DRHOOK- Hard knocks: Skull hematomas can be deadly

the handsome doctor John Hong

Skiing is the most freeing experience in the world: more than figure skating, more than running on the beach with Maggie Moo (my beloved doggy), more than singing to sold-out crowds at Carnegie Hall. (Okay, I might be telling a fib about Carnegie Hall: it's my Walter Mitty dream.)

So skiing this past weekend in Vermont was as good as a free lifetime supply of Ben & Jerry's. Okemo Ski resort was perfect for me; there I felt like Susie Chapstick. The next day at Killington, I was going down the hill like, "La la la la la—aaaaahhh!!" Seemingly hundreds of teenagers were zooming around me and clipping my skis. They were practically Killing-ton me.

What can happen when a careless skier slams into you, and you bonk your head?

Well, first of all, I wear a helmet when I bike, rollerblade, and ski. Some dudes at the ski resort made fun of my spouse's and my helmets. I said, "Hey, they're red and fashionable. Get with it!" 

They need to remember stars like Natasha Richardson and Sonny Bono who died in ski accidents. Natasha was taking a ski lesson– sans helmet– and died of an epidural hematoma. Farewell mein lieber Herr, Sally Bowles.

The skull isn't flexible (like Nancy Grace), so if there's bleeding under the skull, there's nowhere for the blood to go, and it squishes the brain. A hematoma is a "bump" like when you bang your leg really hard and get a painful raised bruise. The hematoma is a buildup of blood that can't drain; it takes time for it to be slowly reabsorbed into the body. 

From a head injury, there are two main types of hematomas: Epidural (EDH) and Subdural (SDH). SDH occurs from the venous structures of the brain, so the bleeds tend to be slow. In fact, symptoms from an SDH can be so slow that it can take days to weeks before a diagnosis is made.

If the SDH is severe, it presents acutely with impaired thinking and diminished awareness. In fact, 50 percent of the time, the person with an acute SDH will be in a coma. From increased pressure inside the skull, symptoms develop like headache, vomiting, problems swallowing, and stroke-like symptoms, and one pupil could be blown open. 

Slower bleeds in SDH are subtler with confusion, poor memory, change in mood, apathy, lightheadedness, and sleepiness.

For some reason, alcoholics are more vulnerable to SDH– and not just because of falling down drunk. Perhaps chronic alcohol use makes bleeding in the brain easier. 

Also, older people who fall down and hit their head usually get a CT scan to check for a bleed. Why? The brain atrophies as we get older, meaning it shrinks, and that is a risk factor for SDH. Folks on blood thinners like aspirin or warfarin are definitely more at risk for developing a hematoma. 

The EDH usually involves a ruptured artery that can cause death within hours. Most folks with EDH will have a fracture of the skull, so needless to say a headache is usually present before a coma ensues. Strangely (and really unfortunately), there is a "lucid interval" in which the injured person is alert and aware after a transient loss of consciousness. So the injured person might refuse medical attention– only to quickly go downhill within hours, experiencing vomiting, confusion, seizures, paralysis on one side, coma, and eventually death. 

Immediate medical attention in an ER after a head injury can save a person's life. And advice to dangerous skiers and snowboarders: Share the mountain! It is a slippery slope between life and death.


Dr. Hook cracks a joke or two, but he's a renowned physician with an interesting website, drjohnhong.com. Email him with your questions.