Traumatic Intracranial Bleeds

The significance of these types of brain injuries is that they are the most common causes of death in athletes (Bailes & Hudson, 2001).

An important part of assessing an athlete with a head injury is to exclude the possibility of more severe structural damage to the brain than is the case in a concussion. In particular, we are concerned with possible bleeds within the cranium (skull). For this reason a concussed player may be referred for a brain scan (CT or MRI) or be kept in hospital for observation by a neurosurgeon.

Examples of types of traumatic intracranial lesions are:

Epidural or Extradural Haematoma (EDH)

EDH is the accumulation of blood between the inner table of the skull and the dura (lining of the brain).

A traumatic blow to the head may cause the dura to separate from the skull.
This may occur on the side of the blow (coup injury) or on the opposite side (contra-coup injury). The trauma often causes deformity of the skull with or without a fracture. The bleed is usually arterial and associated with tearing of the meningeal vessels, but may be venous in origin if the dural sinus is torn. The haematoma (blood accumulation) is usually biconvex. The mass of accumulating blood may compress the brain, but patients with EDH are often asymptomatic until the haemorrhage reaches a critically large size.

Subdural Haematoma (SDH)

A post-traumatic collection of blood in the subdural space usually resulting from a venous bleed. SDH occurs more commonly on the contra-coup side and are not usually associated with skull fractures but result from shearing of the bridging veins. SDH may be one of 2 types:

Acute SDH presents within 24-48 hours post injury and is often associated with significant brain tissue damage and bruising.

Chronic SDH which presents at a later stage, even days or weeks after a head injury.

Intracerebral Haemorrhage (IH)

IH is bleeding into the cerebral parenchyma (brain tissue). The most common causes of this type of bleed are NOT traumatic (e.g. high blood pressure and aneurysms). However, IH may occur following blunt trauma to the head resulting in cerebral contusion (bruising), often associated with other types of bleeds.

In order to distinguish concussion (“mild traumatic brain injury”) from the possibility of intracranial bleeds, Concussion South Africa uses the following guidelines:




Findings Findings Findings
  • Asymptomatic
  • Stable headache
  • Scalp haematoma, laceration
  • No moderate or high risk criteria
  • Deterioration of consciousness
  • Worsening headache
  • Alcohol, drugs
  • Seizure, vomiting
  • Deterioration of consciousness
  • Unreliable hx
  • Age < 12years
  • Skull # or Multiple Injuries


  • Depressed / decreasing level of consciousness
  • Focal neuro signs
  • Penetrating skull injury or depressed #


Recommendations Recommendations Recommendations
  • No X-ray / CT
  • Discharge with written head injury instructions


  • CT
  • Discharge or Admit For neurosurgeon according to specified


  • Urgent CT
  • Admit & Notify Neurosurgeon


Specified Criteria For Observation At Home

  • Initial GCS 14 or 15
  • Neurologically intact (amnesia acceptable)
  • No moderate or high risk criteria
  • Normal CT
  • Responsible, sober adult at home
  • Ability to return to hospital if necessary