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CONCUSSION

CONCUSSION. DR A.E NKUSI Department of neurosurgery Johannesburg hospital . Concussion . Definition Grading Mechanism of injury Pathophysiology Concussion in sports Sequelae (post concussion syndrome ) 2 nd impact syndrome Management - Goals

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CONCUSSION

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  1. CONCUSSION DR A.E NKUSI Department of neurosurgery Johannesburg hospital

  2. Concussion • Definition • Grading • Mechanism of injury • Pathophysiology • Concussion in sports • Sequelae (post concussion syndrome ) • 2nd impact syndrome • Management - Goals - Initial evaluation and treatment - Extended Observations VS Discharge home

  3. Post concussion Syndrome • Aetiology : organic & neurosis theories • Symptoms • Risk factors • Diagnosis

  4. Concussion/Confusion

  5. Concussion/Teasdale

  6. Concussion grading • Mild • Moderate • Severe

  7. Concussion PTA

  8. Concussion GCS Severity of TBI Mild GCS 13-15 Moderate 9-12 Severe(Coma) 3-8 [Rimel et al 1981]

  9. Concussion Grading Systems

  10. Mechanisms • Threshold of acceleration /deceleration forces • Rotational or angular forces cause concussions - MVAs , falls , sport , assaults • Translational or linear forces cause focal lessions .

  11. Pathophysiology(Diffuse Axonal Injury-Concussion) • Diffuse impact injury • Acceleration of white matter • Axonal strain • Axonal shear • White matter lesions

  12. Brain Contusions and Haematomas(comparison) • Local impact • Coupe contra coupe • Frontal/Temporal • Extra cerebral • Intra cerebral

  13. Concussion in Sport • Concussion in Sport very common • South African Rugby • Incidence 20% • Prevalence 50% • Horse riding • Hockey • Paragliding • Soccer 120mph/1000s times • Cricket • Boxing • Cycling

  14. Concussion in Sport • Minor • Professional Athletes • Returning to contact again • Unstable post concussion state • Cumulative effect • Second impact injury • When is safe to go back • When to retire • Development of grading systems and guidelines

  15. Post concussion Syndrome

  16. Post concussion syndrome (cont.) • Controversies : - organic theory ; some believe that this syndrome is a result of the head injury . - Neurosis theory ; the proponents of this theory believe that the patients have psychological rather than organic . • Incidence ; following mild head injury , 50% of patients have atleast 1 symptom and 25% of pts have headache .

  17. Guidelines for return to playafter first concussion

  18. Guidelines for return to playafter 2nd 3rdconcussion

  19. Traumatic Encephalopathy • Traumatic Encephalopathy • Cumulative Concussions • Martland 1928 Boxers • Punch drunk • Tysvaer Soccer players • 40% cognitive • Symonds • Gronwall MVAs

  20. 2nd Impact syndrome • Schneider 1973 • Saunders and Harbaugh 1984 • “Catastrophic head injury” • First concussion • Post concussion symptoms still present • Second Impact • Minor/Mild • Seconds to 5 minutes collapse • Rapid deterioration due to brain swelling • Incidence low/35 cases in 13y US football players • Seen in non sport concussion as well • M/M 50-100%

  21. Management • Concerns :3% mortality in minor head injury. • Goals : early diagnosis and intervention . • Initial evaluation : - clinical - neuroimaging - admission criteria - cost consciousness

  22. Extended observation VS discharge • Low risk group ; asymptomatic ,headache, dizziness ,soft tissue injuries . - Discharge on head injury chart . • Moderate risk group ; history of changes of conscious level , increasing headache, intoxication , age <2yrs ,unreliable history ,PTA , seizures ,skull fractures . - Close observation and CT brain .

  23. High risk group ; decreasing level of consciousness , focal signs , penetrating injury . - do CT scan brain , admission and urgent neurosurgical consultation . • SXR; Useless if normal ,helpful if positive . • CT brain : Non-contrast , 8-46% of patients with mild head injury have intracranial lessions . • Need follow up CT ? Timing

  24. Neuropsychological Assessment • Objective assessment • Important body of literature • Validated results • Still some concerns • Not fully objective • Depression • Over diagnosing

  25. Treatment • Concussion is diagnosis of exclusion ; usually made confidently on basis of history and clinical findings. • Patient education ; explain natural history ,BE SUPPORTIVE ,sympathetic and +ve in outlook . • Drug therapy : Pharmacological treatment has been disappointing , dramatic improvement is uncommon .

  26. Narcotic analgesic should be avoided . • CDP(Cystidine Diphosphoryl Choline) was reported to have some effect on post traumatic symptoms . • EEG : Where no improvement on or seizure suspected . • Mainstay of treatment is supportive plus NSAIDS .

  27. THANK YOU !

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