Natasha Richardson and Traumatic Brain Injury

The most common head injury after a fall, or while playing sports, is a minor concussion. In rare cases, the trauma of hitting your head can have dire consequences, including bleeding and swelling of the brain. In some instances, these injuries aren't immediately apparent because the patient may initially be lucid and without serious symptoms.

Actress Natasha Richardson's recent skiing accident appears to be one of these unusual and tragic situations. The Tony Award-winning wife of actor Liam Neeson fell during a ski lesson on a beginner slope at a Canadian resort on March 16. At first, she showed no signs of major injury and was even joking about the incident, according to media accounts. But within hours, her health deteriorated and the 45-year-old mother of two was hospitalized and then subsequently transferred to a New York hospital.

Dr. Stephan Mayer, head of the Neurocritical Care Unit at Columbia University Medical Center, spoke with NEWSWEEK's Dina Fine Maron about how a seemingly minor fall could become a life-threatening emergency and what to watch for after any head trauma. Excerpts:

What's the difference between an ordinary bump on the head, and an injury that may not appear to be serious at first but is potentially critical?
The most common thing that happens is that a fall shakes the brain and it then manifests as a concussion. Concussion is a syndrome of a temporary lapse of consciousness triggered by trauma. That's where you pass out or you see stars or are generally zonked out when people talk to you. But a concussion by definition is a brief or temporary disruption of the brain. Concussion never lands you in an intensive-care unit.

A possibility [in accidents similar to what reportedly happened to Natasha Richardson] is that the fall triggered a syndrome of delayed massive brain swelling. In fact, being in an area with low oxygen like on top of a mountain, might actually increase that chance.

How can doctors make a diagnosis of a serious brain injury when the patient doesn't have symptoms immediately?
Through a different mechanism than concussions, trauma can rarely trigger a delayed and more sinister reaction or form of injury. These more sinister life-threatening situations occur in two ways: huge swelling of the brain or bleeding on the surface of the brain—both would have an abnormal CAT scan. [After a fall] there is commonly a lucid interval where you may seem fine for an hour or two and then may develop symptoms of a more urgent nature unless something is done to reverse it ... like surgery. We've known this forever. That's why you observe someone for the next hour or two after a fall.

With a concussion, a CAT scan is always normal. You can't ever see anything wrong because it's a functional disruption of the brain—it was just jiggled around a little. But [a condition that] lands you in a life-threatening situation, you will see that on a scan. The brain will be swollen, shifted, or there would be a hematoma pressing on the brain or something like that.

What can be done for someone when there is a severe reaction to a head trauma, such as swelling of the brain?
[If it were my patient, he or she] would have a probe placed in the brain which will measure intracranial pressure. Some hospitals don't even have intracranial pressure monitoring, but that's the really important thing to manage care for someone who is in a coma with trauma.

What advice would you give to someone who hits their head and may be unsure whether it's a serious injury?
What happens a lot of times is that someone is on a ladder and falls off, and they have a concussion. They may pass out, wake up and have a persistent headache and generally don't feel good. Then, you call 911 and take them to the emergency room. Really, the moment anyone is aware of the potential of a serious brain injury and [the patient] seems to be drooping, the main thing that will make a difference is calling 911 and getting medical emergency care right away.

We have a saying in neuro:  "Time equals brain." For these kind of neurological emergencies, the earlier you can figure out what's going on the better. Literally every minute counts. What happens to you in that first day will often dictate if you're going to live, die, live with a full recovery or live with some kind of permanent brain injury.

Are there any long-term effects of a minor concussion?
Imagine you drop your laptop. If you drop your laptop and it comes right back up with a smiley face, you know it's going to be fine—that's most concussions. If it comes up with a frowning face, that means it's not going to work well. That would be in situations where you feel nauseous, dizzy—and that's postconcussion syndrome. But even with that, wait a week or two weeks and it'll get better. The terrifying thing is when you drop a computer and the screen stays black. That's a medical emergency. And that's where every minute counts.

Concussions beget concussions. Once you get one it's actually easier to get the next one. Your system is healing, but healing systems are fragile and with another bonk you are more susceptible. With postconcussion syndrome it's not life threatening, but it can be life-wrecking. It can occur after one concussion or multiple, it's not really well understood. It's kind of a grab bag of types of symptoms, but the defining symptom of it is a kind of clouding of your mind, [an] inability to concentrate or focus and fatigue and trouble remembering.

How common is it to have a serious reaction to a head injury?
It's uncommon. It's actually very uncommon and unlucky. There are a huge number of people that walk into emergency rooms every year after minor head injuries, and there is no permanent harm, but people come in to get it checked out. There is nothing you can do to increase or decrease your chances of how your body will react. Sometimes you just have bad luck and the body reacts in a certain way and you make the best of it.

Any other advice?
Prevention is No. 1.  Everyone on a bicycle should wear a helmet. Everyone who skis should wear a helmet. If you have a concussion and have these types of symptoms—lethargy, trouble focusing, feeling generally cloudy—they are serious and real. There's a biological basis for this, and you should see a neurologist. For more minor symptoms, you should get rest, eat right and have light exercise—the things you should really do for yourself all the time.

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