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

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.

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.

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.

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.

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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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