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Intracranial haematoma, the layer of the bleed changes everything.

A collection of blood inside the skull is a time-critical problem. Where it sits - extradural, subdural, subarachnoid or intracerebral - decides the imaging, the operation and the outlook.

Jump to treatment
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

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against NICE, BOAST and the Royal College of Surgeons standards you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice on head injury imaging, anticoagulation reversal and neurosurgical thresholds.

Key facts

Intracranial haematoma at a glance.

The essentials, in plain English - what it is, the layers of the bleed and how it is treated in the UK today.

  • What it is

    A collection of blood within the skull - inside, above or below the meninges - that can compress the brain and raise intracranial pressure.

  • Main types

    Extradural (epidural), subdural, subarachnoid, intracerebral and intraventricular - each sits in a different anatomical layer.

  • Commonest cause

    Head trauma - falls, road-traffic collisions and assaults account for the majority of extradural and acute subdural bleeds.

  • Key risk factor

    Anticoagulation - warfarin, DOACs and antiplatelets sharply raise the risk of chronic subdural and spontaneous bleeds.

  • Gold-standard test

    A non-contrast CT head - fast, accurate and available in every UK emergency department.

  • Definitive care

    Neurosurgery for evacuation or drainage where indicated, alongside ICP control and reversal of anticoagulation.

Why this guide matters

A time-critical diagnosis with a clear pathway.

Speed to CT, speed to reversal of anticoagulation and speed to a neurosurgeon are the three levers that change outcomes.

  • CT head is the gold standard

    Every suspected intracranial bleed is imaged with a non-contrast CT head - typically within one hour in the UK when red flags are present.

  • Anticoagulation is the modifier

    Warfarin, DOACs and antiplatelets change both the risk and the response - urgent reversal is often the first drug given.

  • Neurosurgery is not optional

    For extradural, acute subdural and symptomatic chronic subdural bleeds, evacuation or drainage is definitive treatment.

How the diagnosis is made

From first symptom to a clear plan.

The steps a UK emergency team and neurosurgical service will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    History and mechanism

    Trauma, timing, loss of consciousness, lucid interval, anticoagulants and antiplatelets - all shape the level of concern.

  2. 02

    Assessing

    GCS and neurological exam

    Glasgow Coma Scale, pupillary size and reactivity, limb power and cranial nerves - repeated to spot deterioration.

  3. 03

    Assessing

    Red-flag screen

    Vomiting, seizure, focal deficit, worsening headache or age with anticoagulation trigger urgent imaging under NICE CG176.

  4. 04

    Confirming

    CT head - the gold standard

    A non-contrast CT identifies extradural, subdural, subarachnoid and intracerebral blood and guides emergency management. See our private CT scan guide.

  5. 05

    Confirming

    Selective MRI

    MRI is used for subacute or chronic subdurals, small brainstem bleeds and when the CT is negative but suspicion remains.

  6. 06

    Confirming

    Angiography where indicated

    CT or catheter angiography looks for an underlying aneurysm or arteriovenous malformation - specialist-led, and essential in spontaneous bleeds.

  7. 07

    Preparing

    Coagulation and specialist review

    Clotting screen, platelet count and immediate neurosurgical discussion - the whole plan turns on this conversation.

Typical timeline: from arrival to CT and neurosurgical decision in hours, not days.

Symptoms

What an intracranial bleed looks like.

A mix of headache, altered consciousness and focal neurology - and the late signs that mean pressure inside the skull is rising.

  • Sudden severe headache

    A new, worst-ever or thunderclap headache is a red flag - especially with vomiting or neck stiffness.

  • Reduced consciousness

    Drowsiness, confusion or a falling GCS is the single most important sign of a significant intracranial bleed.

  • Lucid interval

    A brief recovery after head injury followed by rapid decline is classical for extradural (epidural) haematoma.

  • Focal neurology

    One-sided weakness, speech disturbance, visual loss or facial droop points to focal cortical compression.

  • Pupillary changes

    A fixed, dilated pupil - often on the side of the bleed - suggests uncal herniation and needs immediate neurosurgery.

  • Seizures

    New-onset seizures after head injury or in an anticoagulated patient warrant urgent CT and specialist review.

  • Cushing reflex

    Hypertension, bradycardia and irregular breathing are late signs of raised intracranial pressure and impending herniation.

  • Red flag - anticoagulated fall

    Even a minor bump on warfarin or a DOAC deserves a low threshold for CT and admission for observation.

Treatment

How intracranial haematoma is treated in the UK.

Rapid CT, reversal of anticoagulation and a neurosurgical decision on evacuation or drainage - alongside careful control of intracranial pressure.

  • Urgent CT and neurosurgical referral

    Every suspected intracranial haematoma needs immediate imaging and a specialist conversation - time is brain tissue.

  • Reversal of anticoagulation

    Vitamin K and prothrombin complex concentrate for warfarin, specific reversal agents for DOACs - guided by haematology and the treating team.

  • Craniotomy and evacuation

    The standard operation for extradural and acute subdural haematomas - the skull is opened and the clot removed under neurosurgical care.

  • Burr-hole drainage

    For chronic subdural haematomas the collection is drained through one or two small openings, often with excellent recovery.

  • Aneurysm clipping or coiling

    For subarachnoid haemorrhage from an aneurysm - see our aneurysm coiling guide for the endovascular option.

  • Decompressive craniectomy

    For refractory raised intracranial pressure a section of skull is removed to allow the brain to swell - a last-line, specialist decision.

  • Intracranial pressure management

    Head-up positioning, osmotherapy with mannitol or hypertonic saline, sedation and normothermia in a neurocritical-care setting.

  • Rehabilitation and follow-up

    Neurological rehabilitation, seizure prophylaxis where indicated, and a structured MDT plan for the months that follow.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

If you or someone with you shows any of the red flags on this page after a head injury, call 999 or attend the nearest emergency department without delay.

  • NICE. Head injury: assessment and early management (NG232, updating CG176).

  • BOAST. British Orthopaedic and Neurosurgical Standards for the management of traumatic brain injury.

  • Royal College of Surgeons of England. Standards for the initial management of head injury.

  • National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Managing the flow.

Red flags

When to call 999 without delay.

Any one of the following features after a head injury, or in someone on anticoagulants, is a reason for immediate imaging and specialist review.

  • Falling GCS

    Any drop of two or more points on the Glasgow Coma Scale is a neurosurgical emergency and needs immediate re-imaging.

  • Fixed, dilated pupil

    An unreactive dilated pupil suggests herniation - call 999 or the on-call neurosurgeon without delay.

  • Lucid interval then decline

    The classical extradural pattern - do not be reassured by an initial recovery after head injury.

  • Anticoagulation with new headache

    Warfarin, DOAC or antiplatelet users with a new or worsening headache need CT even without obvious trauma.

  • Thunderclap headache

    A peak-in-seconds headache is subarachnoid haemorrhage until proven otherwise - see our subarachnoid haemorrhage guide.

  • Post-traumatic seizure

    Any first seizure after head injury is an indication for urgent CT and specialist review.

  • Cushing reflex

    Rising blood pressure, falling heart rate and irregular breathing are pre-terminal signs of raised intracranial pressure.

  • Persistent vomiting after head injury

    More than one episode of vomiting following a head injury is a NICE indication for a CT scan within an hour.

  • Age and frailty

    Older adults on anticoagulants can develop chronic subdural haematoma after trivial trauma - low threshold for scanning.

Living with it

Recovery is patient work, with the right team.

Life after an intracranial bleed asks for patience, structured rehabilitation and a careful conversation about when and how to restart medicines that thin the blood.

A quiet reminder

Small steady steps beat heroic weeks.

Sleep, hydration, graded activity and honest reporting of symptoms give the brain the best conditions to heal.

  1. 01 Recovery

    Expect a gradual climb

    Cognitive fatigue, headache and slowed processing are normal for weeks to months - rehabilitation is designed for this.

  2. 02 Anticoagulants

    A structured restart

    When and how anticoagulation is restarted after a bleed is a specialist decision balancing stroke risk and re-bleed risk.

  3. 03 Driving

    DVLA rules apply

    A significant intracranial bleed usually means a period off driving - your neurosurgical team and DVLA will confirm the timeline.

  4. 04 Follow-up

    Keep the MDT close

    Neurology, neurosurgery, rehabilitation medicine and psychology all have a role - the sum is greater than the parts.

Frequently asked

Everything we get asked about intracranial bleeds.

Quick answers on the types of bleed, imaging, surgery and anticoagulation.

  • What is an intracranial haematoma?

    A collection of blood within the skull. Depending on the layer it sits in, it is called extradural (between skull and dura), subdural (between dura and arachnoid), subarachnoid, intracerebral (within brain tissue) or intraventricular. Each behaves and is managed differently.

  • What is the difference between extradural and subdural bleeds?

    Extradural bleeds are usually arterial - typically from the middle meningeal artery after a temporal skull fracture - and cause rapid deterioration after a lucid interval. Subdural bleeds are venous, often from bridging veins, and can be acute (rapid, post-trauma) or chronic (slow, common in older adults on anticoagulants).

  • How is an intracranial haematoma diagnosed?

    A non-contrast CT head is the gold-standard first test - it is fast, accurate and identifies almost every acute bleed. MRI is used selectively for subacute and chronic bleeds, and CT or catheter angiography looks for an underlying aneurysm or arteriovenous malformation.

  • Do all intracranial haematomas need surgery?

    No. Small bleeds with a stable neurological picture may be managed conservatively with close observation and repeat imaging. Larger bleeds, deteriorating patients and chronic subdural collections with symptoms usually need neurosurgical evacuation - craniotomy, burr-hole drainage or, occasionally, decompressive craniectomy.

  • What happens if someone is on anticoagulants?

    Anticoagulants substantially raise the risk of intracranial bleeding and worsen outcomes if a bleed occurs. Urgent reversal - vitamin K and prothrombin complex concentrate for warfarin, specific reversal agents for direct oral anticoagulants - is a priority alongside imaging and neurosurgical review.

  • What is the outlook after an intracranial haematoma?

    It depends on the type, the size, the initial GCS, the speed of treatment and the underlying cause. Many patients with extradural bleeds treated promptly recover fully, chronic subdurals often do well after burr-hole drainage, and severe traumatic brain injury still carries meaningful mortality and disability - which is why speed to imaging and surgery matters so much.

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