner use. P: Emergency plain CT with artery imaging, stop apixaban, pressure control, neurosurgical review and intensive care admission.

DIFFERENTIAL DIAGNOSIS CONTEXT

Sudden headache with weakness favours bleed over ischaemic stroke when blood shows on plain CT. No blood with vessel block favours ischaemia. Fever with stiff neck favours meningitis. Marching visual aura with full recovery favours migraine. Check artery imaging with clotting and pressure history.

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Classifications & Scoring

GRADING SYSTEM

Hunt and Hess Grade

Clinical grade for subarachnoid bleeding using headache, stiffness and consciousness to predict outcome.

GRADING SYSTEM

World Federation of Neurosurgical Societies Grade

Subarachnoid grade using coma score with focal deficit to guide care timing.

STAGING SCALE

Modified Fisher Scale

CT blood amount with ventricle blood to estimate vessel-narrowing risk after subarachnoid bleeding.

STAGING SCALE

Marshall CT Classification

Trauma CT scale using fluid spaces, midline shift and lesion size to stratify injury severity.

SCORING TOOL

Intracerebral Haemorrhage Score

Six-point score using age, volume, site, consciousness and ventricle blood to estimate early death risk.

SCORING TOOL

Glasgow Coma Scale

Eye, verbal and motor score tracking consciousness and detecting decline in brain bleeding.

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Prognosis

SHORT-TERM OUTCOME

Short term course follows bleed size, site and consciousness level. Large bleeds with coma carry high early death risk. Fast reversal of blood thinners with pressure control improves survival. Selected clots benefit from early surgical removal.

LONG-TERM PROGNOSIS

Many survivors keep weakness, speech or memory problems for months. Rehab with physio, speech and mood support improves independence. Return of bleeding follows cause control such as pressure care and vessel repair. Long term follow-up covers mood, thinking and driving safety.

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References & Coding

ICD-10 DIAGNOSTIC CODE

I62.9

LITERATURE CITATIONS & GUIDELINES

[1]WHO ICD-10 I62 Other nontraumatic intracranial haemorrhage

[2]NICE guidance on head injury and subarachnoid haemorrhage

[3]American Heart Association guidance on spontaneous intracerebral haemorrhage

[4]Harrison's Principles of Internal Medicine cerebrovascular disorders

MEDICAL DISCLAIMER — This content is intended for educational purposes and qualified healthcare professionals only. Always refer to current clinical diagnostic criteria, institutional protocols, and official guidelines. Medobo is not responsible for clinical decisions made based on this content.