Intracranial hemorrhage in newborns: subdural, subarachnoid, epidural and subgaleal

How does this happen?

The brain sits inside several layers. Working outward from the brain: a thin layer called the arachnoid, then a tough layer called the dura, then the skull bone, then a sheet of tissue over the skull, then the scalp. A bleed is named for the space it fills.

Subdural hemorrhage

Blood between the brain's tough outer cover and the brain. It comes from torn bridging veins, usually caused by the molding and stretching a head goes through during birth. Small subdural bleeds are common and often produce no symptoms at all. Large ones can press on the brain. ¹

Subarachnoid hemorrhage

Blood in the thin fluid-filled layer that wraps the brain. This is the most common newborn intracranial bleed and is usually small and self-limiting. Some babies have seizures on about day two and then do well. ¹

Epidural hematoma

Blood between the skull and the dura. It is rare in newborns and is usually associated with a skull fracture. Because it can expand, it needs watching and sometimes surgery. ¹

Subgaleal hemorrhage

Blood in the loose space between the sheet of tissue over the skull and the scalp itself. This space is not enclosed by bone, so it can expand across the whole head, from the eyebrows to the back of the neck and out to the ears.

That is what makes it dangerous. It can hold a very large volume, and a newborn's total blood volume is small. A baby can bleed into their own scalp until they go into shock. ¹

It is most associated with vacuum-assisted delivery, particularly when the cup detaches and is reapplied, or when the procedure is prolonged. Guidance on operative vaginal birth addresses exactly this. ²

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• The normal forces of birth. Small subdural and subarachnoid bleeds occur in uncomplicated births and in babies who are entirely well. ¹
• A long labor, a fast labor, or a large baby, all of which increase molding forces.
• Breech or other malpresentation, where the head is delivered under different forces. ³
• Clotting differences, including vitamin K deficiency bleeding, which is why vitamin K is given at birth.
• An assisted delivery that was genuinely necessary, where the alternative was worse. Instruments exist because sometimes a baby needs to be out quickly. ²

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• Vacuum used outside recommended limits, including repeated cup detachments, prolonged application, or continuing after there has been no progress with pulls. Guidance on operative vaginal birth addresses duration, number of attempts and abandoning the procedure. ² See vacuum extraction injuries.
• Vacuum followed by forceps, or the reverse, which raises the risk to the baby.
• A baby not monitored after an assisted delivery. After vacuum, standard practice is close observation of the head, heart rate and blood count, precisely because subgaleal bleeding can develop over hours. ²
• A boggy scalp not recognized, or head circumference not measured serially, so blood loss went undetected.
• Vitamin K not given at birth.
• Shock not recognized or not treated fast enough once bleeding was underway. ⁴

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• Subgaleal: a soft, boggy swelling that crosses the suture lines and moves when the head is turned. A fast heart rate. Pallor. Poor tone. These are emergency signs.
• Subdural or subarachnoid: often nothing at all.
• Low Apgar score scores if the birth was difficult.
• A caput succedaneum or cephalohematoma, which are different, less serious and often confused with subgaleal bleeding.

The first week

• Seizures, most often around day two with subarachnoid bleeding. ⁵
• Sleepiness, poor feeding, apnea or vomiting.
• A bulging soft spot.
• A falling blood count.
• Jaundice as the body breaks down the collected blood.

Around 3 months

• Most babies with small bleeds have no signs at all by now.
• Head growing faster than expected, which can suggest hydrocephalus. ⁶
• Differences in tone or feeding after a larger bleed.

Around 6 months

• Delay in rolling. ⁷
• Asymmetry if the bleed injured one side.

Around 12 months

• Not sitting independently. ⁷
• Weakness on one side.
• Seizures.

Toddler years

• Most children with small bleeds develop typically.
• After a large bleed, motor, speech or learning differences may appear.

School age

• Learning and attention differences after a significant bleed.
• Epilepsy in a small number of children. ⁸

How is it diagnosed?

Subgaleal hemorrhage is diagnosed at the bedside, not on a scan. The head is examined for a boggy swelling that crosses suture lines, the head circumference is measured repeatedly, and the heart rate and blood count are followed. Waiting for imaging in a baby who is bleeding is the error to avoid. ¹

For the others, imaging decides.

• CT scan is fast and shows fresh blood well, which is why it is often used first when a baby is unwell. It uses X-rays.
• MRI shows more detail, tells old blood from new better, and uses no radiation. It usually needs a more stable baby.
• cranial ultrasound is done at the bedside and is good for bleeding deep in the brain, but it is poor at the surface, where subdural and subarachnoid bleeds sit. A normal ultrasound does not rule these out. ¹

Other tests that belong in the workup: a full blood count and clotting studies, and a bilirubin check as the collected blood breaks down. ⁹

How to tell the three scalp swellings apart

This confuses almost every family, and the distinction matters.

What is the treatment?

Subgaleal hemorrhage

This is treated as blood loss. Replacing blood volume, transfusion, correcting clotting problems, and intensive monitoring. It is managed in a NICU. The critical variable is how quickly it is recognized. ¹

Subdural and subarachnoid

Most need only observation. A large subdural bleed that presses on the brain may need drainage by a neurosurgeon. Seizures are treated with medicine and guided by EEG. ⁵

Epidural

Watched closely, and drained surgically if it expands. ¹

For all of them

• Vitamin K if it has not been given.
• Watching for jaundice as the blood breaks down, since a large collection can push bilirubin up several days later. ⁹
• Head circumference tracking, watching for hydrocephalus. ⁶
• Developmental follow-up after any significant bleed. ¹⁰

What is the long-term outlook?

Most newborns with small subdural or subarachnoid bleeding recover completely with no lasting effects. ¹

Subgaleal hemorrhage that is recognized early and treated promptly can also end with a healthy baby. The harm comes from the shock and the period of low blood flow to the brain, not from the blood in the scalp itself. That is why time to recognition is the thing that matters most.

Larger intracranial bleeds and those that injure brain tissue can lead to cerebral palsy, epilepsy or learning differences, depending on size and location. ¹

Ask two questions to place your own child: how large was the bleed, and was there a period when blood pressure or oxygen was low.

What does daily life look like?

For most families with a small bleed, daily life returns to normal and the bleed becomes a line in the medical history.

Where there was significant blood loss or brain injury, the picture follows the injury rather than the bleed: therapy, developmental follow-up, and sometimes shunt care.

One practical note. Families whose baby had a subgaleal hemorrhage often describe lasting fear about the first hours. If that is you, the parent's own health guide is worth reading. Post-traumatic stress after a traumatic birth is common and it is treatable. ¹¹

What does care cost over a lifetime?

Where a bleed resolves without lasting injury, the cost is the hospital stay.

Where it leads to cerebral palsy, the published anchor is the CDC estimate of about $921,000 in 2003 dollars per person. ¹²

No agency publishes a cost estimate specific to newborn intracranial hemorrhage, so this site does not give one. See the cost of care estimator for ranges by outcome with sources attached.

What can you do this week?

1. Ask which kind of bleed it is, in exact words, and ask for the imaging report.
2. If it was subgaleal, ask what time it was recognized, what the head circumference measurements were, and what the blood count did.
3. If an instrument was used, ask which one, how many pulls, and whether the cup came off. All of this is recorded in the operative note.
4. Ask whether bilirubin is being followed, since a large collection can push it up days later.
5. Ask whether head circumference is being tracked for hydrocephalus.
6. Request the complete records using the records request builder.
7. Ask for developmental follow-up to be arranged before discharge.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the neonatologist

• Exactly which kind of bleed is this, and how large?
• Was there a period of low blood pressure or low oxygen?
• What were the head circumference measurements, and at what times?
• What did the blood count do over the first 24 hours?
• Is bilirubin being followed as the blood breaks down?

For the obstetric team

• Was an instrument used, and which one?
• How many attempts, and did the vacuum cup detach at any point?
• What was the indication for the assisted delivery?
• Is all of that in the operative note?

For the neurologist or neurosurgeon

• Does this bleed need any intervention, or watching?
• What are we watching head circumference for?
• Is there a seizure risk?
• What follow-up do you want, and when?

You can also build a printable list with the question generator.