Wednesday, March 18, 2009

What Happened to Natasha Richardson?

Monday, Natasha Richardson was skiing on a beginner slope and suffered a fall. She seemed to recuperate, but later became symptomatic and was rushed to a hospital in Canada. Tuesday night she was reported as "brain dead."

What happened?

Three most likely possibilities:

1. Epidural hematoma (see CT scan on the left)
-arterial bleed between skull and brain with rapid and devastating pressure developing on brain; short time course, usually over hours

2. Subdural hematoma
-venous bleed between skull and brain, slower time course but reaches a point when pressure can create catastrophic pressure effects

3. Subarachnoid hemorrhage (ruptured aneurysm- blood around and/or into the brain)
- rapid symptoms and time course with potential for devastating spasm of vessels

Epidural or Subdural?
Both epidural and subdural hematomas suggest a significant blow to the skull. Dr. Michael Baden suggested an epidural hematoma lat night on Fox news, mainly because of Richardson's rapid decompensation and the "lucent" period (she was normal for a short time after the injury), which, clinically, is the time it takes for the blood collection to get large enough. However, most epidural bleeds require a significant focused blow to the skull:

The inciting event often is a focused blow to the head, such as that produced by a hammer or baseball bat. In 85-95% of patients, this type of trauma results in an overlying fracture of the skull.

A subdural hemorrhage that is bad enough to render you brain dead in a day, also usually involves a significant blow to the skull and an associated brain injury:

Acute SDH is commonly associated with extensive primary brain injury. In one study, 82% of comatose patients with acute SDH had parenchymal contusions

Both of these lesions can be rapidly and simply diagnosed with a noncontrast CT scan of the brain and both of these lesions can be rapidly treated --with reversal of the outcome-- in a modern, competent, well-equipped emergency room.

Subarachnoid Hemorrhage (SAH)

When I first heard the sequence of events, I assumed Richardson had an SAH from an aneurysm rupture because:
1. Her age
2. Minor trauma (assumption because she was on a beginner slope with a pro)
3. Lucent interval (SAH can frequently have a small initial bleed which is followed later by a catastrophic bleed)
4. Both epidural and subdural hematomas should have / would have been rapidly diagnosed and she would have had an emergency procedure to release the pressure
5. Rapid progression to massive brain injury: SAH can quickly cause diffuse spasm of brain vessels leading to brain infarction -- which is irreversible and catastrophic

The problem I have with SAH is that they would not have put her in a plane and flown her to NY the next day...aneurysm patients are at a high risk for rebleed and need to be treated quickly, if at all possible in a nearby geographic location; unless the course of events was so rapid and tragic that it didn't matter.

Also, the time course is very bizarre, I mean, to go from a minor fall to brain dead in 24 hours??

Whatever the mechanism, this concatenation of events is tragic it its absolute unlikeliness and in the devastation that has ensued.
Thanks to Kevin, M.D. for link. Read what he has to say...
Also discussed by an ER Doc at Movin' Meat...


shadowfax said...

Don't forget the other less-sexy, non-bloody brain injuries such as cerebral contusions and DAI, which can also cause progressive cerebral edema and brain death. Much more likely to cause death than SAH.



Dr.T said...

Thanks for the input.

Something catstrophic happened with minor injury. That's the premise. A cerebral contusion significant enough to create brain death in 24 hours should be associated with major trauma.

Shearing injuries (DAI) are becoming better understood in the setting of mild trauma (they used to only be associated with major injury); but, again, in order to create a vegetative state so rapidly we would be talking about a major catastophic force to cause that degree of shearing.

The key to this mystery lies in the "lucent" interval, if we are to connect the trauma with the result, and the quick progression to brain death.

It adds up to subarachnoid hemorrhage, unless she was just so unlucky to arrive at the hospital before they could diagnose and treat those other fixable lesions.

otyikondo said...

Dr. T wrote:

"The problem I have with SAH is that they would not have put her in a plane and flown her to NY the next day...aneurysm patients are at a high risk for rebleed and need to be treated quickly, if at all possible in a nearby geographic location; unless the course of events was so rapid and tragic that it didn't matter."

By all accounts, it didn't matter. The flight to NYC appears to be a medical red herring. It was performed merely "to get the victim home". By that stage nothing else could be done. Whether this reinforces the original SAH viewpoint is moot. The autopsy, as is now known, came down on the side of an epidural hematoma caused by the fall (however insignificant the fall was). From the perspective of the relatives and the legal aspects of the case, it means little one way or another: this was accidental death, and no amount of arguing over HOW it happened is going to bring the victim back.

On the other hand, the autopsy finding does have two broader social ramifications.

Firstly, it unleashes all those who will bring up the quite different cases of Sonny Bono and Michael Kennedy and argue for mandatory use of helmets (presumably also when getting out of the bath, ice-skating, crossing the road, or even walking downstairs, given that most accidents happen in the home...),


Secondly, in the wider public mind it creates an almost mythical image of beauty struck down in its prime by a tragic quirk of fate, which - for all that it is deeply discomforting - has a greater resonance in the context of "celebrity death" than a latent medical condition that might have been brought on by the patient's age, or her smoking.

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