Let’s learn from Will McKamey’s death

The cranium is an un-yielding house for the brain. Even the smallest bit of swelling in the brain can be a problem because the bony cranium does not expand.

The cranium is an un-yielding house for the brain. Even the smallest bit of swelling in the brain can be a problem because the bony cranium does not expand.

Recently, Will McKamey, a Navy football player, died at the age of 19. He had been in a coma since falling unconscious and unresponsive after an unremarkable practice involving no noticeable blows to his head. A couple of years ago, while still in high school, Mr McKamey suffered a severe concussion, after which he was hospitalized. This year, Mr McKamey had been examined by four “independent” neurosurgeons and had received multiple scans (both MRI and CAT). Nothing suggested to medical personnel that Mr McKamey had anything to worry about and he was cleared for resuming his football career.

I am guessing that “independent” means that the neurosurgeons don’t work for the team. But it is hard to imagine that they are doing the exams for free; and equally hard to imagine that the high school league office pays them. Maybe independent means that the four physicians are unrelated to each other. If a reader knows the answer to this, please fill us all in.

This case is just so tragic, in large part because it was so avoidable. We need to recognize that we do not know who can safely resume everyday activity and gentle exercise after a head trauma. Knowing when a person can once again safely participate in contact sports is an even more mysterious art. Furthermore, I argue here that concussion is not a useful term or concept. We should be worried about all head trauma whether or not we are able to discern any immediate symptomatic or anatomical consequences.

Blows to the head can produce dramatic and sudden consequences such as unconsciousness, confusion, and anterograde amnesia. When this happens, we call the event a concussion. When no symptoms are evident, the event is sub-concussive. Unfortunately sub-concussive head trauma is not without dire consequences that can occur either acutely or after a long delay.

Let’s look at what happens when the brain bumps violently into the skull. Neurons are excited by the mechanical impact and they release gads of neurotransmitter. The released neurotransmitter overly excites other neurons, which in turn leads to excitotoxicity (a toxic reaction to too much excitement, really), and cell death. Axons may be stretched so much that the grip between the axon and the surrounding myelin sheath is disrupted, leading to an eventual demyelination. Some cells may be so strongly affected that they break open, die, and release substances that in turn harm nearby, intact, and previously healthy cells. Blood vessels may break open, leaking blood into the brain, causing a tiny “brain bruise.” The brain is likely to swell, producing an increase in pressure within the unyielding cavity of the cranium.

Head trauma may also initiate a degenerative cascade related to that which occurs in Alzheimers (AD) or Parkinsons (PD) Disease. this biochemical cascade promotes the production and aggregation of proteins such as beta-amyloid, alpha-synuclein, and tau which can ultimately lead to plaques and tangles in the brain, cardinal pathological signs of AD and PD. People may be more or less susceptible to this consequence from head trauma just as some of us are more or less susceptible to developing AD. For example, some forms (aka alleles) of the ApoE gene increase a person’s risk of developing AD.

In sum, lots of bad stuff can happen after you hit your head. The big, big problem is that we don’t know how to predict which blows to the head will resolve and which will go on to create either a delayed dementia or a vulnerability such as that which Mr McKamey clearly possessed.

My plea is that we recognize our ignorance. After a trauma, we may not see any symptom or sign that the brain is in fact in dire straits, severely damaged, and within a whisper of going over the edge and past the point of no return. Err on the side of caution.

Treat all head trauma as the potentially lethal event that it is.

5 Comments »

  1. So what would be advisable after a severe concussion? No sports? Are there other checks except of brain scans that should be done regularly in such cases?
    Sorry if my questions are naive or simple, don’t have much medical knowledge. But am participating in your Coursera MOOC to get more understanding about the brain, very excited to start tomorrow!
    P.S. By the way the announcement on the top of the page says the wrong starting date (21 instead 28 April)

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  2. I think that following a severe concussion, lowering the risk of another blow to the head as much as possible would be advisable. And unfortunately, the risk for head injury is high in team sports. Once the acute effects of the concussion have passed, individual sports may be possible.

    I have great respect for neurologists but my read is that there is no symptom or sign that can tell even the most knowledgeable or skilled neurologist whether any given blow to the head has set in motion effects that may not be immediately visible. Brain scans don’t tell us this information either. Non-immediate effects could include 1) starting someone down the path toward developing a neurodegenerative condition later in life; or 2) lowering the threshold needed to produce the perfect storm of inflammatory reaction and neuronal death. The latter appears to have happened in the case of Mr McKamey. He was in such a sensitized state that simply exertion, without any observable blow to the head, took him over the edge and killed him.

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    • I totally agree. In the Shane Morris case (MI college football), you can see that Mr Morris had a whiplash-like acceleration-de-acceleration-acceleration event just a few minutes before the hit to the head that made him clearly disoriented (which side is my team on?). To the brain in its fluid filled dural sac, accelerations and forces are the same deal. They both knock the brain against the inside of the skull.

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