Richardson Died From Clot That Compressed Brain

By David Brown
Washington Post Staff Writer
Friday, March 20, 2009

Natasha Richardson, the British actress who fell during a ski lesson on Monday and later in the day lapsed into a coma, died of a large blood clot compressing her brain, New York City's medical examiner said yesterday.

The bleeding that led to the clot was caused by "blunt impact to the head," according to the official report, which also labeled the death an accident.

The formal name for the condition is "epidural hematoma." It is usually the result of bleeding from arteries torn when the skull is struck hard, often on the temple where the bone is thinnest.

Arterial hemorrhage inside the skull is a potential catastrophe. Each heartbeat pumps blood under high pressure into a confined space, compressing the brain tissue.

"It is the most feared, treatable problem in neurosurgery," said Gail Rosseau, chief of surgery at the Neurologic and Orthopedic Hospital of Chicago. "These are the patients who 'talk and die.' "

If the condition is recognized in time, a surgeon can drill a hole through the skull or cut away a piece of it, remove the clot and relieve the pressure. This often results in complete recovery.

Although many details of Richardson's accident have not been made public, she apparently demonstrated a "lucid interval" typical of many traumatic epidural hematomas -- a period soon after the impact when the victim is alert and feels well that is followed by a rapid decline into unconsciousness.

The Toronto Globe and Mail newspaper reported Wednesday that an ambulance was dispatched to the Mont Tremblant ski resort in Quebec on Monday but "turned around" when paramedics were told they were no longer needed. Richardson reportedly went back to her hotel to rest. When her condition began to deteriorate, another ambulance was called.

Where and when she first got a computerized axial tomography, or CAT, scan, the usual way subdural hematomas are discovered, was not known.

The actress was first taken to Centre Hospitalier Laurentien, in Sainte-Agathe-des-Monts, 25 miles from the ski area, arriving shortly after 4 p.m., said hospital spokesman Alain Paquette. That hospital does not have neurosurgical services, so she was stabilized and transferred by ambulance two hours later to Hôpital du Sacré-Coeur, a trauma center 50 miles away in Montreal.

She was ultimately flown to Lenox Hill Hospital in New York, where she died Wednesday at 7:26 p.m.

The Montreal hospital gave no details yesterday about Richardson's treatment.

Lenox Hill Hospital referred all calls to the company that represents actor Liam Neeson, Richardson's husband. The company did not return calls.

"Typically, epidural hematomas occur in the setting of a skull fracture -- and usually you have to hit yourself pretty hard to get a skull fracture," said Javier Provencio, a neurologist and intensive-care physician at the Cleveland Clinic.

Rosseau concurred, saying that "it is a rarity that we see trivial injury causing catastrophic consequences, except in those rare occurrences where there is a skull fracture adjacent to a blood vessel or a patient is on an anticoagulant."

The prescription anticoagulant warfarin and over-the-counter painkillers such as aspirin and ibuprofen (but not acetaminophen) can promote bleeding and increase the risk of serious complications after head trauma.

A spokeswoman for the New York medical examiner's office would not say whether the autopsy found a fracture.

It is also not known whether Richardson lost consciousness, even briefly, after the fall, which would suggest a forceful impact. News reports said the snow was soft and the temperature was above freezing at the time of the accident.

Richardson, 45, was reportedly being taught by an experienced instructor and was not wearing a helmet. After the accident, the ski patrol was called, and she was taken off the hill in a toboggan, which is standard protocol, according to reports. Reportedly, she was advised to see a physician but said she did not want to.

Physicians used to think that a person had to lose consciousness to have a serious head injury, but research in the past decade has shown that is not true.

A study published in 2000 found that if a person with a minor head injury has a headache, vomits, is older than 60, is intoxicated in any way, has a problem with short-term memory, has a seizure or has an injury above the collarbones, then he or she should have a CAT scan.

In the 2007-2008 ski season, 44 people were killed skiing and nine snowboarding in the United States. There were about 10,000 head injuries, according to the National Ski Areas Association.

Forty-three percent of U.S. skiers and boarders wear helmets, up from 25 percent in the 2002-2003 season. Helmets are worn by 70 percent of children younger than 9, but 32 percent of people ages 18 to 24.

Twenty-six percent of beginners wear helmets, compared with 55 percent of advanced skiers and riders, according to the association's statistics.

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