Brain Bleed Basics

Case Report:


65 year old female with PMHx Hypertension presents with bilateral leg weakness onset three days ago. Patient states “my legs feel heavy”. Symptoms are worse with exertion and better with rest. She denies any recent trauma, change in physical activity, bleeding, dietary changes. Patient was seen by her primary physician via tele-health appointment and received a referral for outpatient MRI. Upon MRI patient was found to have an intracranial hemorrhage and was immediately transported to the ED via EMS. On arrival, vital signs were stable. Neurologic exam was unremarkable for any focal deficits. CT scan on arrival demonstrated bilateral acute on chronic subdural hematomas. Neurosurgery was consulted and took the patient to the OR for emergent evacuation of the hematomas. 



Subdural vs Epidural Hematoma




Epidural Hematoma

Subdural Hematoma





Between skull and dura

Between dura and arachnoid layer 

Blood Vessel

Middle Meningeal Artery

Bridging Vein 

Crosses Suture Lines




Most Common: Traumatic head injury with or without skull fracture


Most Common: Trauma or translation injury (i.e. whiplash) 


Less Common: coagulopathy, diffuse cerebral atrophy (elderly population), dural metastasis, administration of thrombolytics


Short loss of consciousness with return to baseline. The lucid interval is then followed by sudden onset altered mentation: “Talk and Die”


Duration of symptoms: minutes to hours  

Gradually progressing headache, confusion, loss of consciousness, vomiting, ataxia, seizures



Acute: 1-14 days after onset

Chronic: 15+ days

Physical Exam

Severe: confusion, aphasia, seizures, ipsilateral dilated pupil, Cushing reflex- hypertension, bradycardia, respiratory depression 


Mild: vomiting, focal extremity weakness, focal sensory deficits


Craniotomy and hematoma evacuation 

Surgery vs observation 


     -  Worse outcomes in elderly and delayed surgical intervention 
     -  Intracranial hemorrhage score:
               - Components:
                         - GCS
                                - Age >80
                                - ICH volume >30mL
                                - Intraventricular Hemorrhage

               - The more points the patient has the increase 30 day mortality 





Godoy, D. A., Piñero Gustavo, & Napoli, M. D. (2006). Predicting Mortality in Spontaneous Intracerebral Hemorrhage. Stroke37(4), 1038–1044. doi: 10.1161/01.str.0000206441.79646.49


Ma, O. J., Yealy, D. M., Meckler, G. D., Stapczynski, J. S., Cline, D., & Thomas, S. J. (2016) Trauma. In J.E. Tintinalli (Ed). Tintinallis emergency medicine: a comprehensive study guide. (8th ed.) (pp. 1703-1704). New York: McGraw Hill Education.