Intracranial Bleeding: Warning Signs and What to Do

What intracranial bleeding means

The brain is enclosed in the rigid skull. Bleeding there takes up space and raises pressure, squeezing brain tissue and cutting off its blood supply. How quickly symptoms appear depends on where the bleeding is and whether it comes from an artery (fast) or a vein (slower).

The types are explained in more depth on our intracranial hemorrhage page, and recovery after a bleed on the brain hemorrhage page.

Brain bleed symptoms

• headache, often sudden or steadily worsening
• nausea and repeated vomiting
• confusion, unusual behavior or slurred speech
• increasing sleepiness or difficulty waking
• weakness, numbness or clumsiness on one side
• vision changes or unequal pupils
• seizures
• a stiff neck and sensitivity to light (typical of subarachnoid bleeding)

Use BE FAST to spot a bleeding stroke: Balance, Eyes, Face drooping, Arm weakness, Speech difficulty, Time to call 911.

Signs of a brain bleed after hitting your head

Most head bumps cause no bleeding. These signs suggest one may be developing and need emergency assessment, even if the person seemed fine at first:

• a headache that gets worse rather than better
• vomiting more than once
• becoming drowsier, harder to wake or confused
• a seizure
• weakness, numbness or poor coordination
• slurred speech or not recognizing people or places
• in babies and young children, inconsolable crying, refusing to feed or a bulging soft spot

An epidural hematoma classically causes a brief knockout, a period of apparent recovery, then rapid decline within hours. A chronic subdural hematoma in an older adult may cause only gradual headache, unsteadiness, memory problems or personality change weeks after a minor fall that may have been forgotten.

Who is at higher risk

• People taking blood thinners: warfarin, apixaban, rivaroxaban, dabigatran and edoxaban increase bleeding risk; aspirin and clopidogrel to a lesser degree. See bleeding on blood thinners.
• Adults over 65: the brain shrinks with age, stretching the bridging veins, and falls are more common.
• High blood pressure, particularly if poorly controlled.
• Heavy alcohol use, which raises fall risk and affects clotting.
• Bleeding disorders, low platelets and liver disease.
• Brain aneurysms or vascular malformations, sometimes running in families.
• Cocaine and amphetamine use.

When to get a CT scan after a head injury

Emergency guidelines such as NICE and the Canadian CT Head Rule recommend a CT scan when a head injury is followed by:

• loss of consciousness or memory loss around the event
• a dangerous mechanism, such as a fall from more than 3 feet (1 meter) or 5 stairs, or being hit by a car
• vomiting more than once
• a seizure
• confusion or reduced alertness
• signs of a skull fracture
• age 65 or older with any of the above
• use of an anticoagulant, even with no symptoms

What happens in the ER

1. Rapid assessment: airway, breathing, blood pressure, the Glasgow Coma Scale (a score of alertness) and a check of the pupils and limb strength.
2. CT scan of the head without contrast, which shows fresh blood within minutes. CT angiography looks for an aneurysm or abnormal vessels.
3. Blood tests: clotting tests, platelets and kidney function.
4. Reversal of blood thinners: vitamin K and prothrombin complex concentrate for warfarin, or specific reversal agents such as idarucizumab (for dabigatran) or andexanet alfa (for factor Xa inhibitors), where available.
5. Blood pressure lowering for spontaneous bleeds, to limit growth of the clot.
6. Neurosurgery when needed: a craniotomy to remove a large clot, burr holes to drain a chronic subdural, a drain to relieve fluid pressure, or coiling or clipping of an aneurysm.

Small bleeds may need only observation in hospital and a repeat scan.

Outlook

Outcome depends on the type, size and location of the bleed, the person's age and how quickly treatment starts. Small subdural and epidural bleeds treated promptly often lead to good recovery. Large intracerebral and subarachnoid bleeds carry a high risk of death or disability, and many survivors need months of rehabilitation. Controlling blood pressure, reviewing blood thinner needs and preventing falls all reduce the risk of another bleed.

Prevention

• Treat high blood pressure and check it regularly.
• Take blood thinners exactly as prescribed, keep INR checks up to date if on warfarin, and avoid adding NSAIDs or supplements without advice.
• Reduce fall risk in older adults: good lighting, removing trip hazards, reviewing sedating medicines, strength and balance exercise.
• Wear helmets for cycling, motorcycling and contact sports, and seat belts in cars.
• Limit alcohol and avoid stimulant drugs.

Frequently asked questions

What are the first signs of a brain bleed?

A sudden or rapidly worsening headache, vomiting, confusion, drowsiness, weakness or numbness on one side, trouble speaking and seizures. A sudden "worst headache of your life" can signal bleeding from an aneurysm. Call 911 or your local emergency number immediately.

Can a brain bleed happen days after hitting your head?

Yes. Some bleeds grow slowly. An acute bleed usually shows within 24 hours, but a chronic subdural hematoma can cause symptoms 1 to 6 weeks after a minor bump, especially in older adults and people on blood thinners. New headache, confusion or unsteadiness needs urgent review.

Should I go to the ER if I hit my head on blood thinners?

Yes, in most cases. People on anticoagulants such as warfarin, apixaban or rivaroxaban have a much higher risk of bleeding after head injury, and guidelines recommend a CT scan even when they feel well. Do not skip a dose without medical advice.

Can a small brain bleed heal on its own?

Small bleeds without pressure on the brain are often managed without surgery. The body gradually reabsorbs the blood over weeks. Doctors monitor with repeat scans and neurological checks, control blood pressure and reverse blood thinners to stop the bleed from growing.

What is the difference between intracranial bleeding and a stroke?

About 1 in 10 to 1 in 7 strokes are caused by bleeding (hemorrhagic stroke) rather than a clot. Intracranial bleeding also includes bleeds outside the brain tissue, such as subdural and epidural hematomas from injury, which are not usually called strokes.