The death of popular comedian Bob Saget while on tour in Florida last month was surprising and tragic, but the injury that claimed his life is more common than you might think.
According to the medical examiner in Florida who performed the autopsy, Saget most likely fell and struck the back of his head, causing bleeding on his brain. Saget’s family said he probably thought nothing of the injury and went to sleep. A hotel employee found him dead in bed the next afternoon.
On a typical day, brain injuries like Saget’s claim the lives of more than 160 people in the United States, the Centers for Disease Control and Prevention says. About 61,000 people died from a traumatic brain injury, or TBI, in the U.S. in 2019 alone.
Granted, the most common cause of death from TBI is a gun-related suicide. Car crashes and assaults are other common sources of these injuries. But almost half the hospitalizations from TBI come from the simple act of falling down, the CDC says.
Saget was 65, putting him in an age group that’s particularly susceptible to damaging falls. A 2006 study published by the Journal of the American Geriatrics Society found that “in persons aged 65 and older, TBI is responsible for more than 80,000 emergency department visits each year; three-quarters of these visits result in hospitalization as a result of the injury.” More than half of those injuries resulted from falls.
According to the CDC, “data suggest that some groups are at greater risk of dying from a TBI or experiencing long-term health problems after the injury.” Those groups include racial and ethnic minorities, members and veterans of the armed services, homeless people, and residents of rural areas.
Everyone hits their head on something at some point in their lives. So how do you tell when there’s cause for alarm? Here’s some advice from three experts on brain injuries: Dr. Christopher C. Giza, director of the UCLA Steve Tisch BrainSport Program; Dr. May Kim-Tenser, a neurologist with Keck Medicine of USC; and Dr. Joshua Marcus, a neurosurgeon at Nuvance Health in Connecticut.
—What causes a traumatic brain injury?
Thousands of Americans suffer traumatic brain injuries every year, but incidents like the ones that claimed Saget’s life are rare. And although head traumas are “super common,” Marcus said, “the overwhelming minority result in anything serious.”
Bumping the headboard as you’re getting into bed shouldn’t send you to the hospital. “It has to be a pretty traumatic fall,” Kim-Tenser said. “It really has to be a pretty hard hit to the head,” involving a hard impact on a hard surface.
Giza agreed. “Hitting your head on the headboard is not going to create a lot of force,” he said. By contrast, he said, “slipping in the bathroom and hitting your head on the side of the bathtub is going to have considerable force.”
The brain can also be injured in a less direct way, when a forceful event — a car wreck, for example — shoves it against the skull. A shearing injury is when “the brain is going one way, the force is going the other way,” Marcus said. Then there are contracoup injuries, when a force on one side of the head sends the brain into the skull on the other side.
The damage is caused when a blood vessel inside the skull ruptures, causing blood to pool between the brain and its surroundings. “The skull is a closed box, largely,” Giza said, “so if you start filling up part of that space with bleeding, the rest of the stuff gets squished.”
Once you start squeezing the brain, it doesn’t work very well. People can go into a coma or become paralyzed. And if the pressure is applied to the brain stem (the part near the spinal cord), it can interfere with a person’s breathing and heartbeat, Giza said. Beyond that, he said, the pooled blood irritates the surface of the brain, potentially triggering seizures.
Giza and Marcus said that some parts of the head are worse than others when it comes to brain injuries. Because the compartment around the brain stem is relatively small, Giza said, it takes less blood to cause problems there. And fracturing the temporal bone above the ear could sever an artery, causing blood to flow rapidly into the brain, Marcus said.
—Red-flag symptoms
Experts say the telltale signs of a serious brain injury tend to be changes in behavior and mental functions. A seizure, paralysis, substantial confusion, a loss of coordination and vomiting are red flags that should send you straight to the emergency room, Giza said.
Kim-Tenser also pointed to feeling disoriented and drifting in and out of lucidity as indications of a real problem. Marcus added numbness and tingling to the list, as well as feeling lethargic or sleepy. “Being tired after a head injury is a bad sign,” Marcus said.
That’s not necessarily a reason to keep a person who’s suffered a blow to the head awake all night, Giza said. But monitoring that person is extremely important, he said, because it’s a sign of a serious problem if neurological or behavioral symptoms get worse over time.
For example, mild headaches are common after head injuries, so they’re not red flags on their own. But if they get worse instead of fading after a few days, that’s a reason to see your doctor.
Marcus noted that sometimes injuries cause delayed bleeding, so crucial symptoms may take a few days to emerge. That’s especially true with older patients, he said.
“It isn’t very common for somebody to hit their head and then to have a serious brain bleed and not have it detected,” Giza said. “But another risk that can amplify things is if somebody is completely alone. Being completely alone is extremely problematic if your symptoms start to get worse.” If you start to get confused or have memory problems and you’re by yourself, he said, you may not recognize the situation you’re in.
As with so many things in medicine, personal factors can play an important role in determining whether a head trauma results in serious injury. According to the Cleveland Clinic, you’re more susceptible to brain bleeding if you’re older, because the blood vessels around your brain are more susceptible to tearing; if you’re a hemophiliac or taking blood thinners; if you play contact sports; if you abuse alcohol, because “damaged livers can’t produce enough of the proteins that help the blood to clot;” or if you’re a baby, because your weak neck muscles leave you more prone to head injury.
—Other things to watch for
Even if there are no red-flag symptoms, a head injury may still be serious enough to warrant calling your doctor and being monitored for a few days.
Being sensitive to light or noise, feeling nauseous and having blurred or double vision are all signs that warrant further attention, Giza said. If you lost consciousness when the injury happened, Marcus said, “that’s a concerning symptom related to the fall itself.”
A lump on the head may look really bad, Giza said, but it doesn’t necessarily mean there’s an underlying brain injury. The swelling may be confined to the outside of the skull. The more swelling there is, however, the harder it will be for a doctor to feel for a skull fracture, he said.
Nor is a lot of bleeding necessarily a sign of a brain injury. “A cut to the scalp can bleed quite impressively,” Giza said, noting that almost 20% of the heart’s output gets pumped to the head (mainly for the brain).
