Remember when you were a kid and you banged your head doing something stupid? Remember how your mother kept coming in and checking on you during the night, waking you up, asking you ludicrous questions? Will it turns out, mom was right.
Yesterday, pitch man Billy Mays died unexpectedly. It is unknown at this time what the exact cause of death was since the autopsy has not been completed, however there is speculation that it could be related to a head entry he suffered on a flight. The plane landed very hard and apparently something fell from the overhead compartment and struck Billy in the head. After the plane landed, he walked off feeling fine and apparently only later began to feel unwell. It’s unclear at this time what his exact symptoms were but apparently when a friend spoke to him on the phone that evening he sounded odd or slow. He went to bed and was found dead early the next morning.
Who can forget the untimely and unexpected death of actress the Natasha Richardson? On March 16, 2009, she suffered a head injury while skiing in Canada. When she was brought off the mountain paramedics were waiting to see her but she said she was fine, sent them away, and went on to her hotel room. Apparently she felt fine for a couple of hours but then developed a headache and was taken to the local emergency room. She deteriorated rapidly and by the time they got her to a major hospital in Montreal, she was brain dead.
How could this happen? To answer this lets look at what happens in closed head injuries. These are bumps and bangs to the head where there is no skull fracture or open wound present, though an occult skull fracture can easily be part of these types of injuries. The point is that the individual does not look seriously injured and has no open wounds that would cause alarm.
Most blows to the head are harmless but occasionally they can cause damage to the brain tissue or to certain blood vessels within the head, which if injured can lead to bleeding inside the skull. We call any bleed that occurs inside the skull an Intracranial Bleed. They come in three basic types: Epidural, Subdural, and Intracerebral. The difference in these three types lies in the location and the cause of the bleed.
An Intracerebral Bleed is one that occurs within the brain tissue itself, while the other two types occur in the space between the brain and the skull. Surrounding the brain in this space is a very tough sheath called the Dura Mater. The space between the Dura and the skull is called the Epidural Space, while the space between the Dura and the brain is called the Subdural Space. A bleed into the outer space (between the Dura and the skull) is called an Epidural Bleed while one that occurs in the space closest to the brain (between the Dura and the brain) is called a Subdural Bleed.
An Intracranial Bleed can be caused by any trauma or can result from ruptured blood vessels such as can occur in some strokes and in some types of ruptured aneurysms. Epidural Bleeds tend to occur in association with skull fractures (typically invisible and only seen on an X-ray) where the fracture tears one of the small arteries that course over the brain in the Epidural Space, which causes bleeding into the Epidural Space. Subdural Bleeds occur from blunt head trauma such as falls or blows to the head. Here the veins that run beneath the Dura bleed and blood collects in the Subdural Space as a hematoma–a collection of blood. Hematoma means blood-tumor.
The skull is made of bone, which means that, unlike a balloon, it cannot expand. If bleeding occurs inside the skull, pressure within the skull will necessarily rise. This will ultimately began to compress the brain and force it out of the skull through the only opening available, the Foramen Magnum. This is the opening toward the back base of the skull where the Brain Stem exits and descends down the spine as the Spinal Cord. This forcing of the brainstem into the Foramen is called “herniation of the brainstem.” Since the control mechanism for our breathing lies within the Brain Stem, a compression of this area interferes with this function. The victim will then stop breathing and die.
One of the dangers of head injuries that are associated with such bleeds is that they may not be apparent at first. In fact, the injury may be minor such as a fall while skiing or something landing on your head from an airplane overhead container. Or any other injury to the head that we have all suffered at some time during our lives. Initially the individual may have a minor headache that is directly related to the injury but otherwise feels well. There can even be a momentary loss of consciousness from the blow. Regardless, the victim initially feels fine and often refuses medical evaluation. After all, it’s just a bump. But as the bleeding continues and the pressure within the skull elevates, symptoms begin to appear. These may be delayed for many hours and it is this seemingly normal period between the injury and the onset of symptoms that is the problem. We call it the “lucid period.”
During this lucid period, the person will speak and act normally and in fact feel well. Only later will the symptoms appear. This delay can be for an hours, days, weeks, and, in some cases, months. These later situations are called delayed Subdurals. The problem is that the delay in symptoms often results in a delay in treatment, which can in turn result in death. This is exactly what happened to Natasha Richardson and may indeed be what happened to Billy Mays. When the symptoms do begin, they cover a very broad range and include things such as: headaches, blurred vision, nausea, confusion, disorientation, slurred speech, poor balance, weakness of one arm or one leg or one side of the body, photophobia (intolerance to light), dizziness, vertigo, hallucinations, sleepiness, and finally coma and death.
The problem is determining which head injuries require a complete evaluation. I mean, you can’t run off and get a brain scan or an MRI every time you bump your head. The key is that after a head injury even if you, or someone you know, feels well don’t just write it off as nothing. Pay attention. If you or this other individual begin to develop any of the above symptoms get to the emergency room for an evaluation. A skull x-rays and CT brain scans are painless and can be lifesaving.
If these tests reveal a bleed, there are several treatment options, depending on the type and severity of the bleed. Intracerebral bleeds are the most difficult since they are often deep into the brain tissue and treatment for these is less effective for the most part. For Epidural and Subdural bleeds a simple opening of the skull and evacuating the clot can be lifesaving. The initial treatment is to simply drill a hole in the skull to release the pressure. We call these burr holes. They can be done in the emergency room on an emergency basis and then a more definitive procedure can follow in the OR.
In this situation time is essential since the brain is being compressed more and more every minute that goes by, so the sooner the pressure is relieved by opening the skull the better the person will do in the long run. Had Natasha Richardson been evaluated immediately and burr holes done at the emergency clinic or had she been immediately helicopter-evacuated to a medical center where emergent surgical treatment could be undertaken, she would likely be alive and well today. Obviously there’s no way of knowing that for sure but that’s the general situation. Both of these cases are sad and it is likely that with rapid and proper medical care these two untimely deaths could have been avoided.