In short
Meningorrhagia – bleeding in or beneath the membranes that cover the brain and spinal cord – is a medical emergency. Treatment depends on where the blood has collected and what caused the bleeding, and usually combines urgent stabilisation, procedures to stop the source of bleeding or remove the blood, and careful monitoring to prevent complications.
Key points
- Meningorrhagia means bleeding in or beneath the membranes covering the brain and spinal cord and always requires urgent hospital treatment.
- Treatment depends on the type of bleed – subarachnoid haemorrhage, subdural haematoma or extradural haematoma – and on its cause.
- A ruptured brain aneurysm is sealed as early as possible, most often by endovascular coiling or, in selected cases, by neurosurgical clipping.
- After a subarachnoid haemorrhage, nimodipine is given for 21 days to lower the risk of reduced blood flow to the brain.
- Large haematomas that press on the brain are removed surgically, while chronic subdural haematomas are usually drained through small burr holes.
- Rehabilitation plays an important role in recovery, which can take weeks to months.
What are the goals of treatment?
Meningorrhagia is not a single disease but a general term for bleeding in the meningeal spaces. In everyday practice doctors use more precise names: subarachnoid haemorrhage (bleeding into the space filled with cerebrospinal fluid around the brain), subdural haematoma (blood collecting between the brain and its outer covering) and extradural (epidural) haematoma (blood collecting between the skull and the outer membrane). Each type is treated somewhat differently, but the main goals are the same.
Doctors aim to keep the patient’s breathing, circulation and brain function stable, to stop the bleeding from getting worse, to relieve pressure on the brain, to prevent the bleeding from coming back and to prevent or treat complications such as brain swelling, a build-up of fluid in the brain or reduced blood flow to brain tissue. Because the condition can deteriorate within hours, treatment usually starts in the emergency department and continues in a specialist neurosurgical or neurocritical care unit.
The choice of treatment depends on the type and size of the bleed, its cause (for example a head injury or a burst blood vessel called an aneurysm), the patient’s level of consciousness, age, general health and any medicines they take, especially blood thinners.
Emergency care and stabilisation
The first hours focus on protecting the brain. The medical team checks the airway, breathing and circulation and, if consciousness is reduced, the patient may need help with breathing from a ventilator. Brain imaging, usually a CT scan, confirms the bleeding and shows where it is. Doctors closely monitor consciousness, pupil reactions, blood pressure, heart rhythm, oxygen levels, body temperature and blood sugar.
Several measures are taken straight away:
- Pain relief and anti-sickness medicines to treat the severe headache and vomiting that often accompany the bleeding
- Blood pressure control to reduce the risk of further bleeding while still keeping enough blood flowing to the brain
- Reversal of blood thinners – if the patient takes anticoagulant medicines, their effect is reversed as quickly as possible with specific antidotes or blood products
- Treatment of seizures if they occur, with anti-seizure medicines
Patients with a subarachnoid haemorrhage are usually transferred to a specialist neuroscience centre, where neurosurgeons and interventional neuroradiologists can treat the cause of the bleeding.
Treating subarachnoid haemorrhage caused by an aneurysm
Most spontaneous subarachnoid haemorrhages are caused by a ruptured brain aneurysm – a weak, bulging spot in the wall of an artery. Because an aneurysm that has bled once can bleed again, with a high risk of death, the key step is to seal it off as early as possible, ideally within the first day or two.
Endovascular coiling
In endovascular coiling, a thin tube (catheter) is passed from an artery in the groin or wrist up to the brain. Tiny platinum coils are placed inside the aneurysm, where they cause the blood to clot and block it off from the circulation. No opening of the skull is needed. Other devices, such as stents or flow diverters, may be used in some cases.
A large international study, the International Subarachnoid Aneurysm Trial (ISAT), found that in patients whose aneurysm was suitable for both methods, coiling led to more people surviving without disability one year later than surgical clipping. For this reason, coiling is often the first choice when it is technically possible.
Neurosurgical clipping
In neurosurgical clipping, the surgeon opens the skull (craniotomy), finds the aneurysm and places a small metal clip across its neck to stop blood flowing into it. Clipping may be preferred when the shape or position of the aneurysm makes coiling difficult, or when a large blood clot in the brain also needs to be removed.
The decision between coiling and clipping is made jointly by a neurosurgeon and an interventional neuroradiologist, taking into account the aneurysm’s features and the patient’s condition.
Preventing complications after a subarachnoid haemorrhage
Even after the aneurysm has been secured, patients remain in hospital for close observation, usually for one to two weeks or longer. One of the most important complications is delayed cerebral ischaemia – reduced blood flow to parts of the brain, often linked to narrowing of the blood vessels (vasospasm), which typically develops between the 4th and 14th day. To lower this risk, patients are usually given nimodipine, a medicine that is taken by mouth or through a feeding tube for 21 days.
Blood can also block the normal flow of cerebrospinal fluid and cause hydrocephalus (a build-up of fluid in the brain). This may require a temporary drain inserted into the brain’s fluid spaces (external ventricular drain) or into the lower back (lumbar drain), and occasionally a permanent shunt. Doctors also monitor and correct the level of sodium in the blood, fluid balance, fever and blood sugar, all of which can affect recovery.
Treating subdural and extradural haematomas
Bleeding between the brain and its coverings is most often caused by a head injury. Treatment depends on the size of the blood collection, how much it presses on the brain and the patient’s symptoms.
Acute haematomas
A large acute subdural haematoma or an extradural haematoma that compresses the brain usually needs urgent surgery. The surgeon removes a section of skull (craniotomy), takes out the blood clot and stops the bleeding vessel. An extradural haematoma can cause rapid deterioration, sometimes after a short period in which the person seems well, so prompt surgery is critical and often leads to a good recovery.
Small collections that do not cause significant symptoms may be treated without surgery. The patient is closely observed and repeat brain scans are done to make sure the blood collection is not growing.
Chronic subdural haematoma
A chronic subdural haematoma develops slowly over weeks, often after a minor head injury in older people or in those taking blood thinners. If it causes symptoms such as confusion, headache or weakness, it is usually drained through one or two small holes drilled in the skull (burr hole drainage), often with a temporary drain left in place for a short time.
Chronic subdural haematomas can come back after drainage. A newer approach, middle meningeal artery embolisation, blocks the small artery that supplies the membrane around the haematoma using a catheter procedure. In a randomised trial published in 2024, adding this procedure to surgery reduced the number of haematomas that returned or needed another operation.
Recovery and rehabilitation
Recovery after meningeal bleeding can take weeks to months. Many people experience tiredness, headaches, problems with memory or concentration, changes in mood or difficulties with movement or speech. Rehabilitation with physiotherapists, occupational therapists, speech and language therapists and psychologists helps patients regain as much independence as possible.
After an aneurysm has been treated, follow-up scans are usually arranged to check that it remains sealed. Patients are also advised to stop smoking and to keep their blood pressure under control, as both reduce the risk of future problems.
New treatments studied in clinical trials
Researchers continue to look for ways to improve outcomes after meningeal bleeding. Clinical trials are testing, among other things, medicines that might prevent narrowing of the brain’s blood vessels after a subarachnoid haemorrhage, new devices for treating aneurysms and catheter-based procedures for chronic subdural haematoma.
Not every promising idea proves effective. For example, the ULTRA trial tested giving the clot-stabilising medicine tranexamic acid very early after a subarachnoid haemorrhage to prevent re-bleeding before the aneurysm was treated. It did not improve patients’ overall recovery, so it is not used routinely for this purpose. Results like this show why new treatments must be tested carefully in clinical trials before they are widely adopted.
Most common treatment methods
- Emergency stabilisation
- Support of breathing and circulation, pain relief and blood pressure control
- Rapid reversal of blood-thinning medicines
- Close monitoring in a neurocritical care or high-dependency unit
- Endovascular coiling of an aneurysm
- Coils are delivered through a catheter to seal the aneurysm from the inside
- Does not require opening the skull
- Often the preferred option when the aneurysm is suitable
- Neurosurgical clipping of an aneurysm
- A metal clip is placed across the neck of the aneurysm during open surgery
- Used when coiling is not suitable or a large clot must also be removed
- Nimodipine
- Given for 21 days after a subarachnoid haemorrhage
- Lowers the risk of delayed cerebral ischaemia
- Surgery for haematomas
- Craniotomy to remove large acute subdural or extradural haematomas
- Burr hole drainage for chronic subdural haematomas
- Middle meningeal artery embolisation as an add-on to reduce recurrence
- Drainage of cerebrospinal fluid
- External ventricular or lumbar drain for hydrocephalus
- A permanent shunt in some patients
- Rehabilitation
- Physiotherapy, occupational therapy, speech therapy and psychological support