What You Should Know About Traumatic Brain Injury

Actor and comedian, Bob Saget, died on January 9th, 2022 at age 65. He was found unresponsive in his Ritz-Carlton Hotel room in Orlando, Florida. At the time, the cause of death was unknown; a January 10th autopsy report ruled out drugs or foul play. Now we know what took the life of this beloved entertainer, husband and father.

The report from the Orange County Medical Examiner, released February 10th, revealed multiple signs of head trauma, including posterior scalp abrasions, skull fracture-induced eyelid discoloration, a subdural hematoma as well as a subarachnoid hemorrhage (more details later).

The autopsy report, obtained by People, also revealed that Saget was positive for Covid-19. In December 2021, The Full House star had revealed that he had Covid-19. A PCR test can remain positive for several weeks. The toxicology report did not reveal illicit substances but was notable for clonazepam (a.k.a. Klonopin), a benzodiazepine used to treat conditions such as panic disorder, seizures and anxiety. He also tested positive for trazodone, a medication for treating insomnia. Chronic heart disease (atherosclerosis of the aorta and coronary arteries), not an uncommon finding in Saget’s age group, was another autopsy finding.

Based on the autopsy and toxicology reports, Chief Medical Examiner Joshua Stephany, MD concluded that Saget died from blunt head trauma: “His injuries were most likely incurred from an unwitnessed fall. A toxicology analysis did not reveal any illicit drugs or toxins. The manner of death is accident.” His family believed that Saget “accidentally hit the back of his head on something, fell backwards, thought nothing of it and went to sleep.”

As an addiction medicine doctor, I treat many patients who take sedating substances: opioids, antidepressants, sleeping meds and many others (alcohol worsens sedation). I always provide the standard warning about drowsiness, not driving or operating heavy machinery. So, I couldn’t help but wonder: did Saget trip and fall backwards after taking clonazepam and trazodone – two medications known to cause drowsiness? Or was he feeling lightheaded from his meds? It’s a moot point now for Mr. Saget’s family. But it’s an important reminder for the millions of people who take sedating medications and other substances including alcohol which can impair both our balance and judgement.  

After the tragic discovery of head trauma as the cause of Saget’s death and as an injury sustained by so many of my patients and family members, I decided to write about the key features about brain and skull trauma.

Traumatic Brain Injury

According to the CDC, traumatic brain injury (TBI) is a leading cause of death and disability in the United States, killing approximately 166 people each day. Males represent nearly 80% of all reported TBI cases. The two main causes of TBIs include a bump, blow or jolt to the head; or a penetrating injury to the head such as a gunshot or knife wound.

“Falls remain the leading cause of TBI, followed by motor vehicle accidents,” explains Isaac Karikari, MD, associate professor of neurosurgery at Duke University Hospital. “Patients who are 65 years and older suffer the highest mortality when they develop TBI.”

The CDC lists 3 main types of TBI. Mild TBI or concussions are typically not life-threatening but can still be serious. Moderate and severe TBI can lead to life-long health problems (for those who survive) and result in a substantial societal and economic toll. The lifetime economic cost of TBI (including medical costs) was about $76.5 billion in 2010.

Symptoms vary widely and depend on the severity of the head injury, ranging from headache, confusion, vomiting and mood changes to slurred speech, paralysis, coma and loss of bowel or bladder control.

TBI-Related Injuries

The American Association of Neurological Surgeons (AANS) describes multiple injuries caused by TBIs including “mass lesions” which can increase pressure within the brain. A hematoma is a blood clot anywhere within the brain; an epidural hematoma (which claimed the life of actress Natasha Richardson) develops between the dura mater and the inside of the skull versus a subdural hematoma (experienced by Saget) which collects between the dura mater and the arachnoid layer.

A contusion is bruising of brain tissue consisting of injured or swollen brain mixed with blood leaked from arteries, veins or capillaries. A subarachnoid hemorrhage (SAH), also found on Saget’s autopsy, occurs when blood enters the subarachnoid space and is mostly mild; severe SAH can lead to hydrocephalus, a buildup of fluid in the ventricles or cavities deep within the brain.

“Epidural hematomas are notorious for causing a lucid interval,” describes Christa Swisher, MD, a neurocritical care physician at Atrium Health. “You may seemingly feel fine but then later as the hemorrhage outside the brain gradually worsens and increases pressure on the brain, it causes more and more symptoms and could eventually lead to death if not recognized and treated in time.”

When to Call 911 – Especially Among Elderly Adults

As a reassuring reminder, most falls and head injuries are benign and do NOT result in serious or long-term consequences. But if the impact was significant (i.e. not just a light tap) or if concerning symptoms develop (dizziness, blurry vision, behavior changes, etc.), then 911 should be called.

“Patients should be monitored at home for new or worsening symptoms such as a severe headache, confusion or vomiting,” states Dr. Swisher. “In a scenario like this, 911 should be called immediately.”

Dr. Karikari concurs: “Any elderly person who falls and strikes his or her head should be monitored closely by family members or caretakers. Any change in their mental status, headache complaints and excessive sleepiness should prompt immediate medical evaluation.”

TBIs may also be missed or misdiagnosed in older adults who are more likely to be hospitalized and die from head trauma. Symptoms of TBI often overlap with other medical conditions commonly experienced by older adults such as dementia. Take special note of older individuals who take anticoagulants such as warfarin (Coumadin), apixaban (Eliquis) or rivaroxaban (Xarelto); or antiplatelet medications like Aspirin or clopidogrel (Plavix). These meds can increase the risk of a brain bleed following a TBI. Have a low threshold for calling 911.

Prevention

Many head injuries are preventable, according to the Cleveland Clinic. Review your medicines with your doctor or pharmacist – find out which ones cause dizziness and increase your risk of falls. Fall-proof your home by clearing away toys, removing loose rugs and installing bathtub grab bars and staircase handrails. Wear a helmet when biking, skating, riding a motorcycle or playing sports like hockey or football. Buckle up when behind the wheel using seat belts, or use car seats or booster seats for kids; avoid driving when under the influence or feeling drowsy. Optimize your vision by getting regular eye exams and setting up good lighting in stairwells and hallways. Build muscle and improve balance through activities such as yoga, tai chi and strength training. Use walking assistive devices, if needed, such as canes and walkers to be steadier on your feet.

*****

On a personal note, I wanted to share my story with the legend himself. I had the opportunity to see Mr. Saget perform live last June at a comedy club, Levity Live, in West Nyack, NY. The cherished comic could not contain his jubilation at the sight of a live audience…and applied his unique brand of sarcasm: “I mean, who goes out on a Wednesday night to see comedy in an abandoned mall?” We all laughed because we all indeed drove out to the Palisades Center in the middle of the week because we loved Bob! And he reciprocated: “YOU do. And I love you.” I got it. The outpouring of love from his fellow comedians and closest friends – Jeff Ross, Steve Martin, Mindy Kaling, George Wallace and countless others – echoed loud and clear in my broken heart. I send my deepest condolences to Mr. Saget’s family and loved ones…and hope Bob’s having a hearty laugh in heaven.