Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
Intracranial (intra=within + cranium=skull) describes any bleeding within the
skull. Intracerebral bleeding describes bleeding within the brain itself. More
specific descriptions are used based upon where the blood is located.
Bleeding in the skull may or may not be associated with a skull fracture. An
intact skull is no guarantee that there is not underlying bleeding, or
hemorrhage, in the brain or its surrounding spaces. For that reason, plain
X-rays of the skull are not routinely performed.
Epidural, subdural, and subarachnoid bleeding are terms that describe bleeding
in the spaces between the meninges, the fibrous layered coverings of the brain.
Sometimes, the terms hemorrhage (bleeding) and
hematoma (blood clot) are
interchanged. Because the skull is a solid box, any blood that accumulates
within the skull can increase the pressure within it and compress the brain.
Moreover, blood is irritating and can cause
edema or swelling as excess fluid leaks
from the surrounding blood vessels. This is no different than the swelling that
can occur surrounding a bruise on an arm or leg. The only difference is that
there is no room within the skull to accommodate that swelling.
When force is applied to the head, bridging veins that cross through the
subdural space (sub=beneath +dura= one of the meninges that line the brain) can
tear and bleed. The resultant blood clot increases pressure on the brain tissue.
Subdural hematomas can occur at the site of trauma, or may occur on the opposite
side of the injury (contracoup: contra=opposite + coup=hit) when the brain
accelerates toward the opposite side of the skull and crushes or bounces
against the opposite side.
Chronic subdural hematoma may occur in patients who have had atrophy
(shrinkage) of their brain tissue. These include the elderly and chronic
alcoholics. The subdural space increases and the bridging veins get stretched as
they cross a much wider distance. Minor or unnoticed injuries can lead to some
bleeding, but because there is enough space in the skull to accommodate the
blood, there may be minimal initial symptoms. Asymptomatic (producing no
symptoms) chronic subdural hematomas may be left to resolve on their own;
however, it may
require attention if the individual's mental status changes or further bleeding occurs.
Depending upon the neurologic status of the affected individual, surgery may be
Thee dura is one of the meninges or lining membranes that covers the brain.
It attaches at the suture lines where the bones come together. If the head
trauma is epidural (epi=outside +dura) the blood is trapped in a small area and
cause a hematoma or blood clot to form. Pressure can increase quickly within the
epidural space, pushing the clot up against the brain and causing significant
While individuals who sustain small epidural hematomas may be observed, most
require surgery. Patients have improved survival and brain function recovery if
the operation to remove the hematoma and relieve pressure on the brain occurs
before they have lost consciousness and become comatose.
An epidural hematoma may often occur with trauma to the temporal bone located
on the side of the head above the ear. Aside from the fact that the temporal
bone is thinner than the other skull bones (frontal, parietal, occipital), it is
also the location of the middle meningeal artery that runs just beneath the
bone. Fracture of the temporal bone is associated with tearing of this artery
and may lead to an epidural hematoma.
In a subarachnoid hemorrhage, blood accumulates in the space beneath the
inner arachnoid layer of the meninges. The injury is often associated with an
intracerebral bleed (see below). This is also the space where cerebral spinal
fluid (CSF) flows and affected individuals can develop severe
vomiting, and a stiff neck because
the blood causes significant irritation to this meningeal layer. It is the same
response that can be seen in patients who have a
leaking cerebral aneurysm or
meningitis. Treatment is often observation and controlling the symptoms.
These terms describe bleeding within the brain tissue itself and can be
considered a bruise to the brain tissue.
Aside from the direct damage to the brain tissue that was injured, swelling
or edema is the major complication of an intracerebral bleed.
Surgery is not often considered except in situations in which the pressure
within the skull increases to the point at which part of the bone is temporarily
removed to allow the brain to expand. When and if the brain swelling resolves,
another operation replaces the piece of skull that was removed.
Diffuse Axonal Injury or Shear Injury
A potentially devastating brain injury occurs when the brain injury occurs
to the axons, the part of the neurons or brain cell that allows those cells to
send messages to each other. Because of the damage of electrical flow between
cells, the affected individual often appears comatose with no evidence of bleeding within
the brain. The mechanism of injury is usually acceleration-deceleration, and the
nerve endings that connect the brain cells rip apart.
Treatment is supportive, meaning that there is no surgery or other
treatment presently available. The patient's basic needs are met hoping that the
brain will recover on its own. Most don't.
Concussions may be potentially considered a milder form of this type of
Picture of the areas of the brain subject to injury
Picture of an epidural, subdural, and intracerebral hematomas