Archive for the ‘Head Injuries’ Category

Acquired Brain Injuries: Subdural Hematomas

Friday, June 17th, 2011

Have you ever bumped your head and developed a “goose-egg?” It’s truly amazing how fast that big bruise under the skin grows. That bruise, or hematoma, is from a broken blood vessel, usually a vein. The pressure from the swelling helps with clotting, along with the blood’s own clotting factors. This types of hematoma typically takes a week or more to go away. And, if it’s on the forehead, it’s often followed by one or two “black eyes.”  That’s because the blood tends to spread along the tissue planes, and gravity notoriously pulls everything downward causing it to pool in the eye sockets, where the blood cells degrade and their components are reabsorbed by the body. Recycling at its best!

A subdural hematoma is that same “goose-egg”, but it happens under the skull and between the coverings of the brain. So what makes it so special that it causes a brain injury? A little lesson in anatomy will help.

Anatomy of the Brain Coverings

A subdural hematoma is a blood collection from broken blood vessels that occurs below the dura mater and above the arachnoid and pia mater; therefore the blood collection becomes “trapped” between the coverings of the brain. Depending on how bad the bleeding is, there can be a fairly large collection of blood.  Where can it expand? It can expand along the planes of these coverings, but since the hard skull is on the surface, the “goose-egg” effect occurs inward, compressing the brain and all of the neurologic tracts within the brain. This pressure leads to loss of blood circulation, oxygen and glucose delivery and ultimately death of that brain tissue. The brain then responds by becoming swollen, increasing the pressures in the brain/cranium and causing even more damage. Depending on the location of the subdural hematoma,the person affected will react in a specific way.

What Causes a Subdural Hematoma?

Some are spontaneous, but these are relatively rare. There is usually a fall or injury to the head that preceeds the development of a subdural hematoma. Interestingly, the fall can be minor without direct trauma to the head in an elderly person or someone on blood thinners. Looking at the diagram above, small blood vessels supply the meninges with the necessary circulation. As some brains age, they shrink, especially in individuals with dementia. As the brain shrinks, the blood vessels are stretched to continue to supply the various coverings with circulating nutrients. The stretching makes the vessels more fragile, and the brain shrinkage allows more room to move around when “shaken” or “dropped”. Thus, a shearing effect occurs, breaking those vessels and allowing for bleeding to occur.  The addition of blood thinners to prevent clotting can cause a tiny injury to become a huge hemorrhage.  Obviously, the bleeding becomes even more profuse when a person is over-anticoagulated, either incidentally or inadvertantly. A direct blow to the head, either related to a fall or simply bumping one’s head, can provide enough impact to cause damage both externally and internally; external hematomas are an obvious sign to a medical provider to consider internal injuries.

What are the Signs and Symptoms of Subdural Hematomas?

According to the NIH website, signs/symptoms of subdural hematomas in adults include the following:

  • Confused speech
  • Difficulty with balance or walking
  • Headache
  • Lethargy or confusion
  • Loss of consciousness
  • Nausea and vomiting
  • Numbness
  • Seizures
  • Slurred speech
  • Visual disturbances
  • Weakness

Also, according to the NIH website, signs/symptoms of subdural hematomas in infants include the following:

  • Bulging fontanelles (the “soft spots” of the baby’s skull)
  • Feeding difficulties
  • Focal seizures
  • Generalized tonic-clonic seizure
  • High-pitched cry
  • Increased head circumference
  • Increased sleepiness or lethargy
  • Irritability
  • Persistent vomiting
  • Separated sutures (the areas where growing skull bones join)

How are Subdural Hematomas Diagnosed?

According to an emedicine article, the best diagnostic tool for identification of an acute subdural hematoma is a non-contrast CT scan of the head; the blood collection has a typical appearance that is easily recognizable. It becomes more complicated in subacute and chronic subdural hematomas; a contrast head CT or a brain MRI might be more accurate.


How are Subdural Hematomas Treated?

It depends on the size and acuity as well as the presenting condition of the patient. A patient with obvious brain injury and neurologic deterioration requires emergent surgical and medical treatment; the surgical interventions can range from a “burr hole” to relieve the pressure to a full-blown craniotomy to evacuate the hematoma and control additional bleeding. Sometimes, secondary surgeries are required. Some small hematomas can be monitored in patients without neurologic compromise, and these can potentially resolve on their own or become chronic. If a patient with a subdural hematoma is over-anticoagulated (too much Coumadin), it is often necessary to reverse the anticoagulation before performing surgery to prevent additional hemorrhage; however, this delay can often cause additional permanent brain injury and functional deterioration of the patient.

Medical therapies include controlling blood pressure, controlling intracerebral pressure, preventing seizures from occurring (due to irritation of the meninges and brain), supporting heart and lung function, and managing fluid and electrolyte levels.

What is the Prognosis for Subdural Hematoma?

Since there is such a wide range of presentations and since each patient provides a unique set of circumstances, prognoses vary greatly, but overall, morbidity and mortality rates are extremely high. According to the emedicine article, the overall mortality of a simple subdural hematoma (without brain injury) is about 20%; the overall mortality rate for a complicated subdural hematoma (brain injury present) is about 50%! Even with successful evacuation, a patient runs the risk of recurrent bleeding, infection, chronic seizure disorder and permanent neurologic functional loss (depending on location).

Important Pearls….

If you are caring for an elderly person, do everything possible to prevent falls!

Monitor anticoagulant levels diligently. Be aware of potential interactions with specific foods and “new” medications.

If a fall occurs, seek evaluation as soon as possible; earlier interventions generally have better outcomes.

If evaluated and discharged, continue to observe the patient for changes in behavior, cognition and function for up to 1 week after the initial injury; seek treatment emergently if any changes are observed.

Avoid alcohol and narcotics which can both aggravate a potential condition and mask its presentation.

Concussions: The Message of Orioles’ Brian Roberts’ Injury Should Not Go Unheeded!

Sunday, May 22nd, 2011

Brian Roberts - NBC Sports photo (modified)

As I was reading the sports page this morning, after working my way past yesterday’s Preakness news, I was motivated to write this post by the report of Jeff Zrebieck in the Baltimore Sun’s Notebook section. Earlier this week, Brian Roberts of the Orioles was removed from the lineup due to headaches. At the time, I thought back over the games that preceded this news report but couldn’t remember any incident when Roberts could have sustained an injury that led to his headaches. For a guy like Brian Roberts, whose recent career has been marred by injuries, it was hard to believe that as tough and gritty as he is, that something like a sinus problem, allergies or the like had felled this guy. Then within a day or so, following examination and testing, we learned that Brian had sustained a concussion.

Once again, I thought through the games leading up to his line-up departure and still couldn’t remember any play or at-bat that would, in my mind, cause a concussion. There was no high and tight, back-him-off-the-plate pitch, no knee to the head by a middle infielder when he was sliding into second on an attempted steal, not even a take-out at second base while he was turning a double play. As we learned later, he sustained his current injury while sliding into first base headfirst trying to beat out a single. He never struck his head on anyone or anything. So how in the world did Brian Roberts wind-up on the disabled list with a concussion?

Last year’s injury set the stage for a recurrence

While no one knows for sure, the speculation during the 2010 season, which was also marred for Roberts by a back injury, was that Roberts had caused the concussion when, out of sheer frustration from a bad plate appearance, he struck himself in the helmet with his bat on the return to the dugout. We’re not talking a violent collision between a defensive back and an unprotected wide receiver, a car crash or a vicious criminal assault. Nevertheless, Roberts’ head injury lingered on well past the end of the season, which ended for him six games early due to dizziness and headache following this incident.

When he reported to spring training, the Orioles faithful were hoping that the past season’s injuries (back, strained abdominal muscle, concussion), which caused him to miss a total of 103 games in 2010, were a thing of the past. Then on Wednesday, February 23, 2011, the report came out that Brian had left spring training that morning due to a stiff neck. What was this all about? Then came the news last week – a slide felled this mighty warrior.

Concussions: a mild traumatic brain injury

Just what is a concussion?, a great resource for those seeking more information about traumatic brain injuries, gives this description:

In a nutshell, a concussion is a blow or jolt to the head that can change the way your brain normally works. Also called amild traumatic brain injury, a concussion can result from a car crash, a sports injury, or from a seemingly innocuous fall.Concussion recovery times can vary greatly.

Most people who sustain a concussion or mild TBI are back to normal by three months or sooner. But others . . . have long-term problems remembering things and concentrating. Accidents can be so minor that neither doctor nor patient makes the connection.

The Days of Yore – “Gut It Out” – are thankfully coming to an end

Anyone who follows sports is well aware that finally the old school mentality of “gut it out and get back in there” following blows to the head are coming (not too soon) to an end. Committees have been formed, articles written and the national spotlight of the media have finally focused on this issue. Those recommendations, debates and guidelines are beyond the scope of this post. Nevertheless, those involved in sports, particularly at the scholastic levels, should constantly be aware of this ever-expanding information, which is available through multiple resources and media channels.

What are the signs and symptoms of a concussion?

While there is apparently no universally accepted definition of concussion despite hundreds of studies and years of research, according to one source, there is some unanimity in what are the worrisome signs and symptoms, which can include:

  • Headaches
  • Weakness
  • Numbness
  • Decreased coordination or balance
  • Confusion
  • Slurred speech
  • Nausea
  • Vomiting

If you or someone in your family has sustained any type of head injury, no matter how minor and they show these signs or symptoms, get to the doctor or an emergency room immediately.

CT Scans, MRI’s and other diagnostic test after head injuries

TBI’s or traumatic brain injuries are reported to be “a major cause of death and disability worldwide, especially in children and young adults.” In cases of obvious severe head trauma, it’s a “no-brainer” that diagnostic testing should be done. But what about cases of mild to moderate head trauma? Who defines what is “minor” and “moderate” when it comes to TBI’s? What testing is necessary; when is it unnecessary?

While these judgments are made by the medical professionals, you need to be your own advocate at times in making this decision-making process. Brian Roberts was tested and submitted to radiographic tests for a host of reasons – probably not the least of which is the fact that he is a very valuable member of a professional sports team. What about the ordinary guy in the street?

Well, the short answer is – the recommendations vary when it comes to mild and moderate head injuries. In fact, the very definition of what constitutes a moderate TBI can also vary depending on whom you read. Nevertheless, certain signs, symptoms and history are not disputed indications for a radiographic study to rule in or rule out a potential brain injury. For example, one need only read the indications for the use of radiographic studies published by or a host of other organizations on this topic.

In a recent case, I personally came across someone whom I believe to be a leader in the field of traumatic brain injuries (TBI), Dr. Andy Jagoda, an emergency medicine specialist in New York. He has done extensive research, writing and lecturing on this topic. I’ll save you the effort, here are the search results for his body of work.

A Lesson – Hopefully – Learned

I started this piece with the story of Brian Roberts. I didn’t simply do this because I am a long-suffering fan of the Orioles (which I am) and an admirer of Brian Roberts (which I also am) but because of the message his story tells us. A self-inflicted bat to the helmet because of a strikeout? A slide into first base with no blow to the head? A concussion none the less – apparently!

Brian Roberts may have a team of medical specialists watching and monitoring his every grimace, complaint and move; you probably won’t have that luxury. If you have a head injury – minor or otherwise – and have any of the known signs, symptoms or risk factors for a traumatic brain injury, be vigilant and pro-active for your own health and well-being.

If you are in an emergency room and the discussion of whether or not you should undergo radiographic testing takes place, get involved – ask questions. If you are discharged from the emergency room, whether you had a CT or an MRI or not, pay very careful attention to the head injury discharge instructions you are given. It is a well known phenomenon that there can be a delay in symptoms and signs of a TBI days if not weeks later. If you are suffering any ill-effects during this post-discharge period, get to a healthcare provider immediately.

The stories of how lives are altered forever more as a result of TBI are legion. Don’t become yet another statistic.

Your time to share

Have you ever had a TBI? Know someone who has? What happened in that situation? Was a test done? Do you think CT scans are overused, particularly in children? Are they underused? How did your “experience” turn out? Any advice for others? Share, Good People, share!

Good luck, Brian – and speed recovery!