Saturday, March 21, 2009

Natasha Richardson

The tragic death of Natasha Richardson stirs memories.

Anyone who has ever watched the inexorable fading of the light that accompanies a traumatic brain injury knows what her family experienced.

There is abiding darkness, but perhaps there is also one tiny bit of silver lining to be found: many more people are now aware of the potential consequences that can follow a seemingly minor "insult" to the brain.

By coincidence, March is Brain Injury Awareness Month and this week is Brain Awareness Week

Education is important. Scientific American offered a neurosurgeon's explanation of possible causes and missed opportunities: getting quick medical attention for a developing trauma is critical - the "golden hour" of emergency medicine.

Because of this tragedy, more people now know that....
The tragic story, if confirmed, is a reminder that even minor blows to the head can lead to devastating bleeding that can cause strokes or otherwise damage brain tissue.
One possibility, sometimes called "talk and die" syndrome, is that the actress had delayed bleeding between her skull and her brain stem, which sits at the top of the spinal cord and regulates consciousness, breathing, and the heart and connects the brain to many of the body's sensory and motor nerves.
Another possibility is that there was a tear in the inner lining of her arteries, causing blood clots. To find out more about Richardson's potential injury, we spoke with neurosurgeon Keith Black, chairman of the Department of Neurosurgery at Cedars-Sinai Medical Center in Los Angeles.

Based on Richardson's symptoms, what kind of injury do you think she suffered?

The possibilities range from what we call an arterial dissection to a preexisting condition that might have been triggered by the event. An arterial dissection is where patients have a very mild injury tear the inner lining of20the arteries of the neck, either the carotid or vertebral arteries, and that can occur with even minor trauma that one may not believe to be significant. That tearing in the artery can cause clotting, which can set up a stroke (an interruption of the brain's blood supply caused by a blockage or a rupture of a blood vessel). If that clot is in the vertebral artery system, it can cause
a stroke in the brain stem, which can be devastating.

The other possibility is delayed bleeding in the brain. That can be from either a tear in a vein or an artery in the brain tissue itself, and that can be either an epidural hematoma (between the skull and the dura, the membrane that surrounds the brain) or a subdural hematoma (between the dura and the brain).

Another possibility is that she had a condition that predisposed her to having a more catastrophic event. This could be an abnormality in how fast her blood clots after a bleed. Or if she's been on any aspirin, blood thinners, or, supplements like omega-3 fish oil, that can make things worse. The other thing one has to worry about is whether she had a vascular abnormality in the brain like an arteriovenous malformation (an abnormal connection between high-pressure arteries and low-pressure veins). If an AVM tears one can get a more significant bleed.

I think the two most likely conditions would either be the arterial dissection in the neck or the delayed bleeding within the brain itself.

What is "talk and die" syndrome?

That refers to the fact that we always worry about people with head injuries that don't show up immediately, which is why we like to observe people after a head injury for 24 hours. Generally when we talk about "talk and die" it's usually a delayed bleed like an epidural hematoma.

How would you assess a patient after a fall like this?

The most important test would be a CT scan (a 3D X-ray that can provide cross-section images of anatomical structures), which would tell you=2 0if there is bleeding in the brain itself. If there is bleeding, it would tell you if it needs to be relieved with surgery or with medication. It would also give you an indication if she's had a stroke, and whether she's had one of these arterial dissections that may be showering blood clots into the brain.

How would you treat her?

If there's bleeding in the brain, if it's causing pressure and if it's an area that's accessible, one may think about surgery to remove the blood clot. Usually, that's done on an emergent basis, and since we haven't heard reports that she's going undergoing surgery then that's probably not the scenario she's facing.

Another possibility is that the clot is in an area that you cannot safely operate on like the brain stem. That's because the structures of the brain are very compact in that area, and it's very risky to operate on. One may then try to manage the clot with medications (such as hypertension drugs like labetalol).

And an interesting article on Medical News points out an obvious lesson in prevention that isn't so obvious to many skiers - it's not that a helmet will always help, but if you're not wearing it, it can't help you...
The apparent lack of focused trauma in Richardson's case cast doubt on whether a helmet would have helped.

But a 2006 Norwegian study found that helmets reduced the rate of head injury among skiers and snowboarders by 60%, regardless of skill level. (See: Helmets Endorsed for Skiers and Snowboarders of All Skills)

Although Richardson may have suffered a freak injury that a helmet could not prevent, injury prevention groups and specialists emphasized that skiers, bicyclists, and others at risk for head injuries should always wear helmets.

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