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

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.