Transcript Approach to Head Injury in the Athlete

Head and Neck Trauma
George C. Phillips, MD, FAAP, CAQSM
Clinical Assistant Professor of Pediatrics
September 20, 2007
Case History
• 16-year-old male football player
• Helmet-to-helmet collision during practice
six days prior to initial visit in our center
• Confused and disoriented at the time of
injury
• Bilateral upper extremity numbness and
tingling that lasted 20 minutes
Case History
• Evaluated on the day of injury at a local
emergency department
– Head CT showed right frontal soft tissue
swelling, with normal brain parenchyma
• Diagnosed with concussion and removed
from participation until follow-up at the
University of Iowa Sports Medicine Center
Case History
• At our initial visit, he reported retrograde
and post-traumatic amnesia
• He denied headache, dizziness, blurry
vision, confusion, tinnitus, or
cognitive/school performance issues
• He went running the previous day without
symptoms
Case History
• Patient reports a previously unrecognized
injury occurring one week prior to the index
injury
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Helmet-to-helmet contact
Bilateral upper extremity numbness/tingling
Brief loss of vision in left eye
Symptoms resolved within 24 hours
Case History
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No prior head trauma
Multiple hand fractures
No surgeries
Exercise-induced asthma, well-controlled
Physical Examination
• HEENT, Neck, Pulmonary, Cardiovascular,
Abdominal, and Skin exams were
unremarkable
• No C-spine tenderness
• Negative Spurling’s maneuver
• No visual or ocular disturbances
• Negative Battle sign
Physical Examination
• Impaired delayed recall (3/5 words)
• Mild concentration difficulties (6 digits,
reverse order of months)
• Balance impairment (single leg stand with
eyes closed)
• Fully oriented, immediate memory intact
• Intact light touch and 2-point discrimination
Differential Diagnosis
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Complex concussion
Spinal cord contusion
Cervical spine injury with cord compression
Arnold-Chiari malformation
Cerebrovascular accident
Vascular injury/anomaly to brain stem /
spinal cord
Concussion
• “Concussion is defined as a complex
pathophysiological process affecting
the brain, induced by traumatic
biomechanical forces.”
– “Summary and Agreement Statement of the 2nd
International Symposium on Concussion in
Sport, Prague 2004” – Clin J Sport Med 2005
Concussion
• Mechanics: direct blow to head/face/neck
or indirect force transmission (body blow)
• Timecourse: rapid onset, short-lived
impairment, spontaneous resolution
• Pathophysiology: function > structure
• Symptoms: graded syndromes, may or may
not include LOC, sequential resolution
Postconcussion Symptom Scale
J Head Trauma Rehabil 1999;9:193-8
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Headache
Nausea
Vomiting
Balance problems
Dizziness
Fatigue
Trouble falling asleep
Sleeping more than usual
Sleeping less than usual
Drowsiness
Sensitivity to light
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Sensitivity to noise
Irritability
Sadness
Nervousness
Feeling more emotional
Numbness or tingling
Feeling slowed down
Feeling mentally “foggy”
Difficulty concentrating
Difficulty remembering
Visual problems
Clinical Signs of Concussion
• Consciousness (LOC) – not required
• Memory – post-traumatic/retrograde
amnesia
• Cognition
• Neurological (physical)
• Personality (emotional)
Question #1
• Should a concussed athlete return to play on
the day of the injury?
Concussion and RTP
• Athletes will not report concussion
– CJSM 2005 McCrea et al
– Only 47 % of HS athletes reported concussion
– Of those not reporting concussion:
• 66% thought the injury was not serious enough
• 41% did not want to be held out of the game
• 36% were not sure what a concussion was
– 15.3% of athletes had a concussion in 1 season
– 29.9% of athletes had a history of concussion
Concussion and RTP
• AJSM 2000 Guskiewicz et al
– 30% of athletes RTP same day
– For the other 70%, average RTP was 4 days
• JAMA 2003 McCrea et al
• Major deficits in balance, cognition,
symptoms
– Balance 3-5 days; cognition 5-7 days;
symptoms 7 days
• 10% of athletes had symptoms > 1 week
Concussion and RTP
• JAMA 2003 Guskiewicz et al
– 75% of same-season repeat concussion
occurred <7 days from the first; 92% < 10 days
• A seven-day waiting period would likely
result in resolution of symptoms and
normalized cognitive function
• A seven-day waiting period may prevent a
majority of repeat concussions
Question #2
• How many concussions are too many
concussions?
Multiple Concussions
• 2003 Neurosurgery Collins et al
– History of ≥3 concussions = 9.3x more likely to
experience 3 of 4 “onfield markers”
• LOC, RG amnesia, AG amnesia, or confusion
– 6.7x more likely to experience LOC
• 2003 JAMA Guskiewicz et al
– ≥3 concussions = 3x more likely to have
another concussion
– ≥3 concussions: 30% had symptoms > 1 week
Multiple Concussions
• 2004 Brain Injury Iverson et al
– ≥3 concussions = more preseason symptoms
– ≥3 concussions = 7.7x more likely to have memory
problems 2 days after injury
• 2005 Neurosurgery Moser et al
– ≥2 concussions = same neuropsych scores while
symptoms free as 1 week post-concussion for first-time
concussions
• 2006 BJSM Iverson et al
– 1-2 concussions versus 0 = no difference on ImPACT
Tests and Results
• Head CT from the day of the index injury
– Mild soft tissue swelling in right frontal area
– Normal parenchyma
– No hemorrhage, ischemia, or hydrocephalus
Tests and Results
• AP and lateral flexion/
extension views of the
C-spine
• No instability, prevertebral soft tissue
swelling, fracture or
dislocation
• Mild levoconvex
curve of upper
thoracic spine
Tests and Results
Tests and Results
• MRI of the C-spine
• Normal alignment
• Normal signal of
brainstem, cerebellum,
and spinal cord
• Cerebellar tonsils
extend 5 mm below
the inlet to the
foramen magnum
Tests and Results
Final Working Diagnosis
• Chiari I Malformation
• Concussion
Treatment and Outcomes
• The athlete was disqualified from contact
and collision sports
– Fortunately, he also had a significant interest in
golf
• Neurosurgical referral was discussed
• The patient has not returned to our center
for any additional visits
Pearls
• Differences in Chiari malformations
– Chiari I: cerebellar tonsils
– Chiari II: cerebellar vermis (Arnold-Chiari)
– Chiari III: portion of cerebellum within an
occipital encephalocele
• At least 30% of persons with Chiari I with
tonsils down 5-10 mm are asymptomatic
• 12 mm down almost always symptoms
Pearls
• Chiari I and II malformations are associated
with syringomelia
– Chiari I is not associated with myelomeningocele or other neural tube defects
• Chiari I can be accompanied by skull
abnormalities
• Neurologic symptoms could include central
cord syndrome
Can we manage SCI?
• Methylprednisolone for 24-48 hours
– Evidence is weak at best
– Respiratory complications, sepsis, GI bleeds
• Hypothermia
– Unclear mechanism
– Decreases cerebral metabolism and ICP
– Hypotension, bradycardia, and infection are
risks of treatment
Can we manage SCI?
• Future agents for study:
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Estrogen
Progesterone
Minocycline
Erythropoietin
Magnesium
Can we manage SCI?
Can we manage SCI?
Can we manage SCI?
Can we manage SCI?
Can we manage SCI?