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Deaths due to brain injury among footballers in Victoria, 1968-1999

Paul R McCrory, Samuel F Berkovic and Stephen M Cordner
Med J Aust 2000; 172 (5): 217-219.
Published online: 6 March 2000
Sports Medicine

Deaths due to brain injury among footballers in Victoria, 1968-1999

Paul R McCrory, Samuel F Berkovic and Stephen M Cordner

MJA 2000; 172: 217-219

Abstract - Introduction - Methods - Results - Discussion - References - Authors' details
- - More articles on Sports medicine


Abstract Objectives: To determine the frequency and nature of fatal brain injuries occurring in Australian football.
Setting: State of Victoria, January to July 1999.
Design: Retrospective case series of football-related deaths identified from the coronial autopsy records of the Victorian Institute of Forensic Medicine (1990-1999) and newspaper reports (1968-1989).
Main outcome measures: Coronial autopsy findings and circumstances of injury.
Results: 25 deaths associated with Australian football were identified, nine due to brain injury. Coronial findings in the brain-injury deaths were intracranial haemorrhage in eight patients and infarct in the territory of the middle cerebral artery in one. In three of four cases of subarachnoid haemorrhage, vertebral artery trauma was noted. In all but one case, injury occurred as an accidental part of play.
Conclusions: The most common findings in deaths due to brain injury in Australian football were intracranial haemorrhage, including subarachnoid haemorrhage from vertebral artery injury.

 


Introduction Traumatic brain injury is common in contact and collision sports. In Australian (rules) football the epidemiology of mild head injury has been well studied. Based on prospective studies, the incidence of concussion in professional play is about 4 per 1000 player hours or 1 per 125 player games.1,2 However, a concern for team physicians is the very rare possibility of severe brain injuries, including intracranial haematomas, sometimes complicated by diffuse cerebral oedema, leading to permanent neurological impairment or death.3-7

To our knowledge there is no systematic, published information on severe and fatal brain injury in any code of football in Australia. Our study aimed to determine the frequency and nature of fatal brain injuries that occurred in football played in the State of Victoria, comprising Australian football and rugby union, in the 32 years to 1999.

 


Methods In Victoria, the Coroners Act 1985 (Vic.) requires all unexplained deaths or deaths due to accident or injury to be reported to the Coroner. In such cases, an autopsy is usually performed and the circumstances surrounding the death are investigated by the Coroner before a formal finding is made.8

The Victorian Institute of Forensic Medicine (VIFM) is responsible for providing pathology services and medical expertise to the Coroner. VIFM records from 1990 onwards are available on a computerised database, while earlier records are filed chronologically according to date of death and archived off-site.

We performed a computerised search of the VIFM database for the period January 1990 to July 1999. A keyword search for the term "football" was used, noting where this word occurred in the coronial findings or the forms detailing the circumstances of the injury. Deaths of officials and spectators at football matches were excluded from the study.

As pre-1990 VIFM records are not on a computerised database, we could not search by text word. Further, as they comprise more than 50 000 case records stored with limited accessibility, a manual search was considered logistically unfeasible. Instead, we searched the clipping libraries of the major daily Victorian newspapers (The Age, the Herald-Sun) for the period January 1968 to December 1996 for cases of football-related fatalities. Reported details of names, injuries and dates of events were compared against coronial case records. The original records of identified cases were extracted for analysis of the circumstances surrounding the injury and the neuropathological findings.

The coronial autopsy always involved gross examination of the brain, but histological and detailed neuropathological examination was not always performed. When necessary, original hospital records were obtained for further details of injuries and neurosurgical findings.

This study was approved by the VIFM Ethics Committee and by the Ethics Committee of the Austin & Repatriation Medical Centre, Melbourne, Vic.

 


Results We identified 25 football-related deaths in the period 1968-1999. Fourteen of these occurred in the 10 years 1990-1999 and were found by computerised search of the VIFM database, while 11 occurred in the 22 years 1968-1989 and were found by newspaper searches. Both search strategies were used for the period 1990-1996, and each identified the same nine cases.

Details of the 25 deaths are shown in the Box. All but three were in Australian rules players, with the remainder in rugby union players (Patients 9, 21 and 22). Nine deaths were due to brain injury, all but one in Australian rules players. The remaining 16 were due to other causes, predominantly unrecognised ischaemic or congenital heart disease.

For the brain-injury deaths, coronial findings were intracranial haemorrhage (in eight patients) and infarct in the territory of the middle cerebral artery (in one). In three of four cases of subarachnoid haemorrhage, vertebral artery trauma was noted.

Diffuse cerebral oedema was noted in five patients -- in conjunction with surgically treated subdural haematomas (Patients 2, 6 and 8), a large subdural haematoma that was not surgically treated (Patient 9), and infarct in the territory of the middle cerebral artery (Patient 7).

Analysis of the circumstances of the fatal injury from coronial depositions, police records and newspaper reports suggested that all but one of the nine brain-injury deaths occurred largely because of accidental injury during normal play. In Patient 9, no injury was noted.

 


Discussion This study adds to knowledge of the severe end of the brain-injury spectrum in Australian football. We identified nine deaths due to brain injury associated with Australian football in Victoria in the 32 years to 1999. The most common coronial finding was intracranial haemorrhage, including three cases of traumatic subarachnoid haemorrhage from vertebral artery injury.

Determination of football-related deaths is limited in part by the difficulties of case ascertainment. Computerisation of Victorian coronial records began in 1990, and text-word searches are limited to this period. Mortality data based on death certification through the Australian Bureau of Statistics do not adequately identify injury risk factors such as sport participation. We used a novel case-ascertainment method -- searching newspaper records -- on the assumption that deaths from football are likely to be "newsworthy" and that the reports are likely to contain narrative details of the incident. Indeed, we found that when the searches overlapped (1990-1996), the two methods had identical case ascertainment (nine cases).

The presence of diffuse cerebral oedema was noted in five cases, all of which were associated with a major intracranial lesion. The mechanism of the middle cerebral artery territory stroke was not established at autopsy. However, given that hemiplegia was evident within minutes of the injury, it was more likely to have been caused by a traumatic middle cerebral artery occlusion than by raised intracranial pressure.

An area of concern shown in epidemiological studies of football injury is the higher concussion rates that occur in elite junior competitive football (age under 18 years) compared with senior levels of competition.9-11 It has been postulated that junior players may not have fully developed the necessary evasive strategies to avoid the elements of the game that put them at risk of brain injury. In our study, three of the nine fatal brain injuries were in teenagers and were associated with vertebral artery injury. Traumatic vertebral artery dissection is the most common reported mechanism of stroke in sport.12 The combination of unilateral neck pain or headache after head or neck trauma should prompt suspicion of vertebral artery dissection, even in the face of seemingly trivial trauma.12 Focal neurological signs, such as vertigo, diplopia, ataxia, dysarthria, cranial nerve palsies or altered mental function, should be an absolute indication for urgent neurological consultation and hospital admission.13

Our results show that, although Australian football has one of the highest participation rates of sports in Victoria, the potential for fatal brain injury is extremely low. We did not identify any risk factors that could be modified to prevent brain injury. All team physicians, regardless of the level of participation, need to be conversant with the appropriate clinical pathways for the safe and efficient triage of neurologically injured athletes.14

Many deaths were due to cardiac causes, such as congenital cardiac disease, unrecognised ischaemic cardiac disease and commotio cordis (sudden death due to low-energy trauma to the chest wall, mechanism unknown, but presumed to be arrhythmia). The first two occurred mostly in teenagers, whereas the last occurred exclusively in players aged between 35 and 44 years. A high frequency of ischaemic cardiac death in football has also been observed in Aboriginal players in the Northern Territory.15 Pre-participation medical screening should be considered by football administrators throughout the country for high-risk groups.

The role of a body to monitor injury over a range of sports in this country should also be considered. Although sport-related deaths are few, detecting injury patterns and identifying injury risk factors are important to ensure safe participation in sport. This task will be easier once the National Coroners' Information System, administered by the Monash University National Centre for Coronial Information, becomes fully functional in six to 12 months' time.

 


References
  1. Seward H, Orchard J, Hazard H, Collinson D. Football injuries in Australia at the elite level. Med J Aust 1993; 159: 298-301.
  2. McCrory P. Neurological injuries in rugby and Australian rules football. In: Jordan B, Tsaris P, Warren R, editors. Sports Neurology. 2nd ed. Philadelphia: Lippincott-Raven Publishers; 1998: 441-449.
  3. Jennett B. Epidemiology of head injury. J Neurol Neurosurg Psych 1996; 60: 362-369.
  4. Jordan B, Tsaris P, Warren R, editors. Sports neurology. 2nd ed. Philadelphia: Lippincott-Raven Publishers, 1998: 45-71.
  5. Adams J. Head injury. In: Adams JH, Duchen LW, editors. Greenfield's neuropathology. 5th ed. London: Oxford University Press, 1992: 106-152.
  6. Cantu RC, Voy R. Second impact syndrome: a risk in any contact sport. Phys Sportsmed 1995; 23: 27-34.
  7. McCrory PR, Berkovic SF. Second impact syndrome. Neurology 1998; 50: 677-683.
  8. Breen K, Plueckahn V, Cordner S. Ethics, law and medical practice. Sydney: Allen and Unwin, 1997.
  9. Orchard J, Wood T, Seward H, Broad A. Comparison of injuries in elite senior and junior Australian football. J Sci Med Sport 1998; 1: 83-88.
  10. McMahon KA, Nolan T, Bennett CM, Carlin JB. Australian Rules football injuries in children and adolescents. Med J Aust 1993; 159: 301-306.
  11. National Health and Medical Research Council. Football injuries of the head and neck. Canberra: NHMRC, 1995.
  12. McCrory P. Stroke in athletes. In: Cantu R, editor. Neurologic athletic head and spine injuries. Philadelphia: WB Saunders and Co, 2000. In press.
  13. Showalter W, Esekogwu V, Newton K, Henderson S. Vertebral artery dissection. Acad Emerg Med 1997; 4: 991-995.
  14. McCrory PR. Were you knocked out? A team physician's approach to initial concussion management. Med Sci Sports Exerc 1997; 29 (7 Suppl): S207-S212.
  15. Young M, Fricker P, Thomson N, Lee K. Sudden death due to ischaemic heart disease in young Aboriginal sportsmen in the Northern Territory, 1982-1996. Med J Aust 1999; 170: 425-428.

(Received 12 Jul 1999, accepted 21 Jan 2000)

 


Authors' details Department of Medicine (Neurology), University of Melbourne, Austin and Repatriation Medical Centre, Melbourne, VIC.
Paul R McCrory, FRACP, FACSP, Neurology Research Fellow;
Samuel F Berkovic, MD, FRACP, Professor.

Department of Forensic Medicine, Monash University, and Victorian Institute of Forensic Medicine, Melbourne, VIC.
Stephen M Cordner, FRCPA, FRCPath(UK), Professor and Director.

Reprints will not be available from the authors.
Correspondence: Dr P R McCrory, 31 Grosvenor Parade, Balwyn, VIC 3103.
pmccroryATcompuserve.com


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Football-related deaths* in Victoria, 1968-1999
 
Patient Age (years) Details of injury Time to death Coronial findings

Brain Injury
1 15 Accidental blow to neck when shepherded during play, fell to ground unconscious and died in hospital 6 hours Traumatic subarachnoid haemorrhage from vertebral artery injury, subdural haematoma
2 17 Accidental knock to the head during game, complained of tinnitus and headache, found unconscious next morning; craniotomy performed because of computed tomography evidence of extradural haematoma 16 hours Extradural and subdural haematomas cerebral contusion, cerebral oedema noted postoperatively
19 Collision during normal play, no head contact reported, collapsed several minutes later and died in hospital 1 day Traumatic subarachnoid haemorrhage from vertebral artery injury
4 20 Accidental blow to occipital region during match, immediate collapse and declared brain dead at hospital 1 day Traumatic subarachnoid haemorrhage from vertebral artery injury
5 21 Forearm to face in tackle during match, may have subsequently hit head on ground, immediately confused and then suffered generalised seizure 2 days Subarachnoid haemorrhage (no comment on vertebral artery findings), cerebral contusion
24 Accidental clash of heads during match and died in hospital after craniotomy 3 days Extradural haematoma, cerebral oedema noted postoperatively
7 26 Accidental knock to the back of the head while marking ball, noted to be "dazed" by team mates and collapsed about 10 minutes later; described as hemiplegic at that time 3 days Cerebral oedema, middle cerebral artery territory infarction
36 Collision during play, fell backward hitting head on ground, immediately unconscious followed by respiratory arrest; craniotomy performed in hospital 6 hours Large subdural haematoma, cerebral noted oedema postoperatively
41 Rugby union player, collapsed during match; no obvious trauma 4 hours Large subdural haematoma, cerebral oedema
Other causes
10† 16 Collapsed after a football game, past history of heart problems DOA Hypertrophic obstructive cardiomyopathy with acute cardiac failure
11 19 Collapsed at football during game DOA Hypertrophic obstructive cardiomyopathy with acute cardiac failure
12 16 Collapsed and died during game DOA Myocardial ischaemia and arrhythmia associated with congenital aortic valve stenosis
13 19 Collapsed and died at football during match DOA Anomalous origin of left coronary artery
14† 20 Collapsed on field, no obvious trauma DOA Anomalous origin of left coronary artery
15 19 Bumped on chest during play, took kick and then collapsed, unable to be revived DOA Commotio cordis‡
16† 19 Hit on chest in collision, took free kick then collapsed DOA Commotio cordis
17 24 Hit in the chest and collapsed DOA Commotio cordis
18 35 Collapsed and died during game DOA Coronary artery occlusion
19 37 Collapsed and died during game DOA Coronary artery occlusion
20† 37 Collapsed and died during game DOA Coronary artery occlusion
21† 43 Rugby union player, collapsed and died during game DOA Coronary artery occlusion
22† 44 Rugby union player, collapsed and died during game DOA Coronary artery occlusion
23† 24 Collision followed by respiratory distress DOA Acute asthma complicated by tension pneumothorax
24 22 Collision during match DOA Liver rupture and haemorrhage
25 18 Collapse during football match; no obvious trauma DOA No obvious abnormalities, neuropathological findings

DOA=dead on arrival at hospital.
*All deaths were associated with Australian rules football unless otherwise stated.
†Deaths in the period 1990-1999, found by computerised database search.
‡ Sudden death after low-energy trauma to the chest wall, characteristically with no structural damage to the chest wall, thoracic cavity or heart -- mechanism unknown, presumed arrhythmia.
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  • Paul R McCrory
  • Samuel F Berkovic
  • Stephen M Cordner


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