March 26, 2009
Head injuries - Cover story
Head trauma
Head injuries can range from a minor bump to a fatal blow like what caused the death of actress Natasha Richardson in a skiing incident. Learning to recognise a serious head injury and getting help early can save a person's life
By Poon Chian Hui
Almost every newspaper and news website had specialist comments and diagrams about fatal brain injuries following Natasha Richardson's death last Wednesday.
The British actress, 45, had fallen on a beginners' ski slope in Canada two days earlier. Although she appeared well and was talking after the fall, she complained of a severe headache an hour later, was taken to hospital and died two days later from bleeding near the brain.
It was a shocking case,mainly because it underscores a chilling fact.
Seemingly simple head injuries can kill.
This is because the initial damage from serious head injuries is irreversible, said Dr Tang Kok Kee, a neurosurgeon at Mount Elizabeth Medical Centre.
However, seeking medical help early can help prevent the damage from escalating.
Close monitoring of the patient in the first 24 to 48 hours is crucial in spotting any signs of major damage, said Dr Tang.
Major damage can manifest itself in several ways. Blood vessels rupture. Nerve fibres tear. The skull fractures. The brain is flung against the hard skull, resulting in bruises known as brain contusions.
'What doctors do is to prevent the cascade of life-threatening events from happening as a result of the initial damage,' he said.
'For instance, if a brain scan reveals bleeding, we will try to remove the blood clot through surgery before it grows bigger,' he said. 'Otherwise, blood supply to the brain will be cut off, resulting in brain death.'
What happened to Richardson was brain death from bleeding. Neurologists said that hers was a classic case of the 'talk and die' syndrome.
This is a condition where patients are well and talking after the incident but deteriorate rapidly, resulting in death, said Professor Yeo Tseng Tsai, a senior consultant at the division of neurosurgery at National University Hospital.
The usual causes are delayed bleeding or swelling of the brain due to cerebrospinal fluid accumulation, he said.
Autopsy results confirmed that the actress died of an epidural hematoma, where a torn blood vessel caused blood to gradually pool between the brain and the skull, forming a clot.
Bleeding and swelling increase pressure within the skull and this is potentially fatal, said Prof Yeo. This is because the skull is an enclosed cavity that has little room for excess fluids. When that happens, the brain gets 'pushed' against the skull.
In the 'talk and die' syndrome, the patient's deterioration can range from several hours to several days, depending on the rate of bleeding or swelling of the brain, said Prof Yeo.
'Most of the time, the patient dies within a few days after sustaining the injury, or goes into a coma,' he said. 'Only about 10 to 20 per cent of those who survive severe head injuries recover fully.'
The rest usually remain in a vegetative state.
However, people above 50 years old may take several months to feel any ill effects from a mild blow caused by, for example, a fall at home.
'As one grows older, brain atrophy occurs,' said Dr Tang. 'The brain loses volume and there is now more empty space in the skull.'
Hence, a longer time is needed for the swelling and bleeding to push the intracranial pressure to breaking point. The bad thing is, the longer the delay, the worse the problem may get, he said. Besides, an atrophic brain is also more susceptible to head injuries.
'Imagine a small ball in a big box,' said DrTang. 'Even if you shake the box gently, the ball hits the wall of the box with significant impact, as compared to a bigger ball, which does not move around as much.'
Severe head injuries can therefore occur without direct impact or any visible bruising, said Associate Professor Christopher Ang, a consultant neurosurgeon at the National Neuroscience Institute.
'Severe rotational or translational - side to side - forces caused by violent shaking motions can result in very severe head injury without visible bruising on the scalp,' said ProfAng.
A common scenario is when one brakes suddenly while driving. The head stops moving but the brain is thrown back and forth against the skull, added Dr Tang.
Rotational forces can also result in chronic brain injury known as the 'shaken boxer syndrome'. It commonly affects boxers, as well as some football and rugby players, as they often sustain repeated blows to the head.
'This syndrome is a result of multiple small shocks to the brain and can take years to develop,' said Prof Yeo. The blows are not strong enough to cause bleeding and death but long-term damage such as decreased mental abilities are likely. A famous example is boxer Muhammad Ali, who upon retiring was diagnosed with Parkinson's disease, a neurological disorder.
Treatment options vary according to the extent of damage revealed in the CT scan. For severe head injuries, drugs to control brain swelling may be given. If there is a large blood clot or severe brain swelling, surgery is needed to remove the clot and part of the skull bone to relieve pressure.
While most head injuries are harmless, one should seek medical help if there are symptoms such as headaches, nausea, vomiting, changes in consciousness, speech problems and weakness of the limbs.
'These symptoms indicate a build-up of pressure within the skull,' said Dr Tang.
Brain swelled due to bleeding
A seemingly harmless fall could easily escalate into a life-threatening head trauma injury.
In January, Mr Geoffrey Goh, 60, became groggy and confused after a fall at work. He was eventually hospitalised for 24 days as his brain swelled dangerously from bleeding.
'My father returned from work that night and said that he was not feeling well,' said his daughter, Ms Danielle Goh, 29. 'He went straight to bed but woke up a couple of hours later and vomited.'
She added: 'The next day, he was very restless. By noon, he became incoherent and very confused. That was when we decided that something was very wrong.'
The family initially feared that Mr Goh had suffered a stroke but a CT scan at National University Hospital revealed bleeding in the frontal area of the brain. Visible bruises on the back of his head and shoulder showed that his brain injury came from a fall.
Thankfully, Mr Goh had sought medical help early enough. Doctors kept him under close observation, performing regular brain scans to monitor his condition.
'My father was very fortunate that the swelling subsided and surgery to remove part of the skull to relieve the pressure was not required,' she said.
Mr Goh was discharged from the hospital last month and is now recuperating at home.
'Apart from the occasional mood swings and flashes of impatience, which doctors told us are typical side effects of brain injury patients, he is doing well,' said Ms Goh.
TYPES OF HEAD INJURIES
1 CONCUSSION: It is the most common type of head injury. Also known as a mild traumatic brain injury, a concussion is characterised by a temporary loss of brain function, such as memory loss. In severe cases, the effects may be long-term. It is usually caused by significant blunt force trauma. The brain is thus jarred or shaken. However, bleeding in the brain or under the skull does not occur in a concussion.
2 HEMATOMA: It is a build-up of blood that later clots to form a bump, either within or outside the skull. An epidural hematoma occurs between the skull and the dura - the outermost layer of the membrane that encloses the brain. Bleeding usually stems from ruptured arteries. In most cases of epidural bleeding, the skull is fractured as well.
A subdural hematoma is a collection of blood in the space between the dura and the middle layers of the covering of the brain. Often, it is caused by torn, bleeding veins on the inside of the dura.
3 SKULL FRACTURE: This is when the skull bone cracks. Broken edges may tear into blood vessels, causing bleeding.
4 CONTUSION: This refers to bruising of the brain tissue. It can be caused by sudden acceleration or deceleration - the head stops but the brain continues to move due to inertia. This causes the brain to collide with the inside of the skull, causing injury to the soft brain tissue. Bleeding occurs, which leads to swelling of the brain.
Symptoms
Most of the head injuries people experience every day are not life-threatening. However, you may want to seek medical help if you experience unexplainable headaches or nausea after hitting your head.
Here is what to look out for:
· Persistent and severe headaches that get worse with time.
· Nausea and vomiting that do not go away.
· Unexplained drowsiness.
· Double vision.
· Behavioural changes, like confusion and irritability.
· Numbness in arms or legs.
· Loss of consciousness.
· Seizures.
Source: Various websites
Only about 10 to 20% of those who survive severe head injuries recover fully
Never take a chance with a head injury
By Gloria Chandy
A head injury story never fails to chill my blood - and even more so when it is fatal.
Having been an alarmed witness to such an incident some years ago, I insist that anyone who has had a fall, even if it's a small impact, see a doctor at once.
As neurosurgeons explain in our article, when someone suffers a blow to the head, be it from a fall or other means, the outcome is largely influenced by how quickly the victim or those around him react to it.
They say it is crucial that the patient gets medical help early so any damage to the brain can be prevented from escalating. Also, close monitoring of the patient in the first 24 to 48 hours is of vital importance.
If only people took such warnings to heart, more lives could be saved. If the victim can't or won't act on it, others absolutely must. Some can be bull-headed, so use threats or force if necessary to get them to see a doctor.
My husband, the victim of an assault while working in Mexico eight years ago - he struggled with an intruder who broke into his house - sustained a cracked skull in the fight. He was saved by the timely observation and intervention of his company physician.
This doctor moved him from a small ill-equipped village hospital to a larger town where a neurosurgeon, suspecting an epidural hematoma, operated on and saved my husband's life. A delay would have been fatal.
Being part of that drama, which included a 33-hour journey from here, uncertain whether I would find him alive when I arrived, has made me alert to the dangers of head traumas.
It was scary, but had it not happened, I might be quite blase. How unfortunate that we do not take a potentially life-threatening situation seriously enough unless we are victims ourselves or linked to the tragedy.
Last week, the buzz over the death of actress Natasha Richardson after what seemed like just any other fall, spilled over websites and newspapers. Many lapped it up but are already beginning to forget that story.
However, there's a lesson to be learnt from it. As happened in her case, a seemingly banal incident might just end tragically.
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