Traumatic intracerebral hemorrhage

Ravindra Kumar Garg MD (Dr. Garg of King George's Medical University in Lucknow, India, has no relevant financial relationships to disclose.)
Steven R Levine MD, editor. (

Dr. Levine of the SUNY Health Science Center at Brooklyn has no relevant financial relationships to disclose.

Originally released August 28, 1996; last updated March 12, 2019; expires March 12, 2022

This article includes discussion of traumatic intracerebral hemorrhage, acute traumatic intracerebral hemorrhage, delayed traumatic intracerebral hemorrhage, traumatic brain injury, and traumatic intracranial hemorrhage. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.


Intracerebral hemorrhage is a common complication of traumatic brain injury. Traumatic brain injuries can be classified into three major groups: closed head injury, penetrating injury, and explosive blast injury. Blast injuries appear to have a high risk for traumatic pseudoaneurysm formation. Differentiation between an intracerebral hemorrhage and hemorrhagic contusion is difficult. Glasgow Coma Scale is the most valuable tool to assess the level of consciousness after traumatic brain injury. Intracranial hemorrhage in patients with traumatic brain injury results in poor neurologic outcomes and high mortality. In severe head injury, a hematoma of more than 50 mL is associated with higher mortality. Brain edema is a very significant independent prognostic variable across all categories of traumatic brain injury severity. Traumatic intracerebral hemorrhage, like spontaneous hemorrhage, often expands over time. The contrast extravasation, on multidetector CT angiography, is a strong and independent predictor of hematoma expansion, poor outcome, and increased risk of in-hospital mortality. Intraventricular hemorrhage on initial CT predicts lesions of diffuse axonal injury in the corpus callosum. Coagulopathies are common in patients with severe head injuries and contribute to the hematoma formation. The patients taking antiplatelet and anticoagulant drugs are at greater risk of intracranial hemorrhage and treatment should include immediate withdrawal of these drugs. Effective neurocritical care coupled with timely and appropriate neurosurgical intervention can significantly improve outcome. A published randomized trial suggested that early surgery (hematoma evacuation within 12 hours of randomization) led to significantly fewer deaths. Many patients even with a Glasgow Coma Scale of 3 may have a good outcome at six months. In this article, the author discusses the pathophysiology, clinical presentation, impact on outcome, and available treatments for traumatic intracerebral hemorrhage.

Key points


• Traumatic intracerebral hemorrhages result from either nonpenetrating or penetrating trauma to the head.


• A contusion consists of blood intermixed with brain tissue.


• Data have shown that traumatic intracerebral hemorrhages often expand over time.


• Delayed posttraumatic hemorrhages may sometimes result from coalesced blood within contusions.


• Therapeutic interventions that are frequently used include administration of hypertonic saline, hyperoxygenation, decompressive craniectomy, and hypothermia.


• Mortality rates in severe traumatic brain injury are very high.


• Use of helmets, seat belts, and airbags has been shown to reduce fatal and serious head injuries.

Historical note and terminology

Traumatic head injury has been noted in human civilization for 3000 years. Descriptions of head injury are available in ancient Sumerian, Egyptian, and Greek medicine. Hippocrates suggested that head injury in which the cranium was perforated might be followed by serious consequences, such as the extravasation of blood. Hippocrates’ treatise On Wounds in the Head represents an excellent classical source of information about head injury (Panourias et al 2005). The first description about gunshot wounds to the head was by Brunschwig, a German surgeon (Brunschwig 1497; McCrory and Berkovic 2001). Cushing in his classical article of 1917 described varieties of missile injuries (Cushing 1917). Surgical treatment of traumatic intracerebral lesions was advanced in the late 19th and 20th centuries by several pioneer neurosurgeons, including Victor Horsley, Harvey Cushing, W H Jacobson, Hugh Cairns, and Walter Dandy. In 1974, the Glasgow Coma Scale (GCS) was first used as a functional scale for the assessment of coma and impaired consciousness (Teasdale and Jennet 1974). The development of brain CT allowed improvements in the diagnosis and characterization of traumatic intracerebral hemorrhage, and the traumatic brain injury field is being further revolutionized by the development and refinement of brain MRI (McArthur et al 2004).

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