How Worried You Should Be If You Hit Your Head, According to a Neurosurgeon

On Wednesday, about a month after Bob Saget’s surprising death, his family announced that a medical examination revealed that he had died of head trauma. After performing a stand-up set in Orlando on January 8, the 65-year-old comedian, known best for his turn as Danny Tanner in Full House, spent a night alone at the Ritz-Carlton Orlando. According to a medical examiner, he accidentally hit his head, most likely as the result of an “unwitnessed fall,” and went to bed. He was found dead in his hotel room the next day, the New York Times reports.

“Now that we have the final conclusions from the authorities’ investigation, we felt it only proper that the fans hear those conclusions directly from us,” Saget’s family told the Times in a statement. “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.”

It might come as a surprise to hear that a seemingly minor hit could prove fatal. But according to Dr. Donato Pacione, an assistant professor of neurosurgery at NYU Langone, blows to the head often present a serious risk, even if they don’t seem like a big deal in the moment. VICE spoke with Pacione about how concerned the average person should be about head injuries, whether certain folks are at a higher risk than others, and what you should (and shouldn’t) do after suffering one, however slight it might seem.

VICE: How common is it for people to die from accidental head trauma like this?

Dr. Donato Pacione: In younger people, to see death from head trauma, it usually has to be a pretty high-impact injury. But in people above the age of 60, you don’t need much of a trauma to develop a bleed that could then become life-threatening. I think there’s a misconception that unless you get knocked out and lose consciousness, you’re probably not at a major risk. But anybody over the age of about 60, if it’s a fall where they hit their head, you have to be vigilant of warning signs, where this might be an issue that could be dangerous.

What are some of those warning signs?

An increasingly severe headache can be part of it. If there’s nausea and vomiting associated with it, that’s always a big red flag for us, too, because that's usually a sign that the brain is under pressure. Outside of that, we start to get into some of the signs and symptoms that are similar to what we see with strokes. People can have difficulty with their speech; they may have weakness on one side of the body; they could have numbness and tingling or lack of sensation on one side of the body as well. And that may be a red flag indicator that there’s something going on.

What’s actually happening inside the brain that results in death after someone sustains head trauma like this?

If there’s something that’s actively bleeding, that fluid will build up pressure, and the pressure has to go somewhere. Since the skull is a fixed unit—it can’t expand and contract if it’s fully formed—the skull can’t move. The only thing that can move is the brain. So as the pressure builds, it pushes the brain. And as the brain gets pushed, it slowly compresses other parts of the brain, specifically, areas called the brain stem, which is kind of the organization center of all the really important and vital structures needed for being alive. Functions like what controls your heart beating, how fast it beats, whether or not you breathe, and how fast you breathe, those are all centered in the brain stem, as well as all of your areas that give you alertness and make you awake. 

So what we see is that as the pressure in the brain builds, people start to lose consciousness. They become less and less alert, they’re usually getting more groggy over time, and then they become completely unconscious. And then from there, you start to lose functions as far as your ability to protect your airway and to breathe on your own. And then eventually, it can affect the ability of your heart to beat. 

Generally speaking, how hard of a blow do you have to take to the head for it to be potentially fatal?

If it’s a blow to the head that’s hard enough to knock you out, that’s something that concerns me. That could become life-threatening, and somebody should seek medical attention for that. If you don’t have that kind of scenario—where you just hit your head kind of hard, or hard enough that it hurts—if you’re on blood thinners, I would be very vigilant. Any time somebody is on a blood thinner, that increases their risk of dying from head trauma. These days, a lot of the population has their blood thinned out for a variety of reasons. And by blood thinners, I mean even things as simple as aspirin, which can thin out the blood, or true blood thinners that people take because of having clotting issues or heart issues. You should be vigilant if somebody is on blood thinners in any type of head injury. 

But there’s not really a hard-and-fast rule where if you hit your head this hard, you will be at risk. It’s hard to try to tell you, “This is when you need to be worried,” as opposed to, “These are your risk factors.” If you’re somebody who is on blood thinners for any reason, and you hit your head, and you notice after the fact that you’re starting to get a worsening headache, I wouldn’t ignore it. I would go seek medical attention.

A medical examiner found that Bob Saget sustained a blow to the back of his head. Is that any more or less dangerous than sustaining a blow to other parts of your head?

It’s not any more fatal than a blow to the front of the head. The areas that are most at risk, in terms of trauma to the underlying area, would be right near the temple. That little hollow area behind the ridge around your eyes, in that area, the bone thins out. Outside of that, the rest of the skull does a pretty good job of protecting the underlying brain. Back of the head, front of the head—I would say that you're dealing with just as much of a risk either way.

Is this something that can just happen to anyone, or are some people more vulnerable than others to head trauma?

If you have any type of bleeding disorders—so people that have underlying problems with their blood clotting, and blood-clotting conditions, which are on the rarer side—those people are going to be at the same sort of increased risk as we would see with people who are on blood thinners. And then there’s age: The older you are, the more susceptible you are to developing a bad head trauma and bleed from even a minor injury.

To what degree does going to sleep after suffering head trauma put you at greater risk, and why is it that the case?

The thing we always worry about with people who have a head injury is they think, I’m going to sleep this off. I just have a headache. But if you’re in a scenario like that, the answer is not  to go sleep it off. The answer is to keep an eye on what's going on. If you’re trying to sleep it off, especially if you’re alone, [you may never spot] all the warning signs we would look for. Because as you’re lying there sleeping, you could pass out from the pressure [on your brain]. If you lose consciousness, there’s no way for you to wake up to do something to save yourself. The cascade of increasing pressure is already in effect. If you have family members that are with you, and you do need to go lay down for a little while, they should be keeping an eye on you to make sure that they can still wake you up, you can still talk to them, you can do the things that you’re expected to do. Going to sleep and locking yourself away somewhere is dangerous after you’ve had a head injury.

It sounds like if you sustain a head injury, you should just be around someone, even if you don’t have family members or friends around. 

Correct. If you’ve had a head trauma, and you are dealing with a severe headache—if it’s that severe that you’re needing to go and lay down to kind of sleep it off—don’t do that. Consider going to seek medical attention instead and be evaluated by somebody. They can monitor you and they can decide if you need to get a scan to make sure that you’re OK.

Do people who sustain head trauma typically think it’s less serious than it actually is? Bob Saget’s family wrote that after he hit his head, he “thought nothing of it.”

When we’re talking about people over the age of 60, that very much can be the case, because they can hit their head and it’s not an immediate issue. Maybe you’re not going to have that severe headache like you would from increased pressure because there’s no pressure built up yet. It takes a while to build up enough blood to cause pressure, which causes things like a headache and nausea and vomiting. So you may think nothing of it. And you may say, “Yeah, it’s kind of sore. And maybe I’m getting a little bit of a worsening headache. I’m going to go lay down because I just need to sleep this off.” But that’s actually the warning sign for you. That’s a red flag.

Would it be bad for someone who hits their head to take Advil—a brand of ibuprofen—or other over-the-counter medication like it?

There’s some data to suggest that Advil can affect your platelets because it's in the category of what we call an NSAID (a non-steroidal anti-inflammatory). Platelets are sort of like bricks, and your clotting factors are like the mortar when you’re trying to block off something that’s bleeding. So if the bricks are not attaching to the mortar and sticking together, then you can’t form a good clot. Aspirin is [also] something that affects the bricks, the platelets, and prevents them from sticking together as much. 

NSAIDs like Advil can also have a similar effect on platelets: It can be something that prevents them from sticking together to form a clot to stop a bleed. Aleve, Advil, Motrin—which are all the same drug, ibuprofen—any of those can all have that effect on platelets and the ability to clot. If somebody has a head trauma, we usually recommend that they don’t take Advil afterwards. 

Instead, if you’re going to take something for pain, take Tylenol. Tylenol does not affect the platelets.

I know you’re working with really limited information here, but in your view, is there anything that could have been done to possibly prevent Saget from dying after he sustained this head injury?

That’s so tough to say. If he had told someone that maybe he was getting a worsening headache and that he had this injury, maybe that would have been enough for somebody to say, “OK, you should go seek some medical attention.” But we’re playing in the world of hypotheticals. It doesn’t sound like there were a lot of other red flags to where you could have said, “OK, this is where we intervene.”

Generally speaking, if someone does hit their head like this, what should they do to make sure they’re safe?

Let somebody know who’s nearby, who can check on you and make sure that things are OK. That way, should you become incapacitated, there’s somebody who can hopefully intervene for you. And then look out for the red flags, which are: Are you getting a progressively worsening headache? Are you getting nausea? Are you vomiting? Are you noticing any of the things that we talked about, in terms of signs of stroke? Do you feel like you’re having trouble walking? Are you stumbling? Are you not able to get words out? Are you slurring your speech? Any of these things that come along with a head trauma are red flags. Your regular, run of the mill, “I banged my head and now I have a bruise on my scalp and just a little contusion” kind of thing, that’s not going to give you any of those other symptoms.

If you do hit your head and you're experiencing some of those red flags, should you be going straight to the ER? 

If you’re having any of the warning signs—headache, nausea, vomiting, or any of those neurologic conditions—yes, you should be going to the ER. I wouldn’t ignore it and just hope that it kind of goes away on its own. Especially if you hit your head and you’re on blood thinners, I would consider going, even with only mild symptoms of headache. You’re just that much more susceptible.

Generally speaking, how concerned should the average person be about head trauma and the risk of death associated with it?

If you have a hard enough head trauma that it causes you to lose consciousness, be concerned and go seek medical attention. If you have a head trauma—even if it’s minor—and you’re on blood thinners, I would be very vigilant and have a very low threshold to go and seek medical attention. 

If you’re a young, healthy person and you hit your head, and you really have no other symptoms other than maybe some soreness at the site where you hit your head, I wouldn’t run to the ER. I think you’re probably somebody that’s not at a major risk for developing this. But it’s [about] varying levels of threshold. If you’re older, it’s a low threshold. If you’re on blood thinners, again, low threshold.

Drew Schwartz is a staff writer at VICE. Follow him on Twitter.