Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
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Blood pattern plus physiology determines urgency
Intracranial haemorrhage can expand, obstruct CSF flow or cause herniation; a small strategically placed bleed may be more dangerous than a larger stable lesion elsewhere.
Action: Stabilise the patient, reverse relevant coagulopathy through the current drug-specific pathway, obtain urgent CT and contact stroke or neurosurgical specialists based on compartment, trajectory and mass effect.
Synopsis
Identify the CT compartments and patterns of intracranial haemorrhage, assess mass effect and complications, and select the next vascular or specialist investigation without inferring cause from shape alone.
First name the compartment: epidural, subdural, subarachnoid, intraparenchymal or intraventricular; mixed patterns are common after trauma or vascular rupture.
Epidural blood is classically biconvex and suture-limited; subdural blood is usually crescentic and can cross sutures but is constrained by dural reflections.
Subarachnoid blood follows sulci, Sylvian fissures and basal cisterns; distribution can guide aneurysm search but does not identify the culprit with certainty.
Key red flags
Falling consciousness, unequal pupils, new weakness, repeated vomiting or seizure after haemorrhage suggests expansion, hydrocephalus or herniation and requires urgent repeat assessment.
Posterior-fossa blood can rapidly compress the fourth ventricle or brainstem; modest volume does not imply low risk in a confined compartment.
Intraventricular extension with enlarging ventricles may cause acute obstructive hydrocephalus and needs immediate neurosurgical discussion.
A lobar bleed in a younger adult, isolated subarachnoid pattern or unusual location raises an underlying aneurysm, vascular malformation, venous thrombosis or tumour.
Anticoagulant or antiplatelet exposure changes haemostasis planning but does not remove the need to describe the anatomical bleed and any surgical complication.
Epidural pattern
Look for a lentiform extra-axial collection limited by sutures, an adjacent fracture and displacement of underlying brain. Venous epidural blood can cross some expected boundaries, so morphology is not absolute.
Subdural pattern
A crescentic collection follows the convexity and may cross sutures but not dural reflections. Inspect falx and tentorium and recognise mixed attenuation in acute-on-chronic disease.
Subarachnoid pattern
Trace hyperdensity through basal cisterns, fissures and cortical sulci. Central basal blood suggests aneurysmal SAH more than a tiny peripheral traumatic focus, but angiography determines cause.
Intraventricular blood
Inspect dependent horns and all ventricular compartments, distinguish blood from choroid calcification and assess ventricular enlargement or transependymal seepage.
Investigation priorities
01
Non-contrast CT headFirst step
Detect and compartmentalise acute haemorrhage and assess immediate complications.
Management branches
Worked pattern pathwayTraumatic extra-axial blood
A patient deteriorates after a temporal impact and CT shows a lentiform hyperdense collection.
Call neurosurgery while resuscitating and documenting GCS, pupils, focal signs and antithrombotic exposure.
Describe the collection as epidural pattern, measure relevant thickness and shift, and search bone windows for fracture plus other traumatic lesions.
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 13 Sept 2026; clinical approval remains outstanding.
NICE NG232 head injury recommendationsPublished 18 May 2023; recommendations on acute assessment, CT criteria, neurosurgical discussion and neurological deterioration read 13 September 2026. This source governs traumatic head injury across ages and was not generalised to spontaneous disease. Applied specifically to Intracranial haemorrhage patterns.
Brain Trauma Foundation surgical management of traumatic brain injuryPublished 2006; acute epidural and acute subdural sections and scientific foundations read, with current index checked 13 September 2026. Older operative thresholds inform specialist judgement and do not replace attention to location, age or deterioration. Applied specifically to Intracranial haemorrhage patterns.
ESO/EANS 2025 guideline on spontaneous intracerebral haemorrhagePublished 22 May 2025; diagnostic-cause imaging, prognostic-score, blood-pressure, haemostatic, hydrocephalus and surgery sections read. European adult spontaneous ICH guidance; many recommendations are weak and do not govern traumatic haemorrhage. Applied specifically to Intracranial haemorrhage patterns.
NICE NG228 aneurysmal subarachnoid haemorrhage recommendationsPublished 23 November 2022; recommendations 1.1.1–1.1.23 read for CT, timing-dependent negative scans, lumbar puncture, spectrophotometry and specialist transfer. The six-hour route assumes accurate onset, adequate imaging and radiologist reporting. Applied specifically to Intracranial haemorrhage patterns.