HEAD INJURY with Delayed Presentation in Football

1. HEAD INJURY with Delayed Presentation in Football Wes Bailey, MD Moses Cone Sports Medicine Fellow SEACSM Annual Meeting February 5, 2011

2. Case • ID/CC • 17 year-old male Varsity cornerback c/o left-side headache (HA). • HPI • HA began during a football game 5 days prior to presentation. • HA started after he suddenly arose from the ground following a play. • The player did not recall the details of the play. • Player eventually pulled from the game when he could not remember a play call.

3. Case • Ensuing 4 Days - Not evaluated by trainer or MD. • Worsening headache severity. • Day # 4 (AM) - One episode of vomiting along with generalized fatigue. • Day # 4 (PM) - Head strike after return to practice. • Blurred vision for ~5 minutes. • Feet felt “asleep” for ~10 minutes. • Went to bed early 2/2 headache. • Day # 5 • Brought by mother to SM office. • Decreased HA severity. • No mood lability or impaired concentration.

4. Physical Examination • Entire PE including neurological exam WNL. • Standard Assessment of Concussion (SAC) • Score: 24/30. • Deficits: • Orientation – Date (1 point) • Immediate memory (2 points). • Delayed recall (1 point). • Recitation of the months of the year backwards (1 point). • Recitation of a six-number string in reverse order (1 point).

5. Panel/Audience Questions

6. Differential Diagnoses • Concussion. • Second Impact Syndrome. • Intracranial Bleed. • Post-Concussive Syndrome.

7. Panel/Audience Questions

8. Image Findings • Cervical Spine X-Rays • Normal. • Head CT • Thin extra-axial fluid collection on the left cerebral hemisphere without mass effect, midline shift, or hydrocephalus.

9. Final Working Diagnosis • Subdural Hematoma. • Concussion.

10. Treatment & Outcome • Referred to a local neurosurgeon on the day of presentation. • Managed non-operatively given stable medical condition and lack of mass effect, midline shift, or hydrocephalus. • Held from practice and physical education activities. • Instructed to f/u with the neurosurgeon for interim re-assessment and repeat head CT(s).

11. Treatment & Outcome • Instructed to avoid non-steroidal anti-inflammatory drugs. • Mother received emergency precautions and instructed to limited the player’s physical activities at home.

12. Treatment & Outcome Head CT - 2 Days Later • Slightly decreased size of the fluid collection.

13. Treatment & Outcome Final Head CT - 3 Weeks Later • Cleared subdural hematoma.

14. Treatment & Outcome • Headache resolved. • Resumed full-time academic activities w/o difficulty. • Returned to baseline without mood/behavior changes.

15. Treatment & Outcome • Held from sports and physical education activities for the remainder of the 2010 football season; for a period longer than 1 month. • Gradually resumed non-contact physical education activities at school. • Restricted from wrestling this season. • Cleared for unrestricted sports participation beginning in the summer of 2011 as long as he remains symptom-free.

16. Key Points • Head injury is the leading cause of death in football, and in sports in general1. • Early communication is key. • Athletes with intracranial bleeding can have normal physical findings. • History is essential. • Individualized neurosurgical management with serial imaging. 1. Gerberich S et al. Concussion incidences and severity in secondary school varsity football players. Am J Pub Health. 1983; 73:1370-1375.

17. Key Points • No official guidelines wrt NSAID use. • No official guidelines wrt activity restrictions. • No physical activity for at least 1 month. • Professional hockey player s/p craniotomy for parenchymal hemorrhage. • Soccer & ice hockey players s/p sx for ant/post wall fractures of the frontal sinus. • 16 y.o. female soccer player s/p drainage of large chronic SDH which communicated with an arachnoid cyst and caused a mass effect. RTP 1 year later. No interim incidents.

18. Panel/Audience Questions