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cerebral concussion

Minor head injury resulting in an immediate & transient impairment of neural function. Classification: Concussion grading system (Colorado, 1991): 1) Grade 1: a) no loss of consciousness b) confusion without amnesia c) resolution within 15 minutes [3] d) most common form, but most difficult to recognize [4] 2) Grade 2: a) no loss of consciousness b) dazed; confusion with amnesia 3) Grade 3: any loss of consciousness Etiology: 1) motor vehicle accidents (MVA) 45% 2) falls 35% 3) occupational accidents 10% 4) recreational accidents 10% 5) assaults 5% 6) contact sports - both games & practices pose a major concussion risk for young American football players [23] - heading the ball in soccer [27,37] - contact with another player (62% in girls, 78% in boys) - contact with the ball (32% in girls, 15% in boys) [27] Epidemiology: - concussion risk for females is higher than males participating in the same sport [9] - adolescent girls take longer than boys to recover from their first sports-related concussion [41] - college football players with highest rate of concussion, 3.52 per 1000 games [30] (excluding professional football) - most children with concussion present to primary care rather than emergency department [31] - annual rate of soccer-related concussion or other closed head injuries among children in U.S. increased from 0.02% to 0.35% from 1990-2014 [34] - 20% of adolescents report a history of concussion [40] - 15% of U.S. high school students report having had at least one sports-related concussion in the past year [44] Clinical manifestations: 1) early manifestations a) a quick head shake after a hard collison may signal concussion [52] b) alteration in consciousness - lack of awareness of surroundings c) disturbance of vision d) loss of equilibrium, dizziness, vertigo e) headache, fatigue, dizziness [17] f) nausea, vomiting g) cognitive symptoms [17] - taking longer to think (58%) - poor concentration (52%) - forgetfulness (42%) h) emotional symptoms [17] - frustration (28%) - irritability (26%) - restlessness (25%) - depression (23%) i) cognitive & emotional symptoms increase until 7 & subsequently decline 2) late manifestations: see post-concussion syndrome - symptoms persist for at least 1 month in most patients [7] - at 90 days, headache is most common symptom [5%] Laboratory: - microtubule-associated protein tau in serum/plasma - one hour post head injury plasma levels predict time to symptom resolution [16] - 5 specific microRNAs in saliva identify prolonged concussion symptoms in children & adolescents with > 85% accuracy [42] - 3 microRNAs in saliva linked with specific concussion symptoms: memory difficulty, headaches, & fatigue [42] - specific microRNAs in saliva identify concussion symptoms in professional rugby players [48] - ubiquitin C-terminal hydrolase in blood & GFAP in blood FDA- approved to evaluate need for CT of brain in adults [43] Special laboratory: - neuropsychologic testing for persistent symptoms [4] Radiology: - computed tomography is imaging modality of choice in an acute setting - indications - post-traumatic seizure - post-traumatic amnesia (retrograde amnesia for events > 30 minutes before impact) - post-traumatic gait disorder - progressive headache - recurrent vomiting - suspected skull fracture, basilar skull fracture - presence of coagulopathy (taking anticoagulant or anti-platelet agent) - age > 60 years - drug toxicity or alcohol intoxication - dangerous mechanism of injury [4] - pedestrian struck by motor vehicle, ejection from motor vehicle, fall from >= 3 feet or >= 5 stairs - MRI neuroimaging - indications: - severe trauma - clinical deterioration - loss of consciousness - post-traumatic amnesia (retrograde amnesia for events > 30 minutes before impact) - focal neurologic defects - symptoms or abnormal neurologic exam persisting > 1 week - smaller right hippocampal volumes in retired NFL players with history of grade 3 cerebral concussion [26] Complications: - even grade 1 concussion is associated with decline in memory after 36 hours [3] - persistent postconcussion symptoms - 30% of children at 4 weeks - associated with diminished quality of life at 12 weeks - reduced cerebral blood flow associated with persistence of neuropsychiatric symptoms 1 month after injury [22] - symptomatic children suffer academic difficulties [24] - mild cognitive impairment associatied with history of grade 3 cerebral concussion in retired NFL players [26] - 13% of persons with concussion have poor cognitive outcome at 1 year [49] - increased risk for suicide ~3 fold [29] - abnormal menses in adolescent & young women [38] Management: 1) athletes with suspected concussion should be removed from play immediately & not allowed to return until - evaluated by a licensed healthcare professional [9,25] - at least the remainder of the day [50] - removal from play reduces recovery time [33] 2) repeated cognitive & neurologic assessment may be more important than grading [2] 3) outpatient followup computerized neurocognitive testing may identify persistent symptoms not detected by other clinical assessment - ImPACT software FDA-approved August 2016 [32] 4) persistent symptoms lasting > 1 hour warrant medical observation [4] 5) grade 1 concussion allows a player to return to play in the same game [3,8] - symptoms & mental status must return to normal within 15 minutes at rest & with exercise [8] 6) grade 2 concussion prohibits player from returning to game - player should be asymptomatic for 1 week at rest & with exercise prior to returning to competition [8] - 2 week recovery period for multiple grade 2 concussions 7) grade 3 concussion a) remove from competition b) if symptoms brief & examination findings normalize, may return home with family with observation c) if prolonged symptoms. persistent abnormal examination, or prior concussion, emergency department evaluation with neuroimaging d) player with brief symptoms should be asymptomatic for 1 week before returning to competition e) player with prolonged symptoms should be asymptomatic for 2 weeks before returning to competition f) player with second occurrence should be asymptomatic for 4 weeks before returning to competition [5,8] 8) return to work as per recommendations for return to play 9) no treatment expedites recovery or prevents long-term cognitive impairment [9] 10) post-concussion cognitive rest a) limit activities requiring concentration [20] - reading, texting, playing video games, schoolwork b) adjust academic workload [12] c) strict rest following concussion not helpful for children & adolescents [21] d) most concussion symptoms improve within 3 weeks e) persistence of symptoms longer than 3 weeks should prompt further investigation f) students should return to baseline academic performance before returning to extracurricular activities, including sports [12] 11) physical activity at any level (light, aerobic, full) within 7 days after concussion is associated with lower rate of persistent symptoms in children (29% vs 40%) [36] 12) moderate aerobic activity after sports-related concussion reduces time to recovery [47] 13) moderate-to-vigorous physical activity within 1 week is associated with lower postconcussion symptom burden [51] 14) patient education - telling patients that symptoms are common after concussion significantly changes their responses [28] Notes: - American Academy of Neurology concludes physicians have an ethical responsibility to protect patients from concussion - physicians should provide information about - concussion risk factors, symptoms, & risk for post-concussion syndrome - shared decision making regarding concussion management & return to play [19] - almost 2/3 of players at the 2014 FIFA World Cup with >= 2 signs of concussion were not assessed by sideline healthcare professionals [39]

Related

cerebral contusion

Specific

post concussion syndrome

General

traumatic brain injury (TBI)

References

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