CONCUSSIONS:A Hard Hitting Problem

Zohar Shamash, M.D. Columbia University Medical Center - Pediatrics

ANDY

17-y.o. male, no significant past medical history

Hit in head by a line drive while playing short stop on his high school baseball team

Lost consciousness for ~1 minute and had some retrograde amnesia

No vomiting or difficulty walking Now with 7/10 dull headache Normal vitals, physical exam

significant for 3x4cm boggy hematoma on R forehead, TTP

Normal neurologic exam

1/2

ANDY

What happened? How to manage this patient

acutely? What are his discharge

instructions? What to expect when he goes

home? What about returning to play? When to follow-up?

2/2

OVERVIEW

Concussion fundamentals Epidemiology and pathophysiology Management Return to play Sequelae Prevention

DEFINITION

a complex pathophysiological process that affects the brain, induced by traumatic biomechanical forces

International Multidisciplinary Conference on Concussion

a trauma-induced alteration in mental status that may or may not involve loss of consciousness

American Academy of Neurologyding

knock-outbell-ringer

MILD TRAUMATIC BRAIN INJURY=CONCUSSION “Clinicians may use the concussion

label because it is less alarming to parents than the term mild brain injury, with the intent of implying that the injury is transient with no significant long-term health consequences.”

“…the concussion label is strongly predictive of earlier discharge from the hospital and earlier return to school, independent of GCS and the presence of other associated injuries.”

My Child Doesn't Have a Brain Injury, He Only Has a Concussion –DeMatteo, et. al.

FEATURES

direct blow or impulsive force short-lived impairment resolves spontaneously functional rather than structural

injury may involve loss of

consciousness normal structural neuroimaging

studies

GRADING SCALES

>25 different published grading systems developed through expert opinion rely heavily on LOC

Prague, 2004, 2nd CIS symposium: classified into simple and complex groups simple concussion sxs lasting <10 days complex concussions sxs lasting >10 days or involving

prolonged LOC, seizures, prolonged cognitive impairment or a history of multiple concussions.

Zurich, 2008, 3rd CIS symposium: groups abandoned

2010 recommendation: use symptom based approach for determination of return to play

DEPRECATED GRADING SYSTEMS

OVERVIEW

Concussion fundamentals Epidemiology and pathophysiology Management Return to play Sequelae Prevention

A PUBLIC-HEALTH PROBLEM CDC estimates 300,000

sports related concussions occur each year Only includes LOC

(~10%) so underestimation

Children and young adults at increased risk. Possible reasons: Less force required for

same injury in child Children more

engaged in sports Developing brain more

susceptible to disruption

…EVEN BIGGER THAN WE KNOW

Under-recognition:> 1/3 athletes do not recognize their symptoms as a result of concussions

Under-reporting: athletes do not regularly report their symptoms to trained personnel

28% of athletes report continuing to play after a blow to the head that results in dizziness

61% of football players stay in the game after a hit in the head resulting in headache

YOUTH SPORT INJURY RATE

football

soccer

lacrosse

baskeball

baseball

wrestling

volleyball

0

0.2

0.4

0.6

0.8

1

1.2

boysgirls

Football has highest incidence of all youth sport

Girls have higher rate of concussion than boys in similar sports

*

*per 1,000 athlete exposures

PATHOPHYSIOLOGY

Functional disturbance without gross structural injury

Mild head injury may result in cortical contusions due to coup and contrecoup injuries

cerebral blood flow

Na+/K+ pump activity

PATHOPHYSIOLOGY

Disruption of cell

membrane

K+ efflux to extracellular

space

Release of glutamate

Further K+ efflux

Depolarization/ suppression

neuronal activity

ATP consumption and glucose utilization

lactate

Energy crisis Cell death Hypometabolic state

PATHOPHYSIOLOGY

OVERVIEW

Concussion fundamentals Epidemiology and pathophysiology Management Return to play Sequelae Prevention

ACUTE EVALUATION AND MANAGEMENT ABCs and stabilization

of the c-spine, especially if LOC

Can be done by a health professional on the sidelines of a game

Neurological assessment and mental status testing

MANUAL STABILIZATION OF THE PEDIATRIC C-

SPINE

Example of standardized tool for the sideline evaluation of athletes who suffer a head injury

“AAOx3” found to NOT be reliable method of screening

S.A.C.

SIGNS AND SYMPTOMS

Physical Headache Nausea Vomiting Balance

problems Visual problems Fatigue Photosensitivity Phonosensitivit

y “Dazed” “Stunned”

hallmarks are confusion, amnesia often without preceding LOC LOC occurs <10% but important sign that may herald need for

further imaging/intervention

Cognitive Mental

“fogginess” Feeling slowed

down Difficulty

concentrating Difficulty

remembering Amnesia Repeats

questions Speaks slowly

Emotional Irritability Sadness More

“emotional” Anxiety

Sleep Drowsiness Altered sleep

patterns Difficulty falling

asleep

WESTMEAD POST-TRAUMATIC AMNESIA SCALE

Measures post-traumatic amnesia and other cognitive deficits associated with mild TBI

Takes<1 minute, useful in ED

correlates with findings in more detailed neuropsychologic testing

incorrect response to one question is test for cognitive impairment after head injury

□ What is your name?

□ What is the name of this place?

□ Why are you here?

□ What month are we in?

□ What year are we in?

□ In what town/suburb are you in?

□ How old are you?

□ What is your date of birth?

□ What time of day is it?

□ Three pictures are presented for recall

TO IMAGE OR NOT TO IMAGE

CT typically normal in concussive injury, should be considered whenever suspicion of intracranial structural injury exists

Concussion rarely associated with a c-spine injury, skull fracture, or intracranial hemorrhage

Other imaging: MRI and SPECT (gamma radiation) Post-concussion syndromeabnl SPECT and

PET scans.

WARNING SIGNS severe headache seizures focal neurologic findings on

examination Repeated, prolonged emesis significant drowsiness or

difficulty awakening slurred speech poor orientation to person,

place, or time neck pain significant irritability  LOC for > 30 seconds GCS <15 at 2 hours or <14 at

any time

Looking for who TO NOT scan The prediction rule for children

aged 2 years and older had a negative predictive value of 99.95% and a sensitivity of 96.8% normal mental status no loss of consciousness no vomiting non-severe injury mechanism* no signs of basilar skull

fracture ** no severe headache

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Kupperman et al

Vol 374 No 9696 October 3, 2009

•severe= motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 5 feet or head struck by a high-impact object•** haemotympanum, ‘racoon’ eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle's sign

BATTLE’S SIGN

Minor head injury is defined as witnessed LOC, definite amnesia, or witnessed disorientation in a patients with a GCS score of 13–15

Looking for who TO scan High risk (for neurological intervention)

GCS score <15 at 2 h after injury Suspected open or depressed skull fracture Any sign of basal skull fracture  Vomiting ≥two episodes Age ≥65 years

Medium risk (for brain injury on CT) Amnesia before impact >30 min Dangerous mechanism (pedestrian struck by motor vehicle,

occupant ejected from motor vehicle, fall from height >3 feet or five stairs)

The Canadian CT Head Rule for patients with minor head injury Stiell et al

Vol 357 No 9266 May 5, 2001

GLASGOW COMA SCALEFeature Scale

ResponsesScoreNotation

Eye opening

SpontaneousTo speechTo painNone

4321

Verbal response

OrientedConfused conversationWords (inappropriate)Sounds (incomprehensible)None

54321

Best motor response

Obey commandsLocalize painFlexion – Normal -- AbnormalExtendNone

654321

TOTAL COMA ‘SCORE’

3/15 – 15/15

DISPOSITION

Observation (for 2-4 hours) in ED for patients with normal neurologic exam

Discharge with a responsible person—give excellent discharge instructions

Is it necessary to wake patient up every 2 hours at home? No data, but if you’re worried enough you should probably admit Might make patient worse because treatment for concussion is

sleep/relaxation Hospital admission is recommended for patients at risk for

immediate complications from head injury , patients with: GCS <15 Abnormal CT scan: intracranial bleeding, cerebral edema Seizures Bleeding risk

TREATMENT: PHYSICAL/COGNITIVE REST Physical rest Increased symptoms with cognitive

activities after concussion, so cognitive rest encouraged. May include: Temporary leave of absence from school Shortening of school day Reduction in workload Increased time to complete assignments/test

“cocoon therapy” Medication?

OVERVIEW

Concussion fundamentals Epidemiology and pathophysiology Management Return to play Sequelae Prevention

SO, WHEN CAN I RETURN TO PLAY?

Many "return to play" guidelines, but little scientific evidence to support them 

No athlete should return to play when symptomatic at rest or with exertion

In fact, it is illegal in 11 states Most will be asymptomatic

within one week, but conservative management recommended in children Wait 7-10 days longer

No activityComplete physical and cognitive rest

Light aerobic activityWalking, swimming, stationary cycling at 70% maximum heart rate; no resistance exercises

Sport-specific activitySpecific sport-related drills but no head impact

Noncontact training drillsMore complex drills, may start light resistance training

Full-contact practiceAfter medical clearance, participate in normal training

STEP-WISE RETURN TO PLAY

Return to previous step if symptoms recur

Graduate to following step after >24 hours without symptoms

Return to play!

NEUROPSYCHOLOGICAL TESTING

Provides objective measure of brain function in athlete with concussion—validated for test retest reliability Computerized tests: ANAM,

CogState,HeadMinder, and ImPACT Vast majority of studies conducted by

developers of test Ideally compared to baseline/preinjury

test

IMPACT TEST CLINICAL REPORT

Run by Department of Neuropsychology

Departments of Neurology Neuropsychiatry Sports Medicine Physical Therapy

Uses ImPACT testing

OVERVIEW

Concussion fundamentals Epidemiology and pathophysiology Management Return to play Sequelae Prevention

SEQUELAE

second impact syndrome post concussion syndrome cumulative neuropsychologic

impairment post-traumatic epilepsy post-traumatic headaches post-traumatic vertigo other cranial nerve injuries

SECOND IMPACT SYNDROME

Occurs when an athlete who has sustained an initial head injury sustains a second head injury before the symptoms associated with the first have fully cleared Can cause severe brain injury or even death

Cause is hypothesized to be disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased ICP

All reported cases in athletes younger than 20 years old

VIDEO

LEGISLATION

In 2006, a 13 year old named Zackery Lystedt suffered a concussion while playing football but went back into the game.

He collapsed after the game and had a brain bleed, and suffered severe brain damage.

On May 14th 2009, Gov. Christine Gregoire of Washington state signed the “Zackery Lystedt Law,” the nation's toughest youth athlete return-to-play law.

It requires medical clearance of youth athletes suspected of sustaining a concussion, before sending them back in the game, practice or training

POST CONCUSSION SYNDROME (PCS) Constellation of physical, cognitive,

emotional, and behavioral symptoms DSM IV requires presence of symptoms in at

least 3 of 6 categories for at least 3 months after injury and evidence of neuropsychological dysfunction.

Prevalence in adults between 11-64% Limited studies done on children

P.C.S. SYMPTOMS

fatig

ue

head

ache

forg

etfu

lnes

s

slee

p di

stur

banc

e

anxiet

y

irrita

bilit

y

dizz

ines

s

noise

sens

itivity

0%

100% 91%

78%73% 70%

63% 62% 59%

46%

Prospective cohort study of epidemiology and natural history of PCS children with mild TBI compared with children with extracranial injury

Among school-aged children with mTBI, 13.7% were symptomatic  3 months after injury compared with 2.3% symptomatic after 1

year Finding could not be

explained by trauma, family dysfunction, or maternal psychological adjustment.

Epidemiology of Postconcussion Syndrome in Pediatric Mild Traumatic Brain Injury -Barlow, et. al.

SEIZURES AND CONCUSSIONS

3 different types of events: “impact seizure”

immediately following a concussive injury (w/in 2 secs)

Not associated with epilepsy, underlying brain injury, similar to convulsive syncope

Manage similar to concussions Early post-traumatic epilepsy

Within one week following injury Late post-traumatic epilepsy

After one week following injury

CUMULATIVE NEUROPSYCH IMPAIRMENT

Repeated concussions can cause cognitive impairment  

“Dementia pugilistica" has been long recognized as sequelae of boxing (20% of professional boxers)

Neuropsychological symptoms Behavior Personality changes Depression Suicidality Parkinsonism  Other speech/gait abnormalities

Higher incidence of dementia than in general population among NFL players with history of multiple concussions—called “chronic traumatic encephalopathy”

Neuropathological study of boxers with chronic TBI demonstrates some features of AD incuding neurofibrillary tangles, amyloid plaques

ApoE genotype and tau isoforms also may play a role

OVERVIEW

Concussion fundamentals Epidemiology and pathophysiology Management Return to Play Sequelae Prevention

PREVENTION

Mouthguards Helmets

Shown to reduce concussion in skiing and snowboarding In football, developed to reduce severe head trauma but

not concussions In soccer, protect against soft tissue injuries

Concussions usually from head-to-head or head-to-elbow contact

Heading the ball safe if done properly

Education!

As Injuries Rise, Scant Oversight of Helmet Safety

Football helmets not formally tested against the forces

believed to cause concussions, only to withstand high forces that would otherwise fracture skulls

NOCSAE standard hasn't changed since written in 1973 While bicycle helmets are designed to withstand only one

large impact before being replaced, football helmets can encounter potentially concussive forces hundreds of times a season

Helmet companies now developing helmets to specifically reduce concussion

RESOURCES/EDUCATION

cdc.gov/concussion Tons of educational resources Handouts Facebook page

iphone app “Cognit” nytimes.com: concussion

section The most important

mainstay of prevention is education of coaches, athletes, parents

ANDY

17-y.o. male, no significant past medical history

Hit in head by a line drive while playing short stop on his high school baseball team

Lost consciousness for ~1 minute and had some retrograde amnesia

No vomiting or difficulty walking Now with 7/10 dull headache Normal vitals, physical exam

significant for 3x4cm boggy hematoma on R forehead, TTP

Normal neurologic exam

1/2

ANDY

What happened? How to manage this patient

acutely? What are his discharge

instructions? What to expect when he goes

home? What about returning to play? When to follow-up?

2/2

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Rehabil. 1998;13(2):1–8

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THE END!

THANK YOU!

The chiefs: Tom, Mithila, Yaffa

Dr. Maria Kwok and CHONY ED faculty

My family: Joey and Noa Dr. Stanberry, Dr.

Wedemeyer, Dr. Hametz Tuesday Audubon Clinic:

Christine, Annika, Omalara, Jillian, Ronny, Jason, Alanna, Josh

My class—CHONY 2011