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 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.
Natasha Richardson: Wikipedia MSNBC Article
Billy Mays: Wikipedia Yahoo News
June 29, 2009 at 8:06 am
Thanks so much for this. I will certainly pay attention in new ways.
Lori L. Lake
June 29, 2009 at 8:47 am
Excellent article, Doug. You are always SO helpful. Your descriptions and explanations are easy to read and understand, so you make it easy for the layperson to “get.”
June 29, 2009 at 10:00 am
Jonathan E. Quist
June 29, 2009 at 11:22 am
Is there any significant difference between the two types of accidents represented here, in terms of outcome? (Yes, dead is dead…)
In the case of a fall (in N.R.’s case, while skiing), the head (and therefore the brain) has significant momentum at impact – so there would be a “secondary impact” as the brain moves within and strikes the now-stationary skull.
In the case of an object striking the head, the situation is somewhat reversed.
Of course, a physicist would say that acceleration is acceleration, and the only difference is the frame of reference. My gut still wants to believe that there are differences – at the least, in the first case, the body is going through similar acceleration – but I can’t support that belief with a logical reason.
I am reminded of the early ’90’s case of an Illinois State Trooper who slipped on a patch of ice during a routine winter traffic stop. She fell and struck her head, and expired before medical help arrived.
D.P. Lyle, MD
June 29, 2009 at 11:54 am
This is difficult to explain, though I did so in my book Murder and Mayhem with diagrams, but these are called coup and countercoup injuries, which is basically the brain bouncing back and forth inside the skull. The injuries can be both at the point of impact and on the opposite side of the brain where it strikes the skull. Very common in dashboard injuries and in falls.
Karen in Ohio
June 29, 2009 at 12:58 pm
This is so timely for me. Yesterday a tractor mower 40′ away spit out a rock, which hit me in the head hard enough to knock me over. My doctor says to get to the ER if I develop symptoms, but your article gave me a lot more information, and more importantly, a much longer timeframe in which to keep vigilant. If I start feeling nauseous or have a severe headache next week, I will now know what to do.
Thank you so much for the clear information.
June 29, 2009 at 1:36 pm
When my son was about eight, he was running down a hill and fell and hit his head. We were far from home on vacation. He seemed fine, but later that night had a headache and became nauseous. We took him to the nearest ER and they did a CAT scan, found bleeding on the brain and transferred him to a trauma center where they observed him for two days in intensive care. I stayed in his room, my husband and other son stayed at a Ronald McDonald House. The doctors didn’t want him to fly right away because of possible additional pressure on the brain. Everything was a panic. We missed our flight home. But he was okay. Just this morning as we heard that Bill Mays might have died from an undiagnosed concussion, I turned to my husband and told him how lucky we were.
June 29, 2009 at 1:57 pm
Thanks for the information. I remember when Steve Allen died, he had been in some kind of traffic fender-bender, came home apparently okay, lay down on the couch for a nap and died.
This is scary stuff. I don’t think anyone can go through life wirhout bumping a head once or twice. Are there any stats on how often death follows a simple household bump such as bumping into an open cupboard door while busy in the kitchen? Is it a rare thing?
June 29, 2009 at 3:07 pm
I don’t think people realize just how dangerous a head injury can be. I worked in rehab hospital for years & saw the impact of such injuries. Some of them had to relearn how to walk, talk, eat – all those things we as adults take for granted. And they were the lucky ones because their injuries didn’t kill them.
June 29, 2009 at 4:46 pm
Thanks for the info. My dd suffered a serious concussion merely by fainting and I never would have taken her for treatment except the athletic trainers at her school immediately tested her (and they had the baseline test they do at the beginning of each school year, for comparison). Education is so important.
June 30, 2009 at 8:48 pm
My son ran into a tree 5 days ago. It knocked him down and knocked him out momentarily and resulted in a gash in his forehead. I took him to the emergency room for the gash and was surprised at how much testing they did for balance, vision, etc. But I did think of Natasha and was grateful for the young docs there being so thorough. We ended up with durmabond on his forehead, but I did have to wake him up through the night after that.
July 1, 2009 at 11:39 am
Thanks for such a thorough and detailed explanation! I’m working on a story where a character is hit on the head and left outdoors on a cold (10-20 F) night for some hours before he’s found dead. I was thinking hypothermia (as, presumably, would the EMTs), but a subdural hemotoma would be even better for the plot.
August 12, 2009 at 11:04 pm
Natasha Richardson’s death affected me very much. I finally realized it was because the same thing could have happened to me. I fell and hit my head on a hardwood floor a few years ago. I had a terrible headache, but other than that I felt fine. A friend (a doctor) asked me a few questions and sent me home. She told me to go to bed. The next day, I went about my business with no problem. At about 11 o’clock in the evening, almost exactly 24 hours after I fell, I started vomiting and so dizzy I couldn’t walk. I had to crawl to the telephone and call someone to take me to the hospital. The doctor there told me I had a concussion and that I was lucky. He wouldn’t send me home unless I found someone to stay with me. I went home with my parents and my mom had to wake me up every two hours during the night. Later on I learned a person with a head injury sometimes wants to sleep and they should not be left alone. I wonder why my doctor friend didn’t know this? When I read what happened to Natasha Richardson, I literally got chills. It could have been me.
April 28, 2014 at 7:40 pm
About a year ago I got hit in the head by the leg of a chair (long story). It was extremely painful and left a large bruise and cut on the right side of my forehead. I didn’t see stars or black out and I can still remember the whole thing perfectly. The friend who had accidentally injured me made me sit down until an EMS person arrived. They asked me questions then sent me to the school nurse. I sat there with an ice pack for about an hour and a half, then I went back to class. I kept getting headaches around the area where I got hit but ignored them. But, the bruise is still on my head nearly a year after I got it, it hurts when I press on it, and I get headaches sometimes. My mom says it’s probably just scar tissue and when I went to the doctor about 6 months ago, they said I was fine, but I’m still worried.
I’m not sure if this is still being updated but it would be REALLY great if someone would tell me if I’m, like, dying or anything.
D.P. Lyle, MD
April 29, 2014 at 6:46 am
If you are concerned see your physician. Let him or her examine you and decide if all is OK or not—probably is OK but just to be sure.