Talk & Die Syndrome

[SoCalDem]

I know that we don;t yet know if this is what happened to Natasha Richardson, but with so many of us having kids playing contact sports and then onto driving & grown up sports, it;s something we should all be aware of.


Coaches are sometimes too casual, and (especially) boys are reluctant to take themselves out of the game.. our football player son was told to "walk-it-off", when what he had was a C-2 brachial-plexus nerve root tear.. he ended up with right-arm paralysis for nearly 18 months.. The neurologist that he was ambulanced to see after I took him to the ER, said that a fraction of an inch, and he could have been a quadriplegic..

another time in soccer, his coach told him to rest a minute, and when we found out that he had been hit so hard that he had no peripheral vision, we high-tailed it to the ER..

Just because they "seem" ok and are walking & talking, does not mean they are really ok.. only a trained physician can evaluate them and know for sure..



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talk & die 'syndrome'

Traumatology A clinical presentation in acceleration-deceleration brain injury, which may cause massive cerebral edema, that may have a latency period–eg, 48-72 hrs, until death. Cf Sub-arachnoid hemorrhage.

McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.


Sub-arachnoid Hemorrhage
Definition

A sub-arachnoid hemorrhage is an abnormal and very dangerous condition in which blood collects beneath the arachnoid mater, a membrane that covers the brain. This area, called the sub-arachnoid space, normally contains cerebrospinal fluid. The accumulation of blood in the sub-arachnoid space can lead to stroke, seizures, and other complications. Additionally, sub-arachnoid hemorrhages may cause permanent brain damage and a number of harmful biochemical events in the brain. A sub-arachnoid hemorrhage and the related problems are frequently fatal.

Description

Sub-arachnoid hemorrhages are classified into two general categories: traumatic and spontaneous. Traumatic refers to brain injury that might be sustained in an accident or a fall. Spontaneous sub-arachnoid hemorrhages occur with little or no warning and are frequently caused by ruptured aneurysms or blood vessel abnormalities in the brain.
Traumatic brain injury is a critical problem in the United States.

According to annual figures compiled by the Brain Injury Association, approximately 373,000 people are hospitalized, more than 56,000 people die, and 99,000 survive with permanent disabilities due to traumatic brain injuries. The leading causes of injury are bicycle, motorcycle, and automobile accidents, with a significant minority due to accidental falls, and sports and recreation mishaps.

Exact statistics are not available on traumatic sub-arachnoid hemorrhages, but several large clinical studies have found an incidence of 23-39% in relation to severe head injury. Furthermore, sub-arachnoid hemorrhages have been described in the medical literature as the most common brain injury found during autopsy investigations of head trauma.

Spontaneous sub-arachnoid hemorrhages are often due to an aneurysm (a bulge or sac-like projection from a blood vessel) which bursts. Arteriovenous malformations (AVMs), which are abnormal interfaces between arteries and veins, may also rupture and release blood into the sub-arachnoid space. Both aneurysms and AVMs are associated with weak spots in the walls of blood vessels and account for approximately 60% of all spontaneous sub-arachnoid hemorrhages. The rest may be attributed to other causes, such as cancer or infection, or are of unknown origin.

In industrialized countries, it is estimated that there are 6.5-26.4 cases of spontaneous sub-arachnoid hemorrhage per 100,000 people annually. Certain factors raise the risk of suffering a hemorrhage. Aneurysms are acquired over a person's lifetime and are rarely a factor in sub-arachnoid hemorrhage before age 20.

Conversely, AVMs are present at birth. In some cases, there may be a genetic predisposition for aneurysms or AVMs. Other factors that have been implicated, but not definitively linked to spontaneous sub-arachnoid hemorrhages, include atherosclerosis, cigarette use, extreme alcohol consumption, and the use of illegal drugs, such as cocaine. The exact role of high blood pressure is somewhat unclear, but since it does seem linked to the formation of aneurysms, it may be considered an indirect risk factor.

The immediate danger due to sub-arachnoid hemorrhage, whether traumatic or spontaneous, is ischemia. Ischemia refers to tissue damage caused by restricted or blocked blood flow. The areas of the brain that do not receive adequate blood and oxygen can suffer irreparable injury, leading to permanent brain damage or death. An individual who survives the initial hemorrhage is susceptible to a number of complications in the following hours, days, and weeks.

The most common complications are intra-cranial hypertension, vasospasm, and hydrocephalus. Intra-cranial hypertension, or high pressure within the brain, can lead to further bleeding from damaged blood vessels; a complication associated with a 70% fatality rate.

Vasospasm, or blood vessel constriction, is a principal cause of secondary ischemia. The blood vessels in the brain constrict in reaction to chemicals released by blood breaking down within the sub-arachnoid space. As the blood vessels become narrower, blood flow in the brain becomes increasingly restricted.

Approximately one third of spontaneous sub-arachnoid hemorrhages and 30-60% of traumatic bleeds are followed by vasospasm. Hydrocephalus, an accumulation of fluid in the chambers of the brain (ventricles) due to restricted circulation of cerebrospinal fluid, follows approximately 15% of subarachnoid hemorrhages. Because cerebrospinal fluid cannot drain properly, pressure accumulates on the brain, possibly prompting further ischemic complications.

Causes and symptoms

Whether through trauma or disease, subarachnoid hemorrhages are caused by blood being released by a damaged blood vessel and accumulating in the subarachnoid space. Symptoms associated with traumatic subarachnoid hemorrhage may or may not resemble those associated with spontaneous hemorrhage, as trauma can involve multiple injuries with overlapping symptoms.

Typically, a spontaneous subarachnoid hemorrhage is indicated by a sudden, severe headache. Nausea, vomiting, and dizziness frequently accompany the pain. Loss of consciousness occurs in about half the cases of spontaneous hemorrhage. A coma, usually brief, may occur. A stiff neck, fever, and aversion to light may appear following the hemorrhage. Neurologic symptoms may include partial paralysis, loss of vision, seizures, and speech difficulties.
Spontaneous subarachnoid hemorrhages may be preceded by warning signs prior to the initial bleed. Sentinel, or warning, headaches may be present in the days or weeks before an aneurysm or AVM ruptures. These headaches can be accompanied by dizziness, nausea, and vomiting, and possibly neurologic symptoms. Approximately 50% of AVMs are discovered before they bleed significantly; however, most aneurysms are not diagnosed before they rupture.

Diagnosis

To make a diagnosis, a health-care provider takes a detailed history of the symptoms and does a physical examination. The symptoms may mimic other disorders and diagnosis can be complicated, especially if the individual is unconscious. The sudden, severe headache can fuel suspicion of a subarachnoid hemorrhage or similar event, and a computed tomography scan (CT scan) or magnetic resonance imaging (MRI) scan is considered essential to a quick diagnosis. The MRI is less sensitive than the CT in detecting acute subarachnoid bleeding, but more sensitive in diagnosing AVM or aneurysm.

A CT scan reveals blood that has escaped into the subarachnoid space. For the best results, the scan should be done within 12 hours of the hemorrhage. If this is not possible, lumbar puncture and examination of the cerebrospinal fluid is advised.

Lumbar puncture is also done in cases in which the CT scan doesn't reveal a hemorrhage, but there is a high suspicion that one has occurred. In subarachnoid hemorrhage, cerebrospinal fluid shows red blood cells and/or xanthochromia, a yellowish tinge caused by blood breakdown products. Xanthochromia first appears six to 12 hours after subarachnoid hemorrhage, making it advisable to delay lumbar puncture until at least 12 hours after the onset of symptoms for a more definite diagnosis.

Once a hemorrhage, AVM, or aneurysm has been diagnosed, further tests are done to pinpoint the damage. The CT scan may be useful in giving the general location, but cerebral angiography maps out the exact details. This procedure involves injecting a special dye into the blood stream. This dye makes blood vessels visible in x rays of the area.

Treatment

The initial course of treatment focuses on stabilizing the hemorrhage victim. Depending on the individual's condition, this may involve intubation and mechanical ventilation, supplemental oxygen, intravenous fluids, and close monitoring of vital signs. If the person suffers seizures, an anticonvulsant, such as phenytoin (Dilantin), is administered. Nimodipine, a calcium channel blocker, may be given to prevent vasospasm and its complications. Sedatives and medications for pain, nausea, and vomiting are administered as needed.

Once the individual is stabilized, cerebral angiography is done to locate the damaged blood vessel. This information and the individual's condition are considered before attempting surgical treatment. Surgery is necessary to remove the damaged area of the blood vessel and prevent a second hemorrhage. The specific neurosurgical procedures depend on the location and type of blood vessel damage. Typically, clip ligation is the preferred means of treating an aneurysm, and surgical excision, radiosurgery, or endovascular embolization are used to manage an AVM.

Prognosis

Individuals who are conscious and demonstrate few neurologic symptoms when they reach medical help have the best prognosis. However, the overall prospects for subarachnoid hemorrhage patients are generally not good. Of the individuals who suffer an aneurysmal hemorrhage, approximately 15% do not live long enough to get medical treatment. Another 20-40% will not survive the complications caused by the hemorrhage, and approximately 12% of the survivors will experience permanent neurologic disability. Neurologic disabilities may include partial paralysis, weakened or numbed areas of the body, cognitive or speech difficulties, and vision problems. Individuals whose subarachnoid hemorrhages occur as a result of AVMs have a slightly better prognosis, although the risk of death is approximately 10-15% for each hemorrhage.

Subarachnoid hemorrhage associated with traumatic brain injury has a poor prognosis. In clinical studies, 46-78% of head injury cases involving subarachnoid hemorrhage resulted in severe disability, vegetative survival, or death. Furthermore, it is possible that traumatic subarachnoid hemorrhages are accompanied by additional injuries, which would further diminish survival and recovery rates.

Prevention

Traumatic brain injury is the leading cause of subarachnoid hemorrhages, so it follows that efforts to prevent head injury would prevent these hemorrhages. Since accidents cannot always be prevented, measures to minimize potential damage are always advisable. Use of activity-appropriate protective gear, such as bicycle helmets, motorcycle helmets, and sports head gear, is strongly encouraged and promoted by medical associations, consumer organizations, advocacy groups, and health-care professionals. These same groups also advise using seat belts in automobiles.

Spontaneous subarachnoid hemorrhages are more difficult to prevent. Since there may be a genetic component to aneurysms and AVMs, close relatives to individuals with these conditions may consider being screened to assess their own status. Quitting smoking and keeping blood pressure within normal limits may also reduce the risk of suffering a spontaneous subarachnoid hemorrhage.

[EmilyAnne]

1. This happened to my uncle's girlfriend when they were in high school. She had taken off her seat

belt to pick something off of the floorboard. My uncle looked down to seen what she was doing and lost control, hitting a tree. The girl went through the windshield, but got up and told him she was ok. She talked to the emergency crew that showed up, told my uncle to meet her at the hospital and to not feel bad.
My uncle followed the ambulance in a police car and when he got there, she was dead due to her head injury.
He was completely shocked and has never recovered.

[SoCalDem]

3. How awful for him to carry that around with him

:(

[opihimoimoi]

2. Great Post K&R :o)

:kick:

[Control-Z]

4. A little off the subject

but in response to 'our football player son was told to "walk-it-off"'.

My son was injured in PE last year, badly enough that he couldn't get up for a few minutes. His teacher shamed him in front of his class, insinuating he was a sissy. He was then told to take it like a man and "walk it off".

I picked him up when he called me from school, very upset (mostly about the way he was treated in front of his peers), and went straight to the ER. His collar bone was broken in two places. Of course, I couldn't do anything about it because he was so embarrassed already, he thought that mommy defending him would be reason for more ridicule from his macho teacher.

I'm grateful it was only two breaks and not something fatal like a talk and die injury. Still, it is the attitude of these coaches and instructors that makes me livid.



I'm shocked and shaken by what has happened to Natasha Richardson. My heart goes out to her family. I understand she has two children. How terribly sad.

[SoCalDem]

6. Exactly ON subject.. Coaches do this all the time, and the kids are too embarrassed

to make a "big deal" of it...and kids who are desperately trying to earn a "spot on the team" will sometimes not even tell Mom & Dad about their injury..

We even saw a lawyer, but they reminded us that we had signed the papers saying that we knew that football was a contact sport, and that injuries could occur..

We were just damned lucky that the paralysis was not permanent..

sounds like your son got lucky too:)...but no thanks to the coach..

[Berry Cool]

5. I did not know him personally, but know secondhand of an athlete who died a week after a head injury

that had only caused him to temporarily pass out at the time it took place.

He was playing rugby and got his bell rung so badly he was knocked out for a bit. But he came to and was OK to drive himself home. For the whole next week he functioned normally, even got a scan that was said to be OK, after his friends saw what the bruise looked like and worried about him and told him to get it checked out.

About a week after it happened, he woke up vomiting uncontrollably. His neighbor called an ambulance. By the time it picked him up, he was already dead.

This is why head injuries scare me.