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Concussion and Neurologic Injury

Learn about the complex pathophysiological process of concussion and its causes, symptoms, evaluation, imaging, and management. Discover risk factors, grading systems, and guidelines for return to play.

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Concussion and Neurologic Injury

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  1. Concussionand Neurologic Injury Jamie B. Varney, M.D. CAQ Sports Medicine Pikeville Medical Center Orthopedics and Sports Medicine

  2. What is a Concussion? • Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces1

  3. Cause of Concussion • May be caused by direct blow to head, face, neck or elsewhere • Thought to be due to axonal injury caused by acceleration forces • Not typically a structural injury • Electrolyte shifts and release of neurotransmitters and free radicals thought to play role • Fuel need/delivery mismatch

  4. Risk Factors • Previous concussion (strongest factor) • Improper technique • Male > Female

  5. High Risk Sports • Football • Ice Hockey • Soccer • Boxing • Rugby • Field Hockey • Lacrosse

  6. Symptoms • Headache • Loss of consciousness • Confusion/Memory Loss • Dizziness/Vertigo • Nausea/Vomiting • Phono/photo phobia • Incoordination/Slowed reaction • Emotional lability/irritability • Sleep disturbance

  7. Symptoms Confusion • Vacant stare • Slow response • Easily distracted • Decreased focus • Disoriented • Slurred speech

  8. Symptoms • Memory Deficits • Repeats questions • Retrograde amnesia • Anterograde amnesia (inability to form new memories)

  9. Rare Symptoms • Seizure 1% or less • Cortical blindness

  10. Evaluation • Should be evaluated by trained personnel as soon as suspected injury • On Field • Loss of Consciousness • ABC’s • Rule out C-Spine injury • assumed if LOC • Neurological Status • Mental Status

  11. Mental Status • Orientation • Memory • Cognitive skills

  12. Memory • Short term • Events of game (plays/score) • Word recall • Number sequence recall • Intermediate • Delayed word recall • Previous games • World events • Long term • Teammates/Family members • Birthdates • Presidents

  13. Cognitive skills • Serial 7’s • Reverse spelling • Reverse alphabet • Concentration / complex commands

  14. Neurological function • Cranial Nerves • Motor • Sensory • Reflexes • Cerebellar function/Coordination • Finger/nose • Heel/shin • Gait/Tandem (eyes closed as well) • Rhomberg/ Pronator drift

  15. Additional Exam • Skull for depressions • Cervical spine tenderness • Nose for clear drainage • Ears for hemotympanum • Signs of skull fracture

  16. Sideline Tools • SCAT3>13 y/o • Standardized Assessment of Concussion (SAC) • Maddock's Questions • Modified BESS • Balance Error Scoring System • Child SCAT3 <13 y/o

  17. SCAT 3 Demo

  18. Neuroimaging • Typically normal • CT preferred if necessary • MRI more sensitive but may not correlate with severity or outcome • Possible future role for functional MRI

  19. Recommended Imaging • Neurological deficit • Suspected C-Spine injury • Suspected skull fracture • Raccoon eye’s • Battle’s Sign • Rhinorhea • Hemotympanum • Seizure • Coagulopathy / Anticoagulant use • Progressive symptoms

  20. Consider Imaging • Canadian CT criteria • GCS <15 two hours after injury • Two or more episodes vomiting • Age > 65 • Amnesia longer than 30 min prior • Dangerous mechanism • MVA • Fall > 3ft or 5 stairs

  21. Consider Imaging • New Orleans Criteria (GCS 15) • Headache • Vomiting • Age >60 • Drug/ETOH intoxication • Persistent anterograde amnesia • Visible trauma above clavicle

  22. Comparison • Two studies have shown both are 100% sensitive for detecting neurosurgical abnormalities • One study showed higher sensitivity for clinically significant findings with New Orleans (99.4% vs 87.2%) • Canadian CT rules more specific • Lowered CT rates 52.1% versus 88% • Other study specificity 39.7% vs 3%

  23. Bottom Line1 Imaging usually not helpful for concussion Helpful to rule out bleeds if progressive symptoms or clinical suspicion

  24. Hospital Admission • GCS <15 • Abnormal CT scan • Seizures • Bleeding diasthesis or anticoagulants • Consider if no one available to monitor for progression of symptoms

  25. Outpatient Monitoring • Monitor Closely 1st 24 hrs • Educate about warning signs • Somnolence/Confusion • Worsening headache • Vision difficulties • Vomiting or stiff neck • Neurological deficits • Avoid strenuous activity

  26. Grading Concussion • Old system • Colorado • American Academy of Neurology (AAN) • Cantu • Prague Statement 2004 • Simple <10 days • Complex >10 days/seizures/prolonged LOC • Zurich Statement 2012 • Forget Grades

  27. Return to Play1 • No same day play • KHSAA and NCAA • Physical Rest Until Asymptomatic • Consider Cognitive Rest • Exercise Testing

  28. Progressive Return To Play1 • Step 1 • No activity, rest, when symptom free without meds go to step 2 • Step 2 • Light aerobic exercise, no resistance training • Step 3 • Sport specific exercise • Step 4 • Non Contact Practice and Resistance Training • Step 5 • Full Contact Practice • Step 6 • Full Game

  29. Office Exertional Maneuvers • Treadmill/Bike • Sprints/Run in place • Sit-ups, Push-ups

  30. Progressive RTP • If symptoms develop at any step stop and rest. Do not proceed. • ATC's are invaluable resource • More conservative in children with focus on cognitive rest and return to learn before return to play

  31. Second Impact Syndrome • Occurs after second injury before first injury has healed • Diffuse cerebral swelling that can be life threatening • Few cases with documentation that is consistent with description • May only require minor injury

  32. Post traumatic Epilepsy • Seizure within 1st week not epilepsy • Mild TBI associated with twofold risk epilepsy in 5 years

  33. Post Concussive Syndrome • Not related to severity of injury • Symptoms >3 months (DSMIV) • Headache • Dizziness • Fatigue • Irritability • Anxiety/Depression • Insomnia • Loss of concentration or memory • Cognitive impairment

  34. Post Concussive Syndrome • Treatment • Consider referral • Treat symptoms

  35. Mood Disorders Dementia Movement Disorders Chronic Traumatic Encephalopathy (CTE)

  36. Neuropsychiatric Testing • Paper tests interpreted by experienced neuropsychologist • Computerized Tests

  37. Neuropsychiatric Testing • Speed of information processing • Memory • Attention • Concentration • Reaction Time • Scanning • Visual tracking • Problem solving

  38. Neuropsychiatric Testing • Tested at baseline then post injury if needed • More sensitive than classic testing • Concern is maybe too sensitive and not specific enough

  39. Prevention • Proper equipment / fitting • Proper training for coaches and support staff • Enhancement and enforcement of protective rules • Pre-participation evaluation of concussion history

  40. Other Neurological Injury C-Spine Brachial Plexus Transient Cord Neuropraxia

  41. Other Neurological Injury C-Spine Brachial Plexus Transient Cord Neuropraxia

  42. Brachial Plexus Injury • Commonly called stinger / burner • Caused by stretch or compression • Unilateral symptoms • Weakness • Numbness • Stinging pain • C5-6 most common • If has bilateral symptoms think cord injury

  43. Brachial Plexus Injury • Single episode • May return when no pain or neurologic deficit • Recurrent episode • Consider evaluation including flex/ext x-rays and canal diameter • If symptoms last more than 1 week consider MRI/EMG to rule out cord lesion

  44. Stinger/Burner

  45. Prevention • Rehab to strengthen neck/shoulders • Proper hitting technique • Proper equipment (pads) • Neck rolls/cowboy collars

  46. Transient Cord Neuropraxia • Flexion/extension injury with underlying spinal stenosis • Post traumatic neurological findings • Bilateral symptoms of paresthesia and or weakness • Upper > Lower extremities • Lasts minutes to days • If occurs must evaluate with imaging for cord injury and spinal canal diameter

  47. Torg Ratio • Ratio of spinal canal to vertebral body • Ratio <0.8 suggestive of stenosis • MRI measurement of cord vs. canal diameter more reliable

  48. Treatment • If have transient neuropraxia then protect cervical spine until fracture ruled out • Must evaluate canal diameter which may imply risk of future injury • Neurosurgeon familiar with treatment should help make any return to play decision

  49. References • McCrory,P. et al. Consensus Statement on Concussion in Sport (Zurich Statement 2012). Br J Sports Med 2013;47:250-258 • Meehan, WP, O'Brien, MJ. Sports-Related Concussion in Children and Adolescents: Clinical Manifestations and Diagnosis. UpToDate. 9-22-14

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