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Intracranial hemorrhage
Epidural, subdural and subarachnoid bleeds — source, setting, course and CT appearance — with venous sinus thrombosis for contrast.
| Bleed | Source | Typical setting | Course | CT and work-up |
|---|---|---|---|---|
| Epidural | Arterial: the middle meningeal artery torn by a temporal bone (pterion) fracture | Head injury with a skull fracture | Brief loss of consciousness, a lucid interval, then rapid decline — ipsilateral fixed dilated pupil and contralateral hemiparesis (uncal herniation). Emergency craniotomy | Biconvex (lens-shaped) hyperdensity that does not cross suture lines |
| Subdural | Venous: torn bridging veins | Elderly (brain atrophy), alcohol use disorder, anticoagulation, falls; infants (abusive head trauma, with retinal hemorrhages) | Acute after major trauma, or chronic weeks after minor trauma — gradual headache, confusion, fluctuating consciousness, mild hemiparesis | Crescent that crosses sutures but not the falx; hyperdense when acute, isodense subacute, hypodense chronic |
| Subarachnoid | Ruptured saccular (berry) aneurysm of the circle of Willis in most nontraumatic cases; trauma, AVM | Hypertension, smoking, ADPKD, connective tissue disorders, family history | Sudden thunderclap headache, vomiting, neck stiffness, photophobia. Complications: rebleeding, vasospasm (days 3–14; nimodipine), hydrocephalus, hyponatremia | Noncontrast CT first; if negative, lumbar puncture for xanthochromia; then CTA to find the aneurysm |
| Venous sinus thrombosis (for contrast) | Thrombosed dural venous sinus | Oral contraceptives, pregnancy and postpartum, thrombophilia, cancer, dehydration, mastoiditis | Progressive headache worse lying down, papilledema, seizures, focal deficits. Anticoagulate even if there is hemorrhage | Venous (often hemorrhagic) infarcts that do not match arterial territories; empty delta sign; MR or CT venography |
Epidural = arterial, biconvex, stops at sutures. Subdural = venous, crescent, crosses sutures.
Hypertensive intracerebral hemorrhage arises from lenticulostriate vessels in the putamen or thalamus (see internal capsule).