Bob Saget’s Traumatic Brain Injury

In January, the comedy world was shocked by the sudden passing of “America’s Home Videos” host and “Full House” sitcom star Bob Saget at the age of 65.

After performing a stand-up show in Orlando, Florida, Saget returned to his hotel room. When his family was unable to contact him the next morning, he was found unresponsive in his room and confirmed dead by the Orange County Sheriff’s Office. Initial reports said there were no signs of foul play or drug use.

A statement from Saget’s family explained that “authorities have determined that Bob passed from head trauma. They have concluded that he accidentally hit the back of his head on something, thought nothing of it and went to sleep. No drugs or alcohol were involved.”

The autopsy report from the Orange County Medical Examiner’s Office listed the cause of Saget’s death as “blunt head trauma” and the manner of death as “accidental.”

They also listed the following injuries to the head:

• Abrasion of the posterior scalp
• Subgaleal hemorrhage underlying the abrasion of the posterior scalp
• Linear fracture of the base of the skull involving the right occipital bone and right temporal bone
• Comminuted fractures of the roofs of the orbits involving the bilateral frontal bone
• Bilateral partial periorbital ecchymoses
• Subdural hematoma (right greater than left)
• Subarachnoid hemorrhage
• Contrecoup contusions involving the bilateral frontal lobes and bilateral temporal lobes

In an article published in the New York Times in February, Joshua Stephany, MD, the chief medical examiner of Orange County noted that “it is most probable that the decedent suffered an unwitnessed fall backwards and struck the posterior aspect of his head.”

Subsequently, the family requested and received a temporary order to block any further release of the death investigation records.

Traumatic Brain Injury

Traumatic brain injury (TBI) occurs when head trauma causes damage to the brain. The leading causes of head trauma are motor vehicle-related injuries, falls, and assaults. Head trauma is classified as blunt (the most common classification), penetrating (most fatal injuries), and blast. Motor vehicle collisions and falls account for most severe TBIs.

Head trauma is most common in three age groups: children, adults up to age 24, and adults older than 75, with men outnumbering women 3:1.

TBIs are often classified as primary or secondary injuries. Primary injuries are those caused by the direct impact to the skull, penetration of the skull, or from the rapid acceleration/deceleration of the brain within the skull. This can lead to brain contusion, intracranial hemorrhage/hematomas, or injury to the axons themselves. Intracranial hemorrhage can lead to epidural, subarachnoid, subdural, intraventricular, or intraparenchymal hematomas.

Secondary injuries occur as a result of primary injuries and can include hypoxia, a systemic drop in blood pressure, or an increase in intracranial pressure, often caused by alterations of cerebral blood flow or changes in brain tissue or cerebrospinal fluid volume.

Increased intracranial pressure can lead to one of the most dangerous complications — brain herniation, which can put extreme pressure on parts of the brain, cutting off its blood supply. This is often fatal.

Symptoms

The symptoms of a TBI depend upon the extent of the damage to the brain and can range from mild to severe. For mild TBI, they include:

• Loss of consciousness
• Headache
• Confusion
• Lightheadedness or dizziness
• Blurred vision or tired eyes
• Ringing in the ears
• Bad taste in the mouth
• Fatigue or lethargy
• A change in sleep patterns
• Behavioral or mood changes
• Trouble with memory, concentration, attention, or thinking

For moderate or severe TBI, they include the above, as well as:

• Headache that gets worse or does not go away
• Repeated vomiting or nausea
• Convulsions or seizures
• An inability to awaken from sleep
• Dilation of one or both pupils
• Slurred speech
• Weakness or numbness in the extremities
• Loss of coordination
• Increased confusion
• Restlessness or agitation

Falls in Older Populations

According to the CDC, three million adults 65 and older are treated in emergency departments for falls each year. Falls are the most common cause of TBIs.

Factors in older populations that increase the risk of falls include:

• Lower body weakness
• Difficulty walking
• Balance issues
• Vision problems
• Use of medications including tranquilizers, sedatives, antidepressants, and others
• Home hazards such as throw rugs, clutter, pets, and uneven or broken steps or railings

Many of these risk factors can be minimized with proper care and planning.

Treatment

Anyone with signs of moderate or severe TBI should receive medical attention immediately. Brain imaging with CT scan is important to delineate fractures and intracranial hemorrhages. The goal of treatment for TBI is stabilization of the patient with the aim of preventing any further injury.

General measures of care include:

• Airway protection and ventilation
• Careful fluid management to maintain adequate blood flow and control blood pressure
• Frequent evaluation and management of increased intracranial pressure, which may include the use of elevated head position, mannitol, hyperventilation, and monitoring. Neurosurgical intervention is sometimes necessary.
• Temperature control, since fever can increase metabolic demands and affect intracranial pressure
• Possible seizure control or prophylaxis
• Sedation, as agitation and/or muscle activity can increase intracranial pressure

The prognosis for those with TBI depends upon the severity of the injury, the location of the injury, and the general health of the individual. Initial Glasgow Coma Scale (GCS) can be predictive of outcome: those with a GCS of <8 at presentation have a high mortality risk. Recovery may take months to years and may leave some with residual neurologic deficits or deficits in executive function.

Michele R. Berman, MD, is a pediatrician-turned-medical journalist. She trained at Johns Hopkins, Washington University in St. Louis, and St. Louis Children’s Hospital. Her mission is both journalistic and educational: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.