WASHINGTON — A fall of the type that required former President Ronald Reagan to undergo brain surgery recently is a leading cause of injury and death among children and the elderly.
Without proper treatment, health officials say, seemingly minor head injuries and resultant hematomas like Reagan's can lead to puzzling changes in personality, vision problems, dementia and sometimes even death.
Every 15 seconds someone in the United States suffers a head injury, usually from a fall, assault or a car accident, according to a task force report issued earlier this year by the Department of Health and Human Services. And every five minutes one of those people will die and another will become permanently disabled.
More than 2 million Americans annually suffer a head injury, the report states, and 500,000 of them sustain injuries serious enough to require hospitalization.
Of those who survive, 70,000 to 90,000 will endure a lifetime disability, 5,000 will develop epilepsy and 2,000 will exist in a persistent vegetative state, unable to speak or move.
A hematoma is a localized collection of usually clotted blood caused by bleeding from a ruptured blood vessel. It can occur anywhere in the body and varies in seriousness depending on the amount of accumulated blood and the site. A subdural hematoma is one of the more serious types because it causes pressure on the brain.
In Reagan's case, the subdural hematoma that caused a small pool of blood to accumulate outside his brain was the result of his fall from a bucking horse. The accident occurred July 4 while Reagan was vacationing on a ranch in Mexico.
Drill Into the Skull
Surgeons at the Mayo Clinic, who detected the hematoma on a specialized X-ray called a CAT scan, drilled at least one hole on the right side of Reagan's skull to relieve pressure on his brain caused by the accumulation of fluid. During the hour-long operation, they installed a temporary tubular drain which was removed the following day.
Reagan was closely monitored for complications that can occur as a result of such surgery--chiefly infection, additional bleeding or swelling that would cause increased pressure on the brain.
Although neurosurgeons at Mayo and elsewhere have characterized the surgery as minor, the reason it is performed often is not. In severe cases, hematomas can kill victims within a few hours and can cause bleeding inside the brain, a more serious problem. In some cases, symptoms of head injury do not appear for weeks or even months after a fall or other accident.
Things Not the Same
"The worst problem for any disease or disability is to ignore it," said Marilyn P. Spivack, executive director and co-founder of the Head Injury Foundation of Southboro, Mass.
"Unfortunately that's what often happens with supposedly minor head injuries until a relative or close friend notices that things just aren't the same, that the person is forgetful or is acting different."
Most people who suffer mild bumps to their heads may experience temporary symptoms that disappear and require no further treatment. In more serious cases, injuries can be detected through a CAT scan or through magnetic resonance imaging that provides a picture of the brain. In other cases, neuropsychological testing may be required to detect a problem.
Problem of Aging
Head injuries are a problem particularly among the elderly because of the physiology of aging, said Robert Friedland, chief of the section on brain aging and dementia of the National Institute on Aging.
As many people get older, Friedland said, their brains shrink inside the skull. As that happens, the bridge veins that connect the brain to the skull tend to get stretched.
During a fall, as the victim's head smacks a hard surface such as the ground, the brain, which has the consistency of Jell-O, will continue to wiggle until it hits the inside of the skull. The impact can tear tightly stretched veins.
Because it can take weeks, or even months, for symptoms to develop, some elderly people do not connect an injury with symptoms such as forgetfulness or weakness or vision problems.
"Sometimes the trauma was so minor that they don't remember it," said Friedland, "and sometimes it may happen without any trauma at all," and merely be a function of aging.
Concern about head injuries, which the HHS task force estimates cost $25 billion annually, has increased as sophisticated technology has succeeded in keeping nearly dead trauma victims alive, in some cases for years.
Because of motor-vehicle accidents, males between the ages of 15 and 24 have the highest rate of head injury in the country, according to the Centers for Disease Control in Atlanta, Ga. Among infants, child abuse accounts for 64% of all cases of head injury, the HHS task force reports.
"I'm sure with the extraordinary care and his extraordinary good fortune, President Reagan will do very well," said Spivack.
"The question that we have to focus on is what happens to people who don't have those resources or get such good care. This is something that medicine is just beginning to take a look at."