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)

Rare SymptomsRare Symptoms

Seizure 1% or lessSeizure 1% or lessCortical blindnessCortical blindness

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

Mental StatusMental Status

OrientationOrientationMemory Memory Cognitive skillsCognitive skills

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

SCAT 3 Demo

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

Other Neurological Injury

C-Spine Brachial Plexus Transient Cord Neuropraxia

Other Neurological Injury

C-Spine Brachial Plexus Transient Cord Neuropraxia

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

Stinger/BurnerStinger/Burner

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