The head injury Natasha Richardson suffered in a skiing accident Tuesday produced what is often called a "walk and die," syndrome, which is usually due to delayed bleeding from an artery in the brain, said Dr. Christopher Giza, a neurologist at the UCLA Brain Injury Research Center. In such cases, the patients, like Richardson, appear normal immediately after the injury, walking and talking as though nothing happened. But symptoms can develop within an hour, causing the patients first to suffer impaired speech and vision and then to fall into a coma.
She most likely suffered from an epidural hematoma, in which bleeding occurs from an artery in the brain. Because blood in arteries is under high pressure, it can accumulate rapidly in the organ, pushing the brain to one side and leaking down into the brainstem, where it can "cause a change in mental status, the onset of a coma or, in severe cases, kill the person," Giza said. "In general, to have this kind of hemorrhage, you have to experience a significant amount of force."
Such injuries are not common, "but they do occur, even in patients that have been evaluated by a CT scan," said Dr. Keith Black, a neurosurgeon at Cedars-Sinai Medical Center. "That's why, when a person has a head injury, we like to observe them for 24 hours to make sure no delayed bleeding occurs."
When a patient like Richardson develops problems, the first thing physicians do is put them on a respirator to increase oxygen flow to the brain and heart. The respiration rate is typically set high to remove carbon dioxide, a gas that increases swelling. Physicians also give the patient diuretics to remove fluids and steroids to minimize or reduce swelling.
But if there is a bleed or a clot has formed, "the only way to fix it is to perform emergency surgery to drain the blood [and relieve pressure] and to fix the clot," Giza said. The other treatments "are only temporizing measures.... If the blood clot is growing, you are only treating the symptoms and not the cause. I had seen patients who did not require surgery because [the injury] was small and in a location where it was not prone to expand. But in the classic presentation, it has gotten big enough to be operated on."
It is also possible that Richardson suffered a torn artery in the neck, which would produce similar symptoms but would potentially be more lethal, Black said. The situation would also be more severe if she had any inherent problems before the accident, such as a tendency to not clot well or an arteriovenous malformation in the brain -- basically a tangle of blood clots -- that could tear apart in an accident and cause bleeding. Such a tangle could be deep in the brain and difficult to repair.
One more lesson should be learned from this episode, everyone agreed: Skiers, like skaters, bicyclists and other sportsmen, should wear helmets to prevent just this type of injury.
-- Thomas H. Maugh II