Intracranial hematomas

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Intracranial hematomas, also intracranial hemorrhage, are bad stuff that keep neurosurgeons busy. They are usually diagnosed by imaging (CT head).

Not much bleeding is needed to cause death. In a person without atrophy (to provide space for the blood) ~75 ml is considered enough if it is acute.[1]


  • Headache.
  • Neck stiffness.
  • Vomit without diarrhea.
  • Changes in level of consciousness.


By location

  1. Epidural hemorrhage (extradural hemorrhage).
    • Patient may have lucid interval.[2]
    • Middle meningeal artery.
    • Radiology: biconvex.
  2. Subdural hemorrhage
    • Damaged bridging veins: subdural space between the dura and arachnoid mater.[3]
    • Radiology: crescent shape.
  3. Subarachnoid hemorrhage.
    • Classically caused by aneuryms:[4]
      1. Anterior communicating artery (ACA) - most common.
      2. Middle cerebral artery (MCA) - second most common.
  4. Intracerebral hemorrhage.
    • > 60 ml at presentation (assessed via CT scan) assoc. with > 90% 30 day mortality.[5]

By vessel type

  • Arterial - common.
  • Venous - rare (~3-4 cases/1,000,000 people/year[6]).

Cerebral venous thrombosis

See also: Thrombosis.


  • Extremely rare.
  • Female > male.
  • May be associated with trauma.[7]
  • Presentation often mimics subarachnoid haemorrhage.[8]
  • Typically involves superior sagittal sinus.[8]



  • Bilateral involvement.
  • Congested appearance.

Epidural hematoma

  • AKA epidural hemorrhage


  • Extradural hemorrhage.
  • Patient may have lucid interval.[2]
  • Classically due to an injury of the middle meningeal artery.
  • Usually due to trauma.
  • Generally considered artefactual in the context of fire deaths.[11]


  • Blood outside of the dura.


  • Biconvex.



Subdural hematoma

  • AKA subdural hemorrhage.
  • Abbreviated SDH.



  • Bridging veins in subdural space between the dura and arachnoid mater - injured.[3]


  • +/-Trauma.
  • Elderly, esp. those with cerebral atrophy.[12]

Recurrance risks:


  • Blood in the subdural potential space.
  • Crescentic shape.



  • Blood in subdural (potential) space.


Subarachnoid hematoma

  • Abbreviated SAH.
  • AKA subarachnoid hemorrhage.


  • In the forensic context SAH alone is not good enough.
    • One needs to determine the cause, e.g. ruptured berry aneurysm or laceration of left vertebral artery.


Traumatic SAH


  • Blood between pia mater and arachnoid membrane.
  • Typically at the base of the brain.


  • Ruptured berry aneurysms are best found when the brain is fresh; it is hard to dissect away fixed blood.

Intracerebral hematoma

  • AKA intraparenchymal hemorrhage, AKA intracerebral hemorrhage.




  • Blood within the parenchyma of the brain.


  • +/-Hemosiderin-laden macrophages.

Cerebral fat embolism




  • Multiple white matter predominant petechiae.

DDx - medical imaging:

  • Diffuse axonal injury[19] - severe DAI classically has a corpus callosum injury.
  • Herpes simplex encephalitis - temporal lobe hemorrhage.




  • Intravascular fat globules.

See also


  1. McAuliffe. 15 October 2010.
  2. 2.0 2.1 Erşahin Y, Mutluer S, Güzelbag E (April 1993). "Extradural hematoma: analysis of 146 cases". Childs Nerv Syst 9 (2): 96–9. PMID 8319240.
  3. 3.0 3.1 Crooks DA (1991). "Pathogenesis and biomechanics of traumatic intracranial haemorrhages". Virchows Arch A Pathol Anat Histopathol 418 (6): 479–83. PMID 2058082.
  4. Beck J, Rohde S, Berkefeld J, Seifert V, Raabe A (January 2006). "Size and location of ruptured and unruptured intracranial aneurysms measured by 3-dimensional rotational angiography". Surg Neurol 65 (1): 18–25; discussion 25–7. doi:10.1016/j.surneu.2005.05.019. PMID 16378842.
  5. URL: Accessed on: 2 September 2010.
  6. Agostoni E, Aliprandi A, Longoni M (April 2009). "Cerebral venous thrombosis". Expert Rev Neurother 9 (4): 553–64. doi:10.1586/ern.09.3. PMID 19344306.
  7. URL: Accessed on: 12 October 2010.
  8. 8.0 8.1 URL: Accessed on: 12 October 2010.
  9. Milandre L, Pellissier JF, Vincentelli F, Khalil R (1990). "Deep cerebral venous system thrombosis in adults". Eur. Neurol. 30 (2): 93–7. PMID 2187698.
  10. MSP. 12 October 2010.
  11. Ritter, C. (1990). "[A heat gelatinized subdural hematoma in a burned cadaver as an indication of a vital accident].". Z Rechtsmed 103 (3): 227-30. PMID 2309533.
  12. Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 663. ISBN 978-1416054542.
  13. Chon, KH.; Lee, JM.; Koh, EJ.; Choi, HY. (Sep 2012). "Independent predictors for recurrence of chronic subdural hematoma.". Acta Neurochir (Wien) 154 (9): 1541-8. doi:10.1007/s00701-012-1399-9. PMID 22653496.
  14. Ingelmo Ingelmo, I.; Fàbregas Julià, N.; Rama-Maceiras, P.; Hernández-Palazón, J.; Rubio Romero, R.; Carmona Aurioles, J. (Dec 2010). "[Subarachnoid hemorrhage: epidemiology, social impact and a multidisciplinary approach].". Rev Esp Anestesiol Reanim 57 Suppl 2: S4-15. PMID 21298906.
  15. Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 665. ISBN 978-1416054542.
  16. Haacke, EM.; DelProposto, ZS.; Chaturvedi, S.; Sehgal, V.; Tenzer, M.; Neelavalli, J.; Kido, D. (Feb 2007). "Imaging cerebral amyloid angiopathy with susceptibility-weighted imaging.". AJNR Am J Neuroradiol 28 (2): 316-7. PMID 17297004.
  17. Choi, JC.; Kang, SY.; Kang, JH.; Park, JK. (Dec 2006). "Intracerebral hemorrhages in CADASIL.". Neurology 67 (11): 2042-4. doi:10.1212/01.wnl.0000246601.70918.06. PMID 17135568.
  18. 18.0 18.1 Kamenar, E.; Burger, PC.. "Cerebral fat embolism: a neuropathological study of a microembolic state.". Stroke 11 (5): 477-84. PMID 7423578.
  19. Kumar, S.; Gupta, V.; Aggarwal, S.; Singh, P.; Khandelwal, N.. "Fat embolism syndrome mimicker of diffuse axonal injury on magnetic resonance imaging.". Neurol India 60 (1): 100-2. doi:10.4103/0028-3886.93597. PMID 22406792.
  20. URL: Accessed on: 25 March 2012.
  21. Eriksson, EA.; Schultz, SE.; Cohle, SD.; Post, KW. (Apr 2011). "Cerebral fat embolism without intracardiac shunt: A novel presentation.". J Emerg Trauma Shock 4 (2): 309-12. doi:10.4103/0974-2700.82233. PMC 3132375. PMID 21769222. //