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Natasha Richardson's death and what you should know about brain injuries

Natasha Richardson
REUTERS/Lucas Jackson
Natasha Richardson at a Metropolitan Museum of Art Costume Institute Gala in New York last year.

Initial reports of Natasha Richardson's tragic skiing accident, which led to her death yesterday, offered two bits of information that had many people perplexed.

First, the actress' fall had been onto the snow-covered ground. She hadn't run into a hard upright object, like a tree, a building, or even another skier.

And second, Richardson had walked away from the accident seemingly unscathed. She was even heard joking about her fall. Not until an hour or so later, when she started having headaches, did the seriousness of the situation become apparent.


How can that be? How can someone tumble down a beginner's ski slope, appear fine, and yet within hours be fighting for her life in a hospital's ICU?

"Natasha Richardson's example sadly shows how devastating an innocuous brain injury can be," says David King, executive director of the Brain Injury Association of Minnesota.

A major health problem
Many traumatic brain injuries (TBIs) — injuries severe enough to disrupt how the brain functions—have such harmless-appearing beginnings. Symptoms, such as headache, nausea, ringing in the ears, impaired vision, irritability and confusion, may take some time to develop. Or they may be ignored until they become severe — and life threatening.

TBIs are much more common than most people think. In the United States, one occurs every 15 seconds, and every five minutes someone dies from such an injury. Although people with TBIs can recover, particularly if they receive medical treatment early enough, many experience lasting and life-altering impairments.

Here in Minnesota, an estimated 100,000 children and adults are living with disabilities caused by TBIs. Hennepin County Medical Center alone admitted 903 patients with brain injuries in 2008, says Carol Ann Smith, program coordinator for HCMC's Traumatic Brain Injury Center.

Of those patients, 187 were children.

The fragile brain
"People don't realize the fragility of the brain and just how common brain injury is," says King. "Anytime you hit your head, you need to pay attention."

Here's why: Your brain, which is the consistency of firm Jell-O, is locked inside a very rigid structure, the skull. A fall or other accident can cause your brain to be thrown against that hard surface. Furthermore, the inside of the skull is anything but smooth; it's lined with hard nodes and ridges, particularly on the inside of the forehead and around the eye sockets. "Even with a minor injury, bump, or fall, your brain may hit against those ridges," says King. "You can have rips, or tears or bruising."

Don't be fooled by what you see — or don't see — on the outside of your head. Even if you have no visible injury, your brain may be swelling and bleeding. This puts pressure on your brain, for the swollen tissue and blood has nowhere to escape. As the pressure increases, brain cells begin to die — and you are quickly in very serious trouble.

A race against time
The swelling and bleeding can start slowly. That appears to be what happened with Richardson. "It didn't strike me as unusual that she was awake and OK for a while before having symptoms," says Smith. "You have to have enough blood accumulate to have symptoms. For some people that's a few minutes. For others, it can be 30, 40, 60 minutes or longer. Every case is unique."

Time is of the essence. "We always advocate for being on the safe side," says King. "If you hit your head, go to the doctor immediately." King recommends urgent care facilities at hospitals, which have the personnel and equipment to evaluate head injuries. Tell the medical staff what happened. If you're really concerned, push for an MRI, he adds.

"One of the challenges with a brain injury is that it's largely invisible," says King. "If a doctor doesn't know you, they don't have a frame of reference. It can be a tough diagnosis. You have to be your best advocate."

For some people the effects of a TBI are very subtle. Smith recalls the case of a young man who had seen several of his personal relationships sour after he experienced a head injury. "He hadn't put it together that his behavior had changed because of his brain injury," she says. "He thought he was just having a really bad year."

Who's at risk?
In Minnesota, as in the rest of the country, falls — including sports-related ones — are the leading cause of TBIs, says King. Second on the list: motor vehicle accidents.

Wearing a helmet helps (Richardson reportedly didn't have one on during her ski lesson), but it's not a panacea. "A helmet helps diffuse the impact," says King. "It spreads the pressure over a wider area. But your brain is still moving within your head, so you should still be checked out."

Getting kids to wear helmets for activities like biking, snowboarding and skiing can be a struggle, but parents should insist on it, says King. "I have a 16-year-old son who doesn't bike because he won't wear a helmet," he says. "He would rather not ride the bike than wear the helmet."

Adults, of course, can be equally stubborn about wearing "geeky" helmets. Just last week, King said, his organization received a call to send a speaker to a ski-and-snowboarding club in Rochester, Minn., about the importance of wearing helmets. The impetus for the call was the death earlier this month of a Twin Cities college student who died from head injuries incurred while attempting a back flip on a snowboard.

It's not at all clear that a helmet would have saved Natasha Richardson's life, but it might have. Sadly, we'll never know.

Susan Perry, author and journalist, writes about consumer health, with an emphasis on women's health.

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Comments (7)

This is a very helpful article. Lots of folks wandering around, saying, "But how could this have happened?" The bad news is that our retention time is very short, and this will quickly fade into the "eh, whatever" part of memory.

The article speaks of seeking medical attention as soon as possible after a head injury. It was not clear to me whether Natasha Richardson's head actually struck the ground. Is it possible that her injury came from a jarring fall that appeared to have nothing to do with her head? If so, that makes it doubly difficult to be pro-active with treatment, doesn't it? Just asking.

Thank you for brining a local angle and educational awareness to this story.

My father-in-law, who was in his 80s and experiencing a number of health issues, had a bad reaction to a medication he had been prescribed and that resulted in him hitting his head several times, either due to falling or uncontrollably running into a wall because he couldn't stop. But he seemed to have not suffered any real problems due to any of those incidents.

Then I began to recognize symptoms that suggested he might have had a small stroke. We got him to the doctor and tests, including an MRI, indicated he had a subdural hematoma - bleeding between his skull and brain. That was putting pressure on his brain and producing stroke-like symptoms. He was operated on, with a hand sized piece of his skull being cut out so the blood clot could be removed. During the procedure, it was found that there were actually multiple clots, indicating there had been multiple bleedings, resulting in cumulatively increasing pressure on his brain.

Thinking back, after the operation that saved his life, we realized that the multiple bleedings and clotting had been the cause of a number of symptoms he had experienced - including some of the falls. Unfortunately, because of his age and his various other medical issues, we (doctors included) had always felt that all his symptoms could be reasonably explained by what we already knew was wrong with him. The subdural hematomas were the real but hidden cause of some of his symptoms, but that only became apparent after he nearly died due to their increasing impact on his brain functioning.

Sometimes what we think we know blinds us to what we need to see.

What a great article. It's a horrible accident, but hopefully some good can come out of it by more being aware of TBI and how it can happen to anyone, even on the beginner slopes of a ski resort.

If you want to learn more about TBI and brain injury check out:
http://brainline.org

It's got expert reviewed info about TBI. Learn more about it, how to prevent it, so we can help prevent this from happening in the future.

When I stumbled across an announcement just now of Natasha Richardson's death in a ski accident, I was completely taken aback. I want to express that what I felt initially was not so much sorrow as it was guilt. I hope that she somehow will hear my voice now and thereby know that I am thinking of her.

My guilt didn't at all have to do with the cause of her death. I was in France yesterday when she died. I hadn't seen her for many years.

My guilt had to do with a long time feeling of remorse which stemmed from a trifling little misunderstanding between us during a film we made together in Paris years ago, for which she was the lead actress and I was dialog coach.

You see, in all my well intentioned effort to help her perfect her role, in the brief moments we had together, I gave from all my experience and resources and even from my deepest sense of understanding, or so I thought, when all she needed at the time was a quick brush up and a little coaching support. We clashed.

She went on to become a top professional and it is well known that she came from an old family of top professionals. Not knowing about her professional family background, I felt even at the time that she was highly skilled, sensitive and devoted to her work and that she would go on to succeed on her own merit.

I think in retrospect that she had also wanted to set things straight with me as much as I had wanted to do with her during our film production time together.

We never made up, alas, and I am very sorry now that we did not. Smug in all of my own stubbornness and sense of hurt from our encounter, I let years go by without ever trying to make amends with her, grumbling under my breath and uneasy within my thought. It could have been different; would it had been.

I hope now that she will rest in peace and that I will in the future have the good sense and ready awareness I will need in order to prevent such pettiness between people from happening again in my life, even if maybe she wasn't even bothered in the same way I was.

Goodbye Natasha. Goodbye...

Tim Holm

I was smacked into by an SUV while bicycling. I don't recall if my head hit the vehicle or the pavement, but it hit something because my helmet was cracked clear through. I had a headache that was evenly distributed around my skull, but no brain injury. I assume I would have been severely injured or dead otherwise. invite King to show these photos to his recalcitrant teenager:

http://www.ravensblog.net/archives/january1-09.php#accident

Susan Perry has written an important article and her excellent research of the circumstances is a lesson to us all.

I have worked on ambulances since 1971 and have been a paramedic at HCMC since 1980. Upon reading of the tragic accident involving Natasha Richardson, it was obvious what had happened.

Richardson, without a doubt, suffered a subdural hematoma due to a blow to the head. Given the remote location of the accident and the subtle, slow onset of symptoms, this actress was probably doomed to die at the moment that she fell.

I blog at www.ambulancedriver.net. It is my intention to