HEAD INJURIES

Many famous people have incurred head injuries. Entertainer Sonny Bono and Michael Kennedy, son of Robert and Ethel Kennedy, both died of head injuries while snow skiing. Princess Diana and NASCAR legend Dale Earnhardt died from head injuries incurred in auto accidents.

However, one of the most documented – if not the most interesting − was Phineas Gage's head injury. Mr. Gage, as the foreman of a railroad work gang, holds a relevant role in the cultural history of psychology and neurology.

In 1848 while preparing to lay railroad tracks, his work gang was to drill anchoring holes to be drilled into rock. One of Gage's duties was to go by each pre-drilled hole, add gunpowder, a fuse and sand, then tamp the charge down tightly with a large iron rod.

He came up to one hole, apparently one in which someone had forgotten to pour in the sand. As he tamped the gunpowder (without the sand), the iron tamping rod emitted sparks as it scraped up and down the rocky sides of the hole.>>>

The sparks ignited the gunpowder at the bottom of the hole and rocketed the iron tamping rod directly back from the hole and through Gage's head. The iron rod entered on the side of his face, shattering the upper jaw, and passing back of the left eye, and out at the top of the head.

Even though the injuries were very serious, reports indicate that Gage spoke within a few minutes and even walked with little or no assistance despite the blood pouring from the resulting two holes in his head. He seemed to miraculously recover within months.

What makes him unique to the study of the head injuries is that although his injuries were traumatically severe, he survived with only a modified personality.

Reportedly, Gage's next job was as an attraction in P.T. Barnum's famous three-ring circus along with the rod that had penetrated his head.

While Gage's case had a relatively good outcome, many do not.

Background on head injuries

A majority of head injuries occur when the head is directly injured by a sharp or blunt object. They can also result from either the sudden acceleration or deceleration of the head, which can cause the brain to come into contact with the skull.

Head injuries are sometimes mild and have only minor repercussions for the brain. However, severe head injuries can seriously affect the brain and cause problems with speech, movement and behavior.

According to the National Center for Injury Prevention and Control, an estimated 1.4 million people in the United States sustain an internal head injury and approximately 50,000 people die as a result of these injuries annually. Also according to the NCIPC, deaths related to head injuries account for one-third of all injury deaths.

Causes of head injuries

All types of head injuries can be caused by trauma. In adults in the United States such injuries commonly result from motor vehicle accidents (especially someone who is in a car wreck and is not wearing a seat belt), bicycle and motorcycle accidents, assaults and falls. In children, falls are the most common cause followed by recreational activities such as biking, skating, or skateboarding. A small number of head injuries in children are the result of violence and abuse acts.

Types of head trauma

The signs and symptoms of head injuries can vary greatly with the type and severity of the particular injury.

Minor blunt head injuries may involve only symptoms of being "dazed" or brief loss of consciousness. They may result in blurred of vision, headaches, nausea and even vomiting. There may be longer lasting subtle symptoms, including irritability and difficulty concentrating. These post-concussion symptoms may last for a prolonged period of time.

Severe blunt head trauma involves a loss of consciousness lasting from several minutes to several days or even longer. Often seizures may result. The victim may suffer from severe and sometimes permanent neurological deficits or could even die. Neurological deficits from head trauma often resemble those seen in stroke victims and may include seizures, paralysis and difficulty with speaking, seeing, hearing, walking or understanding.

Penetrating trauma may cause immediate and severe symptoms or only minor symptoms despite a potentially life-threatening injury. Death may follow from the initial injury.

Are all head injuries serious?

Many head injuries can be serious, even the ones that initially seem insignificant and even painless. Often bleeding, tearing of tissues and brain swelling can occur when the brain moves inside the skull at the time of an impact. The brain is protected by the thick bones of the skull and a layer of tissue called the meninges that surrounds and helps to cushion the brain and spinal cord. If the head is hit with sufficient force, the skull, meninges or brain can be damaged. Severe brain injury can occur when the brain shifts inside the skull or when bleeding or bruising inside the skull causes pressure to build against the brain. This can disrupt the normal function of the brain and cause symptoms that range in severity from headache to permanent loss of brain function, i.e., brain death.

But the good news is that the majority of people recover from head injuries and have no long-lasting effects. Most head injuries will fall into one of the following categories:

• Concussion – a jarring-type injury to the brain. Most concussion victims usually, but not always, pass out for a short while. The person may feel dazed and may lose his balance or vision momentarily after the injury.
• Contusion – a bruise of the brain; there is some bleeding in the brain causing swelling.
• Skull fracture – occurs when the skull cracks; the edges of the broken skull bones may cut into the brain and result in bleeding or other injuries.
• Hematoma – occurs when bleeding in the brain collects and clots resulting in a bump. A hematoma may not be apparent for a day or even as long as several weeks.

When to get help

• You need to summon assistance if you notice any of the following symptoms after suffering any type of head injury:
• Constant nausea
• Changes in behavior, such as confusion or irritability
• Encountering trouble walking or speaking
• Dilated pupils or pupils of different sizes
• Vomiting
• Seizures
• Drainage of bloody or clear fluids from ears and/or nose

Prevention

While perhaps all head injuries cannot be prevented, there are some sensible steps to take to reduce the likelihood or extent of a severe injury. Prevention includes wearing helmets when bike riding, skiing, inline skating, driving motorcycles and three-wheelers and other similar activities. Utilizing safety belts, baby car seats and airbags properly can help prevent head injuries in motor vehicle accidents. You can help fall-proof your home by reviewing areas where most falls occur, i.e., on the staircase, in bathtubs and showers, on throw rugs and waxed floors and take remedial action.

Head injuries can be initially deceiving

Unlike the injury to Phineas Gage, a blow to the head that at first seems minor and does not result in immediate pain may turn out to be a life-threatening brain injury. A prime example of such a situation was the recent tragedy involving actress Natasha Richardson on the ski slopes at a Canadian resort in March.

Richardson, while on the beginners' ski slope, had a seemingly innocent tumble. But immediately after regaining her composure, she was reportedly talking and even joking.

But shortly after returning to her room at the resort, she complained of head pain and was transported to a nearby hospital. Later that same day, she was taken to a larger medical center in Montreal. She was later flown by private jet to a New York hospital where she died the following day.

"It's very common for someone who's had a fall or been in a car accident to appear perfectly lucid just after the impact but then to suddenly, rapidly deteriorate," Dr. Carmelo Graffagnino, director Duke University Medical Center's Neurosciences Critical Care Unit, reported on CNN at the time.

"A patient can appear so deceivingly normal at first," said Graffagnino. "But they actually have a brain bleed and, as the pressure builds up, they'll experience classic symptoms of a traumatic brain injury."

Such injuries are known as epidural hemorrhage. Blood gets trapped between the skull and the hard layer of skin between the bone and brain, known as the dura mater. As the blood flows from the ruptured artery, the fluid builds and punctures the dura.

Patients are often unaware they've fractured their skull. In these cases, the fracture generally occurs just above the ear, in the temporal bone.

"There is an artery that runs above the skull and can get torn and begin to bleed above the lining of the brain," Graffagnino says.

"At that point all the pressure is pushed on the brain, causing it to swell but there is often no room for it to move inside the skull cavity. And as the pressure continues, it reduces blood flow to the brain and a patient would begin to feel the symptoms."

The condition is commonly referred to as "talk and die" syndrome among neuroscience physicians and surgeons, because the patient can decline so rapidly.

What is so ironic is the initial fall or injury doesn't have to be hard at all, according to Graffagnino. The delay in symptoms can range from five minutes to three hours, or even longer, after the initial accident.

Getting to a hospital within the first few hours is critical to prevent permanent brain damage, experts say. Physicians in the emergency room team can quickly determine the severity of the injury.

An emergency craniotomy – opening of the skull – Graffagnino is often necessary to cease the bleeding and help control the swelling of the brain.

Immediate treatment is essential after a brain injury because the initial damage caused by swelling often is irreversible.

"One of the things we teach to trauma teams is if a group of people are in a car crash and someone dies, we have to assume everyone else has serious injuries – even if they look good and say they feel totally fine," Graffagnino said.