Intracranial Hematoma: Symptoms, Types, Causes and Treatment

Intracranial hematoma is a potentially life-threatening condition that occurs when blood accumulates within the skull, compressing the delicate tissues of the brain. Recognizing its symptoms, understanding the different types, identifying causes, and knowing the available treatments are critical steps in improving outcomes for patients. This article offers a comprehensive, evidence-based guide to intracranial hematomas, synthesizing the latest clinical research and imaging insights.

Symptoms of Intracranial Hematoma

Intracranial hematomas often present with a range of symptoms, from subtle changes in behavior to dramatic neurological deficits. These symptoms can evolve rapidly or develop gradually, depending on the type and location of the hematoma. Prompt recognition is vital—early intervention can be lifesaving and help prevent permanent brain injury.

Symptom	Description	Common in Types	Source(s)
Headache	Persistent or severe ache	All	2 3 4 5 13 16
Nausea/Vomiting	Often due to raised ICP	All, esp. acute ICH	3 16
Loss of consciousness	Fainting, unresponsiveness	Subdural, ICH	1 2 3
Neurological deficits	Weakness, speech/language issues	Subdural, ICH, Extradural	2 3 4 13

Table 1: Key Symptoms

Recognizing Early Symptoms

Headache is the most commonly reported symptom across all types of intracranial hematoma. In some cases, the headache is persistent and severe, especially when associated with raised intracranial pressure (ICP) 2 3 4 5 13 16. In subdural or epidural hematomas, the headache can be accompanied by nausea, vomiting, or even changes in mental status.

Progression of Neurological Signs

As a hematoma grows, it can compress brain structures, leading to neurological deficits:

• Sudden weakness or numbness (often on one side of the body)
• Slurred speech or difficulty finding words
• Visual disturbances, including diplopia (double vision)
• Seizures, especially in intracerebral hemorrhage 3 2
• Behavioral or personality changes, particularly in infants or elderly 1

Signs of Severe or Life-Threatening Hematoma

Rapid deterioration may manifest as:

• Loss of consciousness or coma
• Abnormal pupillary reflexes (loss of light response)
• Hemiplegia (paralysis of one side)
• Signs of increased ICP: bulging fontanel in infants, bradycardia, hypertension 1 3

Symptoms in infants and elderly may be subtle or atypical. In infants, irritability, vomiting, or a bulging fontanel may be the only clues 1. In elderly or those with brain atrophy, initial symptoms may be mild or delayed.

Types of Intracranial Hematoma

Intracranial hematomas are classified by their location within the skull and their relationship to the brain and its coverings. Understanding these distinctions helps guide both diagnosis and management.

Type	Location	Typical Clinical Course	Source(s)
Epidural (Extradural)	Between skull and dura mater	Rapid onset after trauma	8 13
Subdural	Between dura and arachnoid mater	Acute, subacute, or chronic	2 4 5 6 7 13 17
Intracerebral	Within brain tissue	Sudden, severe symptoms	3 11 13 14 16 18
Other (e.g., tumor-related)	Variable	May mimic other types	10 12

Table 2: Major Types of Intracranial Hematoma

Epidural (Extradural) Hematoma

• Usually arterial in origin, often following skull fracture 8 13
• Classic presentation: brief loss of consciousness, "lucid interval," then rapid deterioration
• Prompt recognition and surgical intervention are critical

Subdural Hematoma

• Venous bleeding, often due to tearing of bridging veins
• Can be:
  • Acute: symptoms within 72 hours (often severe trauma)
  • Subacute: symptoms develop over days to weeks
  • Chronic: slow accumulation, especially in elderly or those with brain atrophy 2 4 5 6 7 13 17
• May arise spontaneously or after minor trauma

Intracerebral (Intraparenchymal) Hematoma

• Bleeding occurs directly into brain tissue
• Most commonly due to hypertension, vascular abnormalities, or anticoagulation 3 11 13 14 16 18
• Sudden neurological deficits, rapid deterioration

Other Types

• Hematomas associated with tumors (e.g., hemorrhagic meningiomas, metastases) 10 12
• Postoperative hematomas (after neurosurgical procedures or spinal surgery) 4 5 8
• Hematomas related to coagulopathies or anticoagulant use 15 16

Causes of Intracranial Hematoma

The origins of intracranial hematomas are diverse, ranging from traumatic injuries to spontaneous bleeding related to medical conditions or medications. Understanding the underlying cause is essential for appropriate treatment and prevention of recurrence.

Cause	Description	At-risk Groups	Source(s)
Trauma	Motor vehicle accidents, falls	All ages	1 8 9 13
Vascular abnormalities	Aneurysms, AVMs, hypertension	Adults, elderly	3 14 16 18
Coagulopathy/Medications	Anticoagulants, DIC, antiplatelets	Elderly, cardiac patients	9 15 16
Brain atrophy	Age-related loss of brain mass	Elderly	2 7
Tumors	Bleeding into or around neoplasms	Any, esp. with malignancy	10 12
CSF leak/hypotension	Post-surgery, spontaneous	Post-op, SIH patients	4 5 17

Table 3: Common Causes of Intracranial Hematoma

Traumatic Causes

• Direct trauma (falls, vehicle accidents, sports injuries) is the leading cause, especially in younger individuals 1 8 13
• In infants, even minor trauma can cause significant injury; clinical indicators may be subtle 1

Vascular and Medical Causes

• Chronic hypertension is a major risk factor for intracerebral hemorrhage 3 14 16 18
• Vascular malformations (e.g., arteriovenous malformations, aneurysms) can rupture spontaneously

Coagulopathy and Medications

• Use of anticoagulants (warfarin, direct oral anticoagulants) and antiplatelet agents increases risk 15 16
• Disseminated intravascular coagulation (DIC) can cause delayed or recurrent hematomas, especially after trauma or surgery 9
• Some hematomas occur after lumbar puncture or spinal anesthesia, particularly in patients with additional risk factors 2 5

Age-Related and Spontaneous Causes

• Brain atrophy in the elderly stretches veins, making them more susceptible to tearing and chronic subdural hematoma 2 7
• Tumors may bleed spontaneously, mimicking other hematoma types 10 12
• Intracranial hypotension, whether spontaneous or post-surgical, can lead to subdural bleeding due to stretching of veins 4 5 17

Treatment of Intracranial Hematoma

Timely and effective treatment is crucial for minimizing brain damage and improving survival. Approaches depend on the type, size, location, and cause of the hematoma, as well as the patient's clinical status.

Treatment	Purpose/Action	Indications	Source(s)
Surgical evacuation	Remove hematoma, relieve pressure	Large, symptomatic, or expanding hematomas	4 8 14 16 18
Medical management	Control ICP, BP, coagulopathy	Small, stable, or inaccessible hematomas	14 15 16 18
Reversal of anticoagulation	Stop ongoing bleeding	Hematoma in anticoagulated patients	15 16
Supportive care	Prevent complications, monitor	All patients	14 16 18

Table 4: Main Treatment Strategies

Surgical Interventions

• Craniotomy/Burr hole: Used to evacuate large, acute subdural, epidural, or intracerebral hematomas 4 8 14 16 18
• Minimally invasive techniques: Stereotaxic aspiration, especially for deep or inaccessible hematomas 14
• Ventricular drainage: For relief of hydrocephalus or severe ICP elevation 16

Surgical removal is often lifesaving, especially in cases of rapid neurological decline or when imaging shows significant mass effect.

Medical Management

• Blood pressure control: Acute hypertension should be managed carefully to avoid further bleeding while maintaining adequate cerebral perfusion 14 16 18
• ICP reduction: Osmotic therapy (mannitol, hypertonic saline), controlled hyperventilation, and CSF drainage are key methods 14 16
• Seizure prevention: Prophylactic anticonvulsants may be considered, especially in intracerebral hematoma 3

Reversal of Anticoagulation

• Immediate reversal of coagulopathy is critical in patients on warfarin or other anticoagulants. Options include:
  • Vitamin K
  • Fresh frozen plasma (FFP)
  • Prothrombin complex concentrates
  • Recombinant factor VIIa (rFVIIa) 15 16
• Reversal protocols may differ based on the specific agent involved 15

Supportive and Adjunctive Care

• Intensive neurocritical care improves outcomes: close monitoring of ICP, cardiorespiratory support, infection prevention, glycemic control, and early nutrition 16 18
• In cases of subdural hematoma associated with spontaneous intracranial hypotension, an epidural blood patch may be indicated before surgical intervention 17
• Postoperative cases require vigilance for recurrence, especially in patients with coagulopathy or extensive hematoma extension 7 9

Conclusion

Intracranial hematomas are diverse in their presentation, causes, and management, but all represent neurological emergencies. Rapid identification and tailored treatment can make a critical difference in outcomes for patients of all ages.

Key points:

• Symptoms range from headache and nausea to life-threatening coma; early signs can be subtle, especially in infants and elderly 1 2 3 13 16.
• Types include epidural, subdural (acute/chronic), and intracerebral hematomas, each with unique clinical features and radiologic patterns 2 3 4 5 6 7 8 13 14 16 18.
• Causes span traumatic injuries, hypertension, vascular malformations, coagulopathies, medications, tumors, and cerebrospinal fluid leaks 1 2 3 4 5 7 9 10 12 13 14 15 16 17 18.
• Treatment requires a combination of surgical and medical strategies, including hematoma evacuation, reversal of anticoagulation, careful blood pressure and intracranial pressure management, and intensive supportive care 4 8 14 15 16 17 18.

By staying vigilant for the symptoms, understanding the underlying causes, and applying evidence-based treatment strategies, clinicians can offer the best chance of recovery for patients facing this critical condition.