brain injury basics

The Baltimore Sun

The death of 45-year-old Natasha Richardson last week from what had been labeled a "mild brain injury" after a skiing accident has experts in trauma warning the public to take a blow to the head seriously.

An autopsy confirmed the actress, who fell on the slopes, died of an epidural hematoma, which is bleeding between the skull and the outer layer that covers the brain called the dura. But doctors not involved in her care noted reports that said she initially refused treatment.

It's not possible for those who didn't examine her to say faster treatment would have saved her. And death from such a seemingly minor accident is rare. But they agreed any blow to the head that causes an ache that gets worse requires immediate medical attention. There can be long-term consequences without care.

"There is no such thing as a mild head injury. It's a misnomer," said Vani Rao, director of the Brain Injury Program at Johns Hopkins Bayview Medical Center and a neuropsychiatrist. "Go to the emergency room immediately and get a complete evaluation."

Rao estimates that up to 75 percent of head injuries are labeled mild, but in up to a quarter of those cases, there are significant problems, including sleep and memory troubles, loss of cognitive abilities and changes in motivation and attitude. Many people or their families notice changes in behavior hours, days or even weeks after a person has hit his head, and the injured should seek care then, she said.

In many cases, bleeding is usually revealed by a timely CT scan, which is a more sophisticated X-ray of the body that shows cross-section images, said Dr. Howard Eisenberg, chairman of neurosurgery at the University of Maryland School of Medicine.

An epidural hematoma, which is what an autopsy determined killed Richardson, is usually treatable. Doctors drain the blood that is pooling and clotting and causing pressure on the brain. Small ones can heal without surgery.

Because Richardson was conscious and talking immediately after the accident, she may not have believed the problem was serious. It was reported that she developed a headache about an hour after the accident. Eisenberg said that just meant the initial bleeding was slow.

He said a headache that gets worse is the key symptom of a problem. Others who likely need medical attention after a blow to the head are also increasingly dazed, vomiting or having other behavior changes. They don't need to have lost consciousness.

"We all hit our heads and don't go to the hospital," he said. "But if you're skiing and you hit a tree, if you fall off your roof or get in an auto accident and hit your head, obviously you need medical attention. If you stand up and hit your head on a shelf, probably not. Consider the force."

He also said consider a little prevention. Eisenberg said he decided to start wearing a helmet to ski when he was having lunch with friends before they hit the slopes. They all had their helmets at the table.

"I got up, told them to order me a burger, and I went and bought a helmet," he said. "I'm the neurosurgeon. I should have known."

Sometimes, helmets aren't enough to completely prevent injury. Kyle Wood, 22, of Fishkill, N.Y., is the goalie for the Western Connecticut State University men's team, but has been knocked in the head so many times that he and his doctors are deciding whether he should keep playing. The decision has been made more stressful by the freak accident that killed Richardson, the wife of actor Liam Neeson and daughter of actress Vanessa Redgrave and director/producer Tony Richardson.

Rob Wood, Kyle's father, said that despite the head gear and immediate care, his son has had roughly five concussions and symptoms that have lingered a bit longer each time. Over the summer, he began having more headaches, slower thinking and forgetfulness.

"Will the next one do damage? Will he play the season and never get another one? Will he fall on a bunny slope and be embarrassed and refuse attention?" said Rob Wood. "Who knows."

Wood would like to see better protection developed for athletes and baseline testing for kids before they begin activities so doctors can tell if there are long-term effects that develop from head blows. For now, he'll make sure his son sees the doctor and he'll keep his son's helmet handy.

Those are the right steps, according to Bill Howard, director of the Arnold Palmer Sports Health Center at Union Memorial Hospital. Helmets are a good idea for those engaged in contact sports because they protect the wearers from lacerations, such as from a hockey stick.

Helmets probably wouldn't have saved performer and U.S. Rep. Sonny Bono and Michael Kennedy, son of the late Sen. Robert F. Kennedy, who both died after skiing into trees. Helmets do spread some trauma from a blow, but not that much.

And he said a helmet wouldn't have helped Richardson if, for example, her vein tore from being stretched as she fell or her brain hit her skull suddenly when she hit the ground. Still, he wouldn't discourage skiers from wearing one, as long as they don't believe it makes them invincible. And they should seek medical attention when they need it.

"The problem is, everybody bumps their head, and we don't all need to go to the emergency room for CT scans," he said. "That being said, everyone should be aware if you get struck on the head and it's a moderate blow, [and] there's pain that gets worse, even a little bit, that's a clue to stop what you're doing and get to the hospital."


This is when there is bleeding between the skull and the outer layer that protects the brain, or the dura. The blood pools and clots and puts pressure on the brain. The skull prevents the brain from expanding, so if the pressure is not relieved, it eventually pushes down on the brain stem enough to shut down vital neurological functions housed there, including heartbeat and respiration, and death occurs.

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