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ConcussionConcussionand Neurologic Injury and Neurologic Injury
Jamie B. Varney, M.D.Jamie B. Varney, M.D.
CAQ Sports MedicineCAQ Sports Medicine
Pikeville Medical Center Pikeville Medical Center Orthopedics and Sports MedicineOrthopedics and Sports Medicine
What is a Concussion?What is a Concussion?
Complex pathophysiological process Complex pathophysiological process affecting the brain, induced by affecting the brain, induced by traumatic biomechanical forcestraumatic biomechanical forces11
Cause of ConcussionCause of ConcussionMay be caused by direct blow to head, May be caused by direct blow to head,
face, neck or elsewhereface, neck or elsewhereThought to be due to axonal injury caused Thought to be due to axonal injury caused
by acceleration forcesby acceleration forcesNot typically a structural injuryNot typically a structural injuryElectrolyte shifts and release of Electrolyte shifts and release of
neurotransmitters and free radicals neurotransmitters and free radicals thought to play rolethought to play role
Fuel need/delivery mismatchFuel need/delivery mismatch
Risk FactorsRisk FactorsPrevious concussion (strongest Previous concussion (strongest
factor)factor)Improper techniqueImproper techniqueMale > FemaleMale > Female
High Risk SportsHigh Risk Sports
FootballFootballIce HockeyIce HockeySoccerSoccerBoxingBoxingRugbyRugbyField HockeyField HockeyLacrosseLacrosse
SymptomsSymptomsHeadacheHeadacheLoss of consciousnessLoss of consciousnessConfusion/Memory LossConfusion/Memory LossDizziness/VertigoDizziness/VertigoNausea/VomitingNausea/VomitingPhono/photo phobiaPhono/photo phobiaIncoordination/Slowed reactionIncoordination/Slowed reactionEmotional lability/irritabilityEmotional lability/irritabilitySleep disturbanceSleep disturbance
SymptomsSymptoms
ConfusionConfusion– Vacant stareVacant stare– Slow responseSlow response– Easily distractedEasily distracted– Decreased focusDecreased focus– DisorientedDisoriented– Slurred speechSlurred speech
SymptomsSymptoms
Memory DeficitsMemory Deficits– Repeats questionsRepeats questions– Retrograde amnesiaRetrograde amnesia– Anterograde amnesia (inability to form Anterograde amnesia (inability to form
new memories)new memories)
EvaluationEvaluation
Should be evaluated by trained personnel Should be evaluated by trained personnel as soon as suspected injuryas soon as suspected injury
On FieldOn Field– Loss of ConsciousnessLoss of Consciousness– ABC’sABC’s– Rule out C-Spine injuryRule out C-Spine injury
assumed if LOCassumed if LOC
– Neurological StatusNeurological Status– Mental Status Mental Status
MemoryMemoryShort termShort term
– Events of game (plays/score)Events of game (plays/score)– Word recallWord recall– Number sequence recallNumber sequence recall
IntermediateIntermediate– Delayed word recallDelayed word recall– Previous gamesPrevious games– World eventsWorld events
Long termLong term– Teammates/Family membersTeammates/Family members– BirthdatesBirthdates– PresidentsPresidents
Cognitive skillsCognitive skillsSerial 7’s Serial 7’s Reverse spellingReverse spellingReverse alphabetReverse alphabetConcentration / complex commandsConcentration / complex commands
Neurological functionNeurological function
Cranial NervesCranial NervesMotor Motor SensorySensoryReflexesReflexesCerebellar function/CoordinationCerebellar function/Coordination
– Finger/noseFinger/nose– Heel/shinHeel/shin– Gait/Tandem (eyes closed as well)Gait/Tandem (eyes closed as well)– Rhomberg/ Pronator driftRhomberg/ Pronator drift
Additional ExamAdditional Exam
Skull for depressionsSkull for depressionsCervical spine tendernessCervical spine tendernessNose for clear drainageNose for clear drainageEars for hemotympanumEars for hemotympanumSigns of skull fractureSigns of skull fracture
Sideline ToolsSideline Tools SCAT3>13 y/o>13 y/o
Standardized Assessment of Standardized Assessment of Concussion (SAC)Concussion (SAC)
Maddock's QuestionsMaddock's Questions Modified BESSModified BESS
– Balance Error Scoring SystemBalance Error Scoring System Child SCAT3 <13 y/o <13 y/o
NeuroimagingNeuroimagingTypically normal Typically normal CT preferred if necessary CT preferred if necessary MRI more sensitive but may not correlate MRI more sensitive but may not correlate
with severity or outcomewith severity or outcomePossible future role for functional MRIPossible future role for functional MRI
Recommended ImagingRecommended Imaging
Neurological deficitNeurological deficitSuspected C-Spine injurySuspected C-Spine injurySuspected skull fracture Suspected skull fracture
– Raccoon eye’sRaccoon eye’s– Battle’s SignBattle’s Sign– RhinorheaRhinorhea– Hemotympanum Hemotympanum
SeizureSeizureCoagulopathy / Anticoagulant useCoagulopathy / Anticoagulant useProgressive symptomsProgressive symptoms
Consider ImagingConsider ImagingCanadian CT criteriaCanadian CT criteria
– GCS <15 two hours after injuryGCS <15 two hours after injury– Two or more episodes vomitingTwo or more episodes vomiting– Age > 65Age > 65– Amnesia longer than 30 min priorAmnesia longer than 30 min prior– Dangerous mechanismDangerous mechanism
MVAMVAFall > 3ft or 5 stairsFall > 3ft or 5 stairs
Consider ImagingConsider Imaging
New Orleans Criteria (GCS 15)New Orleans Criteria (GCS 15)– HeadacheHeadache– VomitingVomiting– Age >60Age >60– Drug/ETOH intoxicationDrug/ETOH intoxication– Persistent anterograde amnesiaPersistent anterograde amnesia– Visible trauma above clavicleVisible trauma above clavicle
ComparisonComparison
Two studies have shown both are Two studies have shown both are 100% sensitive for detecting 100% sensitive for detecting neurosurgical abnormalitiesneurosurgical abnormalities
One study showed higher sensitivity One study showed higher sensitivity for clinically significant findings with for clinically significant findings with New Orleans (99.4% vs 87.2%)New Orleans (99.4% vs 87.2%)
Canadian CT rules more specificCanadian CT rules more specific– Lowered CT rates 52.1% versus 88%Lowered CT rates 52.1% versus 88%– Other study specificity 39.7% vs 3%Other study specificity 39.7% vs 3%
Bottom Line1
Imaging usually not helpful for concussion
Helpful to rule out bleeds if progressive symptoms or clinical suspicion
Hospital AdmissionHospital Admission
GCS <15GCS <15Abnormal CT scanAbnormal CT scanSeizuresSeizuresBleeding diasthesis or anticoagulantsBleeding diasthesis or anticoagulantsConsider if no one available to Consider if no one available to
monitor for progression of symptomsmonitor for progression of symptoms
Outpatient MonitoringOutpatient Monitoring
Monitor Closely 1Monitor Closely 1stst 24 hrs 24 hrs Educate about warning signsEducate about warning signs
– Somnolence/ConfusionSomnolence/Confusion– Worsening headacheWorsening headache– Vision difficultiesVision difficulties– Vomiting or stiff neckVomiting or stiff neckNeurological deficitsNeurological deficits
Avoid strenuous activityAvoid strenuous activity
Grading ConcussionGrading ConcussionOld systemOld system• ColoradoColorado• American Academy of Neurology (AAN)American Academy of Neurology (AAN)• CantuCantu
• Prague Statement 2004Prague Statement 2004– Simple <10 days Simple <10 days – Complex >10 days/seizures/prolonged Complex >10 days/seizures/prolonged
LOCLOC
• Zurich Statement 2012Zurich Statement 2012– Forget Grades Forget Grades
No same day playNo same day play• KHSAA and NCAAKHSAA and NCAA
Physical Rest Until AsymptomaticPhysical Rest Until AsymptomaticConsider Cognitive RestConsider Cognitive RestExercise TestingExercise Testing
Return to PlayReturn to Play11
Step 1Step 1No activity, rest, when symptom free without No activity, rest, when symptom free without
meds go to step 2meds go to step 2
•Step 2Step 2• Light aerobic exercise, no resistance trainingLight aerobic exercise, no resistance training
•Step 3Step 3• Sport specific exerciseSport specific exercise
•Step 4Step 4• Non Contact Non Contact Practice and Resistance TrainingPractice and Resistance Training
• Step 5Step 5 • Full Contact PracticeFull Contact Practice
•Step 6Step 6 • Full GameFull Game
Progressive Return To Play1
Office Exertional ManeuversOffice Exertional Maneuvers
•Treadmill/BikeTreadmill/Bike•Sprints/Run in placeSprints/Run in place•Sit-ups, Push-upsSit-ups, Push-ups
Progressive RTPProgressive RTP
If symptoms develop at any step If symptoms develop at any step stop and rest. Do not proceed.stop and rest. Do not proceed.
ATC's are invaluable resourceATC's are invaluable resourceMore conservative in children with More conservative in children with
focus on cognitive rest and return to focus on cognitive rest and return to learn before return to playlearn before return to play
Second Impact SyndromeSecond Impact Syndrome
Occurs after second injury before Occurs after second injury before first injury has healedfirst injury has healed
Diffuse cerebral swelling that can be Diffuse cerebral swelling that can be life threateninglife threatening
Few cases with documentation that Few cases with documentation that is consistent with descriptionis consistent with description
May only require minor injuryMay only require minor injury
Post traumatic EpilepsyPost traumatic Epilepsy
Seizure within 1Seizure within 1stst week not epilepsy week not epilepsyMild TBI associated with twofold risk Mild TBI associated with twofold risk
epilepsy in 5 yearsepilepsy in 5 years
Post Concussive SyndromePost Concussive SyndromeNot related to severity of injuryNot related to severity of injurySymptoms >3 months (DSMIV)Symptoms >3 months (DSMIV)
– HeadacheHeadache– DizzinessDizziness– FatigueFatigue– IrritabilityIrritability– Anxiety/DepressionAnxiety/Depression– InsomniaInsomnia– Loss of concentration or memoryLoss of concentration or memory– Cognitive impairmentCognitive impairment
Post Concussive SyndromePost Concussive SyndromeTreatmentTreatment
– Consider referral Consider referral – Treat symptomsTreat symptoms
Chronic Traumatic Chronic Traumatic Encephalopathy (CTE)Encephalopathy (CTE)
Mood Disorders Dementia Movement Disorders
Neuropsychiatric TestingNeuropsychiatric Testing
Paper tests interpreted by Paper tests interpreted by experienced neuropsychologistexperienced neuropsychologist
Computerized TestsComputerized Tests
Neuropsychiatric TestingNeuropsychiatric Testing
Speed of information processingSpeed of information processingMemoryMemoryAttentionAttentionConcentrationConcentrationReaction TimeReaction TimeScanningScanningVisual trackingVisual trackingProblem solvingProblem solving
Neuropsychiatric TestingNeuropsychiatric Testing
Tested at baseline then post injury if Tested at baseline then post injury if neededneeded
More sensitive than classic testingMore sensitive than classic testingConcern is maybe too sensitive and Concern is maybe too sensitive and
not specific enoughnot specific enough
PreventionPrevention
Proper equipment / fittingProper equipment / fittingProper training for coaches and Proper training for coaches and
support staffsupport staffEnhancement and enforcement of Enhancement and enforcement of
protective rulesprotective rulesPre-participation evaluation of Pre-participation evaluation of
concussion historyconcussion history
Brachial Plexus InjuryBrachial Plexus Injury
Commonly called stinger / burnerCommonly called stinger / burnerCaused by stretch or compressionCaused by stretch or compressionUnilateral symptomsUnilateral symptoms
– WeaknessWeakness– NumbnessNumbness– Stinging painStinging pain
C5-6 most commonC5-6 most commonIf has bilateral symptoms think cord If has bilateral symptoms think cord
injuryinjury
Brachial Plexus InjuryBrachial Plexus Injury
Single episodeSingle episode– May return when no pain or neurologic May return when no pain or neurologic
deficitdeficitRecurrent episodeRecurrent episode
– Consider evaluation including flex/ext x-Consider evaluation including flex/ext x-rays and canal diameterrays and canal diameter
If symptoms last more than 1 week If symptoms last more than 1 week consider MRI/EMG to rule out cord consider MRI/EMG to rule out cord lesionlesion
PreventionPreventionRehab to strengthen neck/shouldersRehab to strengthen neck/shouldersProper hitting techniqueProper hitting techniqueProper equipment (pads)Proper equipment (pads)Neck rolls/cowboy collarsNeck rolls/cowboy collars
Transient Cord NeuropraxiaTransient Cord Neuropraxia
Flexion/extension injury with Flexion/extension injury with underlying spinal stenosisunderlying spinal stenosis
Post traumatic neurological findingsPost traumatic neurological findingsBilateral symptoms of paresthesia Bilateral symptoms of paresthesia
and or weaknessand or weaknessUpper > Lower extremitiesUpper > Lower extremitiesLasts minutes to daysLasts minutes to daysIf occurs must evaluate with imaging If occurs must evaluate with imaging
for cord injury and spinal canal for cord injury and spinal canal diameterdiameter
Torg RatioTorg Ratio
Ratio of spinal Ratio of spinal canal to vertebral canal to vertebral bodybody
Ratio <0.8 Ratio <0.8 suggestive of suggestive of stenosisstenosis
MRI measurement MRI measurement of cord vs. canal of cord vs. canal diameter more diameter more reliablereliable
TreatmentTreatment
If have transient neuropraxia then If have transient neuropraxia then protect cervical spine until fracture protect cervical spine until fracture ruled outruled out
Must evaluate canal diameter which Must evaluate canal diameter which may imply risk of future injurymay imply risk of future injury
Neurosurgeon familiar with Neurosurgeon familiar with treatment should help make any treatment should help make any return to play decisionreturn to play decision
ReferencesReferences
1.1. McCrory,P. et al. Consensus McCrory,P. et al. Consensus Statement on Concussion in Sport Statement on Concussion in Sport (Zurich Statement 2012). Br J Sports (Zurich Statement 2012). Br J Sports Med 2013;47:250-258Med 2013;47:250-258
2.2. Meehan, WP, O'Brien, MJ. Sports-Meehan, WP, O'Brien, MJ. Sports-Related Concussion in Children and Related Concussion in Children and Adolescents: Clinical Manifestations Adolescents: Clinical Manifestations and Diagnosis. UpToDate. 9-22-14and Diagnosis. UpToDate. 9-22-14