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Brain Experts Weigh In on Natasha Richardson's Head Injuries From a Skiing Accident
By Miranda Hitti
WebMD Health News
Reviewed by Louise Chang, MD
March 18, 2009 -- Actress Natasha Richardson, 45, has died in the wake of head injuries she sustained in a fall at a Canadian ski resort.
Media reports have posted a statement from Richardson's family that reads, "Liam Neeson [Richardson's husband], his sons, and the entire family are shocked and devastated by the tragic death of their beloved Natasha. They are profoundly grateful for the support, love, and prayers of everyone, and ask for privacy during this very difficult time."
According to media reports, Richardson's accident, which happened Monday on a beginner slope at Canada's Mont Tremblant ski resort, didn't result in immediate, obvious harm. Richardson is said to have felt fine until an hour or so after the fall, when she developed a headache.
At that point, she went to a hospital near the Canadian ski resort where she was staying and was later transferred to a New York hospital. Richardson and Neeson have two sons.
WebMD talked with three brain experts, none of whom treated Richardson, about her brain injury. The interviews were conducted before Richardson's death was announced.
What would account for a delayed reaction after a fall?
There are at least two possibilities.
First, a pre-existing condition could be exacerbated by the head injury, says Jordan Grafman, chief of the cognitive neuroscience section at the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health. It's not known if Richardson had any pre-existing brain conditions.
Second, a fall could jar the brain inside the skull.
"If the brain moved quickly, it could cause contusions [and] bleeding, and the bleeding could lead to increased intracranial pressure, and that could have severe consequences," Grafman tells WebMD.
That bleeding may take time to cause obvious problems.
"Sometimes, the bleeding and the increase in pressure are delayed," Grafman tells WebMD.
Neurologist Russell Packard, MD, agrees.
"You could get what's called a subdural hematoma -- the injury starts with some slow bleeding and so you seem fine at first, and then, within an hour or two hours ... the start of a headache," Packard tells WebMD.
Packard is the former head of the headache and head injury clinics at Texas Tech and the University of North Texas. He is now in private practice in Palestine, Texas. He's a fellow of the American Academy of Neurology and the American College of Physicians.
"The problem with any kind of blood clot is that you have a fixed and rigid size of the bone. And, so if you've got blood accumulating somewhere, getting bigger and bigger, it has to push against whatever else is in there, which stunts and traumatizes the cells so that they can't function," Taylor tells WebMD.
"The first thing that the body does anywhere there's trauma is send more blood in order to bring the immune system, so the immune system can make an assessment and clean up what it needs to clean up. The same thing is true inside of the brain. So now, not only is there a bleeding into the brain region, but more blood is wanting to get there in order to bring the immune system in order to clean it up," Taylor explains.
"At this point, the brain's in trauma and as long as the cells are essentially swimming in a pool of blood, they cannot perform their function," Taylor says.
How long can that delay last?
Symptoms of brain injury may take an hour or two, or perhaps longer, to develop.
"If something bad is going to occur, it's almost always within the first 24 hours," Grafman says. "That's why anybody who's had any kind of a head injury should be watched closely ... certainly for the first 24 hours, and should almost always go see a doctor," Grafman says.
How rare is a serious traumatic brain injury?
As a rough estimate, there are "probably at least a million head injuries per year in the United States. Probably 80% or more are mild sort of dings you might get playing football or something of that nature, or a slight fall," says Grafman, who has studied brain injuries for nearly 30 years.
"The overwhelming majority of those people who have that kind of very mild head injury are going to recover nicely, either very quickly or certainly with six to nine months," Grafman says.
Does everyone need an MRI or CT brain scan after a head injury?
"I think most people would say that's probably overkill, since the kind of situation that happened to [Richardson] is relatively rare," Grafman says. "If you have symptoms ... then it's likely somebody would have a scan. But if somebody is apparently symptom-free after a ding, it's not likely they would have a scan."
Doctors would also perform a neurologic exam, checking on the patient's mental status and whether they're confused or sleepy, as well as investigating their symptoms.
What are the symptoms of a brain injury?
"All those kinds of things are usually not too subtle if there's a big problem that needs intervention," Grafman says. "For a milder head injury that might cause some subtle symptoms, as often as not, CT scan or MRI is going to be negative. You're not going to see anything" on the brain scan, he says.
After a fall -- even a little tumble -- make a point to be around other people.
"You don't want to isolate yourself," Grafman says. "You want to be around other people who can see how you're doing."
Grafman isn't trying to be alarming. "I don't think there's any reason to be excessively nervous," he says. "Don't be alone after something like that happens, but you don't necessarily have to run to the ER unless you experience changes."
Taylor also encourages people not to let someone who's just had a head injury go to sleep.
"That's very important, because if they do go to sleep, they can slip into unconsciousness, and nobody's watching closely for various types of neurological symptoms," Taylor says.
"If there are neurological symptoms or discomfort or headache, don't be afraid to call 911," Taylor says.
If there is bleeding in the brain, what can doctors do about it? Is surgery an option?
"It depends," Packard says. "If there's just a small amount, they're usually admitted [to the hospital] and just watched."
"If there's a really large blood clot that's pressing on the brain and it looks like it might be expanding, that's a neurosurgical emergency," Packard says.
Packard points out that the bleeding doesn't necessarily happen in the area where someone hits their head.
"A lot of times, people fall and hit the back of their head, but because the brain moves inside the skull ... back and forth, you can actually have bleeding in the front part of the brain," Packard says.
Richardson reportedly wasn't wearing a helmet at the time of her skiing accident. Would a helmet have made a difference?
Grafman recommends wearing a helmet during any activity that could lead to a head injury. "A helmet is usually not going to make a head injury worse," Grafman says. "It can help prevent more serious trauma, particularly when it's due to some sort of blunt injury."
Taylor agrees. "I think that the precautions that we do take are really worth the effort," she says.
Packard says he doesn't believe helmets should be mandatory for skiers, "but it certainly would make sense to protect your head." He points out that skiing isn't as risky as football, riding motorcycles, or boxing, in terms of head injury risk.
Packard and Grafman say that Richardson could still have had a brain injury even if she had been wearing a helmet.
"It could have happened, yes, because of the rotational forces in the brain," Grafman says.
"Helmets can make a difference with any kind of head injury, but ... people can get injured even with the helmet," Packard says.
The New York Times.
Jordan Grafman, PhD, chief of the Cognitive Neuroscience Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health.
Russell Packard, MD, Palestine, Texas.
Jill Bolte Taylor, PhD, author, My Stroke of Insight; neuroanatomist, Midwest Proton Radiotherapy Institute.
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