ARTICLE IN BRIEF
Experts discuss management strategies for emergency head injury cases.
When actress Natasha Richardson died March 18 after a fall while she was skiing in Quebec, the daily press was filled with contradictory information. She hit her head. She hadn't hit her head. She had been knocked unconscious. She was up and joking.
Two days later, the chief medical examiner for New York City — she had been taken to Lenox Hill Hospital there from Montreal — found that she died of a cerebral hemorrhage caused by “blunt impact” to the head. The official cause of death was an epidural hematoma, bleeding between the skull and dura mater covering the brain.
For neurologists, the tragic incident resulted in many questions from press and patients. It was also a chance to emphasize the need for helmets during sports activities and stress that a quick visit to the emergency room could save lives.
Richardson was not wearing a helmet when she fell, reports said. A spokeswoman for the ski resort said in press reports that a member of the ski patrol advised Richardson to see a doctor, but she declined.
Physicians emphasized that millions of people hit their heads every day —bumping on cabinets, or walking into solid objects. In fact, head injuries are among the most commonly seen injuries in Western hospitals, with 100 to 300 per 100,000 population, according to a World Health Organization task force on Mild Traumatic Brain Injury. But only a few people tear an intracranial artery; less than 1 percent lead to neurosurgery.
TBI EFFECTS VARY
Unlike a stroke, where there is a three- to four-hour time window during which doctors can best use tPA, traumatic brain injury (TBI) effects vary, said Joshua Levine, MD, co-director of the Neurocritical Care Unit at the University of Pennsylvania Health System and an assistant professor of neurology at the Hospital at the University of Pennsylvania.
“The general rule is that ‘time is brain,’” he said. “The earlier you get in, the better off you're going to be. We used to think that when you get hit in the head, all the injury occurs at the moment of impact. But now we recognize that the injury continues to occur, sometimes for days afterward, and that's the secondary injury we're often addressing.”
One of the first questions with patients with TBI is whether or not they have a surgical lesion, said Claude Hemphill, MD, director of neurocritical care at San Francisco Hospital and associate professor of clinical neurology at University of California-San Francisco.
The Brain Trauma Foundation has guidelines for pre-hospital management as well as care within the intensive care unit, he said, and the main issue is to alleviate the pressure on the brain and evacuate the blood. But in order to know if there is a lesion, the patient has to go to the hospital for a CT scan, and that's often the sticking point, he said.
“Many patients object, because they feel like they're doing OK at that moment,” Dr. Hemphill said. “What percent deteriorate like Richardson did? Maybe 1- to 2-percent? It's not common, but when it happens, you have so much to lose.”
There have not been many studies about the timing of treatment and TBI, doctors said, simply because when a patient arrives with a possibly surgical lesion, there's often no time to wait and see.
When someone arrives at the hospital with a brain injury, they are assessed on the Glasgow Coma Scale (GCS), based on eye, verbal and limb movement responses. The highest score is 15, a fully awake person; the lowest is 3, someone in a coma (with no response to any of the three measured categories).
One 2005 study in the Journal of the American Medical Association included 3,181 patients with a GCS score of 13–15 and found that doctors who used the Canadian CT Head Rule guidelines lowered the number of CT scans required. (See “The Canadian CT Head Rule.”)
GAPS IN RESEARCH
But Barry Jordan, MD, director of the Brain Injury Program at the Burke Rehabilitation Hospital in White Plains, NY, said there is a large gap in studying TBI, particularly involving sports. In particular, he said, there need to be criteria for returning to competition after a TBI. Dr. Jordan, who was chief medical officer for the New York State Athletic Commission and is a team physician for USA Boxing, has worked ringside, deciding whether it is safe to send boxers back to the fight after being knocked down. He said he has been fielding a lot of questions about brain injuries from his patients, particularly about being able to tell if it's a serious injury or not.
[The AAN published guidelines on managing sports concussion in 1997, and is in the process of updating them.]
“Brain injuries and sports are a silent epidemic,” said Dr. Jordan, “particularly in recreational sports, such as skiing or biking, where people don't always wear helmets.”
All the physicians interviewed pointed to several red flags — loss of consciousness, sudden lethargy, severe headache, amnesia, and cognitive impairment — that should send people to a nearby emergency room.
But the tragic Richardson case shouldn't stop people from enjoying the outdoors, as long as they use common sense, doctors said.
“I was skiing this weekend and I wiped out several times and so did my kids,” said Dr. Hemphill. “No one had any kind of spill that was so bad we thought they should go see a doctor, but we also wore helmets.”
“I was looking around and about 60 percent of the people at the resort were wearing helmets,” he said. “That's much better than it used to be.”
The Canadian CT Head Rule
CT is only required for patients with minor head injury with any one of the following findings: Patients with minor head injury who present with a GCS scores of 13 to 15 after witnessed loss of consciousness, amnesia, or confusion:
High Risk for Neurosurgical Intervention
- GCS score lower than 15 after two hours after injury
- Suspected open or depressed skull fracture
- Any sign of basal skull facture
- Two or more episodes of vomiting
- 65 years or older
Medium Risk for Brain Injury Detection by CT
- Amnesia before impact of 30 or more minutes
- Dangerous mechanism (pedestrian struck by car, or ejected from car, or a fall from an elevation of 3 or more feet or 5 stairs)