Transcript CHOUDHRI Presentation - Mount Sinai School of Medicine
Second Impact Syndrome
Tanvir Choudhri, MD
Assistant Professor of Neurosurgery Ichan School of Medcine at Mount Sinai Department of Neurosurgery
SIS: What is it?
When repeat injury is sustained before symptoms of previous head injury have been resolved Rare, often fatal, traumatic brain injury occurs (Weinstein et al., 2013)
Department of Neurosurgery
SIS: What is it?
Saunders RL, Harbaugh RE The second impact in catastrophic contact-sports head trauma JAMA 252:538-539, 1984
Department of Neurosurgery
SIS: How often does it occur?
Exact incidence unknown
Less than 20 documented SIS cases in world literature
(Randolph et al., 2009, Arch Clin Neuropsychol)
1 possible SIS for every 205,000
player seasons
Annual participation rate: 1.8 million high school/collegiate subjects (McCrory, et al., 2012, Current sports medicine reports)
Department of Neurosurgery
SIS: What are the risk factors?
Males 16-23 years old (Mori et al., 2006, Acta Neurochirugica Supplementum) Most brain fatalities occurred during games (Boden et al., 2013. Am J Sports Med) Fatal injury sustained most frequently either tackling or being tackled (Cantu & Mueller, 2003, Neurosurgery) History of 3+ concussions 3x more likely to sustain incident concussion (Guskiewicz et al., 2003, JAMA)
Department of Neurosurgery
SIS: How does it occur?
Within vulnerable period from previous injury (Weinstein et al., 2013, J Neurosurg) Impairment of cellular energetic metabolism Loss of autoregulation of cerebral blood flow Subsequent vascular engorgement Increased intracranial pressure Eventual herniation Subdural hematoma Brain Swelling
Department of Neurosurgery
SIS: Effects of 2
nd
Impact
Loss of autoregulation Rapid onset massive cerebral edema Transtentorial brain herniation Raised intracranial pressure Death can be as early as 2-5 min (Zollman, 2011, Demos Medical Publishing)
Department of Neurosurgery
SIS: Pathophysiology
Functional injury Reinjury to neuronal cells within vulnerable period from previous injury (Weinstein et al., 2013, J Neurosurg Pediatrics) Dysautoregulation hyperemic brain swelling Increased intracranial pressure Herniation Brainstem compression
Department of Neurosurgery
Concussion: Pathophysiology
Neurometabolic cascade (Marshall, 2012, J Can Chiropr Assoc) Mechanical stretching/shearing of neurons Disrupts ion channels Excitation phase Neuronal suppression Net result = neuronal ion imbalance, cellular dysfunction, cerebral energy deficit Requires max function of Na+/K+ pump to restore homeostasis
Department of Neurosurgery
Concussion: Pathophysiology
▶ http://www.youtube.com/watch?v=KrvC2UUEJ8 Y ▶ http://www.youtube.com/watch?v=uEGXcNNyzp Y Mount Sinai / Presentation Slide / December 5, 2012 10
SIS: How to recognize it?
2 nd injury generally not severe Remains standing - appears dazed Sec-min after 2 nd ground blow collapses to Semicomatose, dilating pupils, loss of eye movement, respiratory failure (Cantu & Gean, 2010, Journal of neurotrauma) Death can be as early as 2-5 min of 2 nd impact (Zollman, 2011, Demos Medical Publishing)
Department of Neurosurgery
SIS: Symptoms
Headache most commonly reported Dizziness Neck pain Nausea and vomitting Light/Noise sensitivity Sleep pattern changes Memory/Concentration problems Fatigue Respiratory arrest Aniscoria Coma
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SIS: Evaluation and Management
Hyperemic swelling Brain Herniation Post-herniation ischemia CT (Cantu & Gean, 2010, Journal of Neurotrauma) Engorged cerebral hemisphere Abnormal mass effect Midline shift MRI (McCrory et al., 2012, Current sports medicine reports) Metabolic change up to 15 d after concussive injury
Department of Neurosurgery
SIS: Neurosurgeon’s role
Neurosurgical consult in case of anatomic abnormality (Bey & Ostick, 2009, Western Journal of Emergency Medicine) Attention for potential c-spine injury Patient immediately stabilized Airway management Rapid intubation Mannitol to minimize morbidity Surgery generally not effective for treatment of impaired autoregulation
Department of Neurosurgery
Case
(Weinstein et al., 2013, J Neurosurg Pediatrics)
- Previously healthy 17 yo M - Helmet to helmet hit - Felt dizzy, played immediately after - Reported H/A after game from hit - Resumed typical activities - c/o fatigue and persistent H/A
Department of Neurosurgery
Case
(Weinstein et al., 2013, J Neurosurg Pediatrics)
- Normal evaluation/neurological exam with PCP 4d after game - Head CT: WNL
Department of Neurosurgery
Case
(Weinstein et al., 2013, J Neurosurg Pediatrics)
- Persistent H/A, difficulty with concentration - 5 days after initial injury participated in practic (including hitting drills) - After a hit on fourth drill: slow to get up “OK” but H/A - Several plays later headache down on one knee couldn't feel legs dizziness and unresponsive generalized seizure activity - Local ER: intubated, treated with lidocaine, mannitol, fosphenytoin, fentanyl, midazolam - Air transport to trauma/NS center - 143/79, HR 93, GCS 7T, 3mm sluggish pupils, ICP 25-30 - Coagulation studies normal, Utox neg
Department of Neurosurgery
Case
(Con’t)
- Brain/cervical spine MRI: mild downward transtentorial herniation, bilateral subdural hematomas, abnormal T2 signal restricted diffusion in medial left thalamus - Midline structures displaced caudally (thalamus hypothalamus)
Department of Neurosurgery
Case
(Con’t)
Hospital course: Episode of hypotension, severe metabolic acidosis and renal failure, Sepsis, ventilator-assoc. pneumonia with empyema, disseminated intravascular coagulation, cardiac arrest Later resolution of subdural hematomas and areas of encephalomalacia At time of discharge (day 98) nonverbal and nonambulatory
Department of Neurosurgery
Case
(Con’t)
3+ years after injury living at home regained limited verbal, motor, cognitive skills
Department of Neurosurgery
SIS
http://www.youtube.com/watch?v=V12Z qmd3Btc
Department of Neurosurgery
Traumatic Subdural Hematoma
Bleeding into the space between the dura mater and the brain From venous hemorrhage 12-30% of patients with severe head injury 36-79% mortality Often requires surgical intervention
Department of Neurosurgery
Traumatic Epidural Hematoma
Bleeding into the space between the dura mater and the skull From arterial laceration Typically from disruption of middle meningeal artery Arterial bleeding increased intracranial pressure cell lesion & brain damage ~20% mortality
Department of Neurosurgery
Post Concussion Syndrome
Persistent post-concussion symptoms 3+ months Increased risk of depression Working memory and Info processing speed impairments in mild TBI and persistent PCS (Dean & Sterr, 2013, Frontiers in Human Neuroscience)
Department of Neurosurgery
Chronic Traumatic Encephalopathy
Repetitive brain trauma necessary for development of CTE Progressive neurodegenerative disease Symptoms present years after trauma (Stern et al., 2011, American Academy of Physical Medicine and Rehabilitation) Decline of memory/cognition Depression Suicidal behavior Poor impulse control Aggressiveness Parkinsonism Dementia Generalized atrophy
Department of Neurosurgery
Conclusions
Vulnerable window following TBI Second impact before resolution of symptoms can result in catastrophic brain injury/ fatality Highlights importance of return-to-play decisions PCS and CTE represent long-term consequences of repetitive head impacts
Department of Neurosurgery
Future Directions
Better identification of concussions X2 Helmet Better protocols (sideline, ER, etc) Increased awareness
Department of Neurosurgery
Acknowledgements
Alexa Dessy, BA Jonathan Rasouli, MD Mount Sinai PLAYSAFE team Alex Gometz, DPT, CIC (Concussion Management of New York)
Department of Neurosurgery