Severe Injury

01.03.14

Brain Bleed: Why Michael Schumacher’s Helmet Wasn’t Enough

The former Formula One champion played by the rules, but sometimes precautions only help so much.

Michael Schumacher is a person who can accurately be described with one word—champion.

Michael Jordan led the way to six NBA titles, Wayne Gretsky counts four Stanley Cups, and Schumacher won seven Formula One (F1) championships. Competing at speeds up to 220 mph, Schumacher is regarded as one of the greatest F1 drivers of all time. Schumacher tempted fate each time he took the wheel of his high performance racecar, and he got away with it.

And so the world was shocked and saddened to hear about his severe brain injury in the Alps last Sunday morning. The details are a blur, but while skiing with his son, Schumacher fell and hit the right side of his head on a jagged rock.

Schumacher had played by the rules, wore a helmet, skied in pairs—but such precautions only help so much. Rescuers say that he maintained consciousness when they first reached him, but his health quickly deteriorated. The exact nature of Schumacher’s injury is unclear, but he did experience significant bleeding in and around his brain—a so-called intracranial hemorrhage.

His period of consciousness and the ensuing downward spiral are reminiscent of British actress Natasha Richardson’s tragic accident on the ski slopes in 2009. Richardson’s bleeding was identified as an epidural hematoma and she tragically passed away soon after her injury.

The skull is often thought of as protective vault for the brain. But, if the soft, gelatin-like brain moved freely within this safe, making contact with the skull frequently, it would quickly succumb to bruising and injury. Fortunately, the brain is suspended in cerebrospinal fluid designed to buffer the motions of every-day life. This impact cushioning system however, cannot stand against a violent traumatic insult like a car accident, blast wave, or head injury. And thus in severe head injuries, it is possible for blood vessels in and around the brain to burst. The result is a rapidly enlarging blood clot, called a hematoma.

A common denominator between Schumacher’s and Richardson’s accidents was the wakeful period following their injuries. Schumacher remained conscious for 90 minutes following his injury. Richardson reportedly had no outward signs of injury after her tumble, joking and declining care from paramedics dispatched to the resort shortly after the actress’s fall.

“This impact cushioning system however, cannot stand against a violent traumatic insult like a car accident, blast wave, or head injury.”

This “lucid interval” is found in nearly half of all cases of epidural hematoma (Bullock, Neurosurgery, 2006). If bleeding around the brain is involved, the hematoma can grow quickly. As this collection of blood expands, pressure in the head begins to rise. This increased pressure can lead to breathing trouble, a depressed level of consciousness, seizures and abnormalities in blood pressure and heart rate.

This lucid period can lead the injured person to waive medical care, as seen in Richardson’s experience. This is not a surprising decision. After all, following a trip or a fall a person often jumps up, brushes themselves off, and insists they are fine in order to nurse their bruised pride away from the attention of others.

It is important to realize the danger of doing this when a head injury is involved. As time passes, more blood is trapped in these very small spaces, causing more pressure and more problems.

Recently, we discussed the devastating long-term effects of concussions, but brain bleeds are dangerous in a very different way. While Schumacher had a history of head and neck trauma, this injury was very different. Both concussions and brain bleeds require quick medical evaluation, but the danger of a bleed in or around the brain is urgent, often life threatening and requires immediate attention.

It is clear that Schumacher did his best to protect his brain; he wore a helmet at the time of the fall. While this likely saved his life, it did not prevent the bleeding and brain injury that he suffered.

As the biology and physics of brain injury becomes clearer, technology develops to protect both professional athletes and weekend warriors from threats to their brains. Impact detectors are one developing frontier. These manifest as “smart” mouth guards and peel-and-stick sensors. These are designed to detect the force on a player’s head after a hit. If a given tackle exceeds a certain level of force, the sensor is activated and the player is notified to seek medical attention. Measuring the force of a hit is an important first step in early detection, but it is an indirect measure of what is really happening to the brain. To date, a comprehensive medical exam is the only way to accurately identify a significant brain injury.

Evidenced by Schumacher’s injury and Richardson’s tragic demise, better protective technology is not advanced enough to prevent significant injury. Currently, participants in sports with a risk for serious brain injury, such as downhill skiing, are advised to wear a helmet. Further steps must be taken.

Informing participants about what brain injuries can look like, their potentially deceptive symptoms, and the importance of immediate medical attention is a logical step forward. Even more critical, people will need to think about the risks of such activities with greater scrutiny. I certainly do not think we should consider limiting activities, but I do hope that with an increased level of awareness participants will be more likely to implement as many safety precautions as possible.

There are many similarities between Richardson’s and Schumacher’s accident but the differences may prove most significant. Though no guarantee of his survival and recovery, Schumacher received high-level medical care almost immediately following his injury. This gives a man who made a career out of finishing first, the best chance to do what he does best: come out on top.