A few hours after a fall on a ski slope in a Canadian resort on March 18th, Natasha Richardson appeared "disoriented... with signs of confusion... a concussion," according to a medic. After a lucid interval, she experienced severe headaches. Within a few hours she was verbal but without orientation. The final moments of Richardson's life illustrate the progressive stages of a fatal brain injury. On March 19, the New York Medical Examiner declared the cause of death was due to a traumatic epidural hematoma. Some epidural hematomas may be treated with surgical evacuations or medically if caught early.
A concussion is defined as a trauma-induced alteration in mental status with or without loss of consciousness. Sports-related concussive injuries are common, with repeated injuries predisposing athletes to cumulative neuropsychological deficits. Symptoms are categorized as early (minutes to hours) or late (day to weeks). Early symptoms include headache, dizziness or vertigo, lack of awareness of surroundings, or nausea and vomiting. Late symptoms include persistent headache and impaired attention, concentration, or memory. Easy fatigability, light-headedness, mood and sleep changes, and intolerance to light and sound are other defining features. Symptoms are graded 1-3.
• Grade 1 injuries may last up to 15 minutes and may involve transient confusion
• Grade 2 signs and symptoms may be last longer than 15 minutes
• Grade 3 injuries occur with loss of consciousness
According to the American Academy of Neurology clinical guidelines, athletes should have on-site evaluations for all concussive injuries and neurologic evaluation for injuries that are grade 2 or 3, as in Richardson’s case. Athletes may return to sports with grade 1 injuries only. Close observation and assessments are standards of care and may prove to be life-saving. Risk factors for more serious injury include the use of blood thinners (including aspirin), bleeding disorders, and alcohol abuse. Helmet, seat-belt use, and home safety proofing may prevent traumatic brain injury.
According to the CDC, 1.4 million people in this country sustain a TBI every year. Of those, approximately 1.1 million sustain a mild TBI, some of whom continue to suffer from late symptoms, including persistent headache, fatigue, sensory abnormalities (visual or hearing deficits), cognitive dysfunction, and mood and sleep problems. With 1.8M soldiers deployed, we may be seeing more of these injuries which are often due to blast exposures. While traumatic brain injury is thought of as the signature wound of the war in Iraq and Afghanistan, headache is the signature symptom. Research efforts are necessary to determine and treat the long-term consequences of TBI and posttraumatic headache.
An epidural hematoma is a collection of blood between the skull and the tough covering of the central nervous system called the dura mater. An epidural hematoma often results from a lateral skull fracture that lacerates the middle meningeal artery. Patients may or may not lose consciousness initially. A lucid interval may last hours to 2 days. In fatal cases, there is a rapid evolution of headache, progressive obtundation, seizures and neurologic deficits. As the hematoma expands, vital brain tissue is compressed and blood flow ultimately cut off.