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Health condition · Clinically reviewed

Brain haemorrhage, the types, the imaging and the modern UK plan.

Bleeding inside the skull covers a family of very different conditions. This guide walks through each type, what to look for and how it is treated on a UK hyperacute stroke pathway.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE, AHA and ESO stroke and neurocritical care guidance you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including PCC reversal, andexanet alfa, INTERACT BP targets and MISTIE III minimally invasive evacuation.

Key facts

Brain haemorrhage at a glance.

The essentials, in plain English: what it is, the main types by anatomy, and the first decisions on a hyperacute pathway.

  • What it is

    Bleeding inside the skull. Grouped by where the blood sits: brain tissue (ICH), subarachnoid space (SAH), subdural, epidural, ventricles or as microbleeds on MRI.

  • Main types

    Intracerebral, subarachnoid, subdural, epidural, intraventricular and microbleeds. Each has different causes, timing and surgery.

  • Commonest causes

    Hypertension and cerebral amyloid angiopathy for spontaneous ICH. Trauma for subdural and epidural. Ruptured aneurysm for SAH.

  • First imaging

    Urgent non-contrast CT of the brain within minutes of arrival. CT angiogram follows if a vascular cause is suspected.

  • Blood-pressure target

    Rapid but controlled lowering to a systolic of 130 to 140 mmHg in the first hours, per INTERACT and ATACH-2.

  • Reversing blood thinners

    Warfarin: vitamin K and prothrombin complex concentrate. Dabigatran: idarucizumab. Apixaban, rivaroxaban, edoxaban: andexanet alfa or PCC.

Why this guide matters

Six different bleeds. One time-critical decision tree.

Intracerebral, subarachnoid, subdural, epidural, intraventricular and microbleeds all look different on imaging and need different responses. The three points below shape everything else on this page.

  • Imaging first, always

    A non-contrast CT within minutes tells you what kind of bleed it is and what happens next - clot busters, blood-pressure control or the neurosurgical theatre.

  • Blood pressure and reversal

    Rapid systolic control to 130 to 140 mmHg plus urgent reversal of warfarin or a DOAC are the two most time-sensitive medical steps.

  • Surgery for the right patients

    Cerebellar bleeds over 3 cm, extradural haematomas and chronic subdurals in the elderly benefit clearly from surgery. Supratentorial ICH is more selective.

How the diagnosis is made

From ambulance door to a clear plan.

The steps a UK hyperacute stroke pathway will normally follow, in order, so you know what to expect and why.

  1. 01

    Assessing

    Rapid neurological assessment

    GCS, pupils, NIHSS, focal deficits and airway status recorded on arrival. Time-critical pathway activated.

  2. 02

    Assessing

    Urgent non-contrast CT brain

    The first-line scan. Fresh blood is hyperdense and shows the pattern: parenchymal, subarachnoid, subdural, epidural or ventricular.

  3. 03

    Assessing

    CT angiogram

    Looks for an aneurysm, AVM, dural fistula or tumour. The spot sign on CTA predicts haematoma expansion.

  4. 04

    Confirming

    MRI with SWI or gradient echo

    Detects microbleeds, cerebral amyloid angiopathy, cavernomas and any underlying tumour once the patient is stable.

  5. 05

    Confirming

    Lumbar puncture if needed

    If SAH is suspected and CT is negative after six hours, LP looks for xanthochromia in the cerebrospinal fluid.

  6. 06

    Preparing

    Bloods and toxicology

    Full clotting screen, platelets, INR, anti-Xa if on a DOAC, glucose, U&E and a urinary drug screen for cocaine or amphetamines.

  7. 07

    Preparing

    Hyperacute stroke unit transfer

    Admission to a hyperacute stroke unit or neurocritical care with a neurosurgery MDT on standby.

Typical timeline: from ambulance to a settled plan within hours.

Symptoms

What a brain bleed actually looks like.

Different bleeds carry different fingerprints - from the thunderclap of SAH to the slow confusion of chronic subdural. Any of the features below deserves urgent assessment.

  • Sudden severe headache

    A thunderclap headache peaking in seconds is the hallmark of subarachnoid haemorrhage and needs same-hour imaging.

  • Focal neurological deficit

    Weakness or numbness down one side, facial droop, slurred speech or visual loss appearing over minutes.

  • Reduced consciousness

    Drowsiness, confusion or coma. A falling GCS is a red flag for expanding bleed or raised intracranial pressure.

  • Vomiting and photophobia

    Nausea, projectile vomiting, neck stiffness and light sensitivity, especially with SAH or hydrocephalus.

  • Seizure

    A first seizure at onset or in the first days after a bleed, especially with lobar or cortical involvement.

  • Lucid interval then decline

    Classic epidural haematoma pattern: head injury, brief recovery, then rapid deterioration and an enlarging pupil.

  • Slow confusion in older adults

    Chronic subdural haematoma often presents insidiously with confusion, falls, headache or behaviour change after minor trauma.

  • Red flag - brainstem signs

    Pinpoint pupils, cranial-nerve palsies, breathing changes or coma suggest brainstem or cerebellar bleed and are an emergency.

Treatment

How brain haemorrhage is treated in the UK.

Rapid BP control and anticoagulant reversal in the first hour. Surgery when the anatomy demands it. Treatment of the underlying cause and long weeks of neurorehabilitation.

  • Hyperacute stroke unit care

    Airway, breathing, glucose and temperature control, with continuous monitoring on a hyperacute stroke or neurocritical care unit.

  • Blood-pressure control

    Rapid lowering of systolic BP to 130 to 140 mmHg with IV labetalol, GTN, nicardipine or clonidine, per INTERACT and ATACH-2.

  • Anticoagulant reversal

    Warfarin: vitamin K plus Beriplex or Octaplex to INR under 1.3. Dabigatran: idarucizumab (Praxbind). Xa-inhibitors: andexanet alfa or PCC.

  • Antiplatelet decisions

    Platelet transfusion is no longer routine after the PATCH trial. Individual decisions depend on drug, dose and planned surgery.

  • Tranexamic acid

    TICH-2 did not show outcome benefit but tranexamic acid can reduce haematoma expansion in selected early cases.

  • ICP management

    Head up 30 degrees, sedation, mannitol or hypertonic saline, short-term hyperventilation and an external ventricular drain for hydrocephalus.

  • Surgical evacuation

    Mandatory for cerebellar bleeds over 3 cm, brainstem compression and hydrocephalus. Supratentorial ICH: selective, often via MISTIE III minimally invasive or endoscopic evacuation.

  • Subdural and epidural surgery

    Chronic subdural: burr-hole drainage. Acute subdural or epidural: urgent craniotomy with haematoma evacuation and middle meningeal artery control.

  • Treating the source

    Aneurysm coiling or clipping, AVM embolisation, surgery or stereotactic radiosurgery, moyamoya bypass, tumour resection or cavernoma removal.

  • DVT and complication care

    Compression stockings and intermittent pneumatic compression from day one. Prophylactic LMWH is added 24 to 72 hours after haemostasis is confirmed.

  • Secondary prevention

    Long-term blood-pressure control, individualised timing for restarting antithrombotics and lifestyle changes to lower rebleed and stroke risk.

  • Neurorehabilitation

    Physiotherapy, speech and language therapy, occupational therapy and neuropsychology from the stroke unit into community rehab.

What this guide is based on

The sources behind every claim on this page.

UK national guidance, international stroke society standards and landmark clinical trials, current at the time of last review.

Key references

Guidelines, trials and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your stroke team and neurosurgeon know your scan and history and can tell you which parts apply to you. If in doubt, call 999.

  • NICE. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (NG128).

  • National Clinical Guideline for Stroke for the UK and Ireland (2023, Royal College of Physicians).

  • American Heart Association / American Stroke Association. Guideline for the management of spontaneous intracerebral haemorrhage (2022).

  • European Stroke Organisation. Guideline on the management of spontaneous intracerebral haemorrhage.

  • INTERACT2, ATACH-2, TICH-2, PATCH and MISTIE III trials.

  • MHRA and BNF guidance on idarucizumab, andexanet alfa and prothrombin complex concentrate.

Red flags

When a headache or head injury needs 999.

These are the situations where minutes matter. If any of these apply to you or someone with you, call 999 and ask for the nearest hyperacute stroke or major-trauma centre.

  • Thunderclap headache

    Sudden severe headache peaking within seconds. Assume subarachnoid haemorrhage until proven otherwise and call 999.

  • Head injury with declining consciousness

    Any head injury followed by drowsiness, vomiting or a new deficit needs immediate CT. Classic pattern for extradural or acute subdural bleed.

  • Lucid interval

    Brief recovery after a head injury then rapid deterioration and a dilating pupil is a surgical emergency for extradural haematoma.

  • Focal deficit in an anticoagulated patient

    Weakness, dysphasia or a fall in someone on warfarin, apixaban, rivaroxaban, edoxaban or dabigatran is a bleed until CT proves otherwise.

  • Seizure with new headache or deficit

    A first seizure with headache, vomiting or focal signs points to a structural cause including bleed, tumour or venous sinus thrombosis.

  • Chronic subdural in older adults

    Progressive confusion, falls, headache or personality change weeks after a minor head knock. Very treatable if picked up early.

  • Pregnancy or postpartum thunderclap

    Severe headache in pregnancy or the puerperium can mean venous sinus thrombosis, eclampsia, RCVS or ruptured aneurysm.

  • Cocaine or amphetamine use

    Sudden headache or deficit after stimulant use raises the risk of hypertensive bleed, vasospasm and aneurysm rupture.

  • Brainstem or cerebellar signs

    Vertigo, ataxia, cranial-nerve palsies or breathing changes need urgent posterior-fossa imaging and surgical review.

Living with it

Recovery is long, but it does happen.

Four things that make the biggest difference after a brain bleed: relentless blood-pressure control, careful decisions about blood thinners, structured neurorehabilitation and the right support network.

A quiet reminder

Progress is measured in weeks and months, not days.

Fatigue, mood changes and cognitive slowness are normal early on. A good stroke rehab team plans for them and works around them.

  1. 01 BP

    Blood pressure is the whole game

    Hypertension is the single biggest driver of rebleed and future stroke. Home monitoring and long-term treatment matter more than any tablet or supplement.

  2. 02 Blood thinners

    Restarting anticoagulation is a shared decision

    Timing depends on the reason for the bleed, the reason for anticoagulation and imaging follow-up. Never restart on your own.

  3. 03 Rehab

    Rehabilitation is where recovery happens

    Physio, speech therapy, occupational therapy and neuropsychology from the stroke unit into community services shape long-term function.

  4. 04 Support

    You do not do this alone

    Stroke Association, Different Strokes, Brain and Spine Foundation and Headway offer helplines, groups and family support.

Frequently asked

Everything we get asked about brain haemorrhage.

Quick answers on types, imaging, blood-pressure targets, anticoagulant reversal and surgery.

  • What is a brain haemorrhage?

    A brain haemorrhage, or intracranial haemorrhage, is bleeding inside the skull. It is grouped by where the blood sits: inside brain tissue (intracerebral), in the subarachnoid space around the brain, between the dura and the brain (subdural), between the skull and dura (epidural or extradural), inside the ventricles or as tiny microbleeds visible only on MRI. Each type has different causes, timing and treatment.

  • How is a brain haemorrhage different from an ischaemic stroke?

    Both are strokes. An ischaemic stroke is caused by a blocked artery starving brain tissue of blood. A haemorrhagic stroke is caused by a burst blood vessel bleeding into or around the brain. The symptoms can look identical, which is why an urgent non-contrast CT scan is the first test - it can tell them apart in seconds and it decides whether clot-busting drugs are safe or forbidden.

  • What causes an intracerebral haemorrhage?

    The commonest causes are long-standing high blood pressure (typically bleeding into the basal ganglia, thalamus, pons or cerebellum) and cerebral amyloid angiopathy, which causes lobar bleeds in older adults. Other causes include ruptured aneurysms, arteriovenous malformations, tumours, coagulopathy, cocaine or amphetamine use, venous sinus thrombosis and moyamoya disease.

  • What is the difference between a subdural and an extradural haematoma?

    A subdural haematoma sits between the dura and the brain and usually comes from a torn bridging vein - it can be acute after major trauma, or chronic in older adults after a minor knock, presenting with slow confusion and falls. An extradural (or epidural) haematoma sits between the skull and the dura, usually from a middle meningeal artery tear next to a skull fracture. The classic picture is a lucid interval after the head injury then rapid deterioration - it is a neurosurgical emergency.

  • How quickly should blood pressure be lowered?

    Current guidance based on the INTERACT and ATACH-2 trials is to bring systolic blood pressure down to 130 to 140 mmHg in the first hours after a spontaneous intracerebral bleed, using intravenous labetalol, GTN, nicardipine or clonidine. This reduces haematoma expansion without harming brain perfusion when done carefully.

  • How is bleeding on blood thinners reversed?

    Warfarin is reversed with intravenous vitamin K and prothrombin complex concentrate (Beriplex or Octaplex) aiming for an INR below 1.3. Dabigatran has a specific antidote, idarucizumab (Praxbind). Apixaban, rivaroxaban and edoxaban can be reversed with andexanet alfa (Ondexxya) or with prothrombin complex concentrate. Antiplatelet reversal is more controversial - the PATCH trial showed platelet transfusion did not help, so it is used selectively around surgery.

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