Post-Concussion Syndrome.ppt

							Sports-Related Concussion

George C. Phillips, MD, FAAP, CAQSM
Clinical Associate Professor of Pediatrics
         Sports Medicine Rounds
           September 16, 2010
     Sports-Related Concussion
• NCAA studies estimated ~ 6% of athletes incurred
  a concussion each season (FB)
• More recent studies of high school athletes
  estimate a seasonal rate of 15%
   – CJSM 2004 McCrea et al
• Sports-related concussions estimated at 300,000
  per year
   – Over 135,000 in high school sports (JAT 2007 Gessel
     et al)
• At least 55,000 to 60,000 concussions occur each
  year in high school football alone.
Simple versus Complex Concussion
 • Simple                     • Complex
   – Resolves in 7-10 days      – Persistent symptoms
   – No complications           – Specific sequelae
                                   • Prolonged cognitive
   – Formal                          impairment
     neuropsychological
     evaluation unnecessary     – Multiple concussions,
                                  perhaps with less force
   – Most common form
                                – Formal
   – Rest until symptoms          neuropsychological
     resolve                      evaluation
   – Graded RTP                 – Sports medicine
                                  expertise
             Classification
• No proposed classification scheme
• Agreement that 80% to 90% of concussions
  have symptom resolution within 7-10 days,
  except…
• Pediatric concussions may last longer
      Are All Athletes Equal?
• CJSM 2007 Iverson
• 114 high school football players
• 52% suffered complex concussions
  – No increased history of prior concussions
  – Symptoms took an average of 19 days to
    resolve (vs. 4.5 days for simple concussions)
      Next Steps in Evaluation
• Neuroimaging – no, for clinical purposes
• Balance testing – can see measurable
  deficits in first 72 hours
• Neuropsych testing – valid tool; best when
  interpreted by an expert
• Genetic testing – unclear value at this time
             Return to Play Guidelines
• Stepwise RTP Protocol
   –   No activity until 24 hours without symptoms
   –   Light aerobic exercise
   –   Sport-specific training (skating, running)
   –   Noncontact training drills
   –   Full contact drills after medical clearance
   –   Return to competition
• Recurrence of symptoms at any stage warrants removal
  from participation until symptom-free for another 24 hours.
  Participation then resumes one stage earlier in the protocol.
 What about Sunday afternoons?
• Team physicians experienced in concussion
  management
• Sufficient resources (access to specialists)
• Immediate (sideline) neurocognitive
  assessment
• Note: 1 study cited for adult RTP same
  day, vs. 7 studies for problems in college
  and high school athletes
                 Return to Play
• Yard EE, Comstock RD. Compliance with return to play
  guidelines following concussion in US high school
  athletes, 2005–2008. Brain Injury, October 2009; 23(11):
  888–898.
•   Reviewed use of RTP guidelines at 100 HS
•   Estimated 400,000 concussions nationwide
•   AAN guidelines – 40.5% returned early
•   Prague guidelines – 15% returned early
•   In football, 15.8% of concussed athletes with LOC
    returned in less than 24 hours
     Other Management Issues
• Consider depression in the athlete
• Athlete should be asymptomatic, off meds,
  for RTP
• Individual consideration for athletes on anti-
  depressant meds and RTP
  – Experienced clinician judgment
    Preparticipation Screening
• Not just number of concussions, but prior
  symptoms
  – How good is the concussed athlete’s recall?
• Head, face, neck trauma history
• Impact vs. symptom severity – mismatch?
How Well Do We Take a History?
         2008 CJSM Valovich McLeod et al
25


20


15


10


5


0
     Head Injury   Knocked Out   Bell Rung or Dinged
How Well Do We Take a History?
         2008 CJSM Valovich McLeod et al
  Symptom       %(+) Responses       # Episodes

 Headache             43.5            3.1 ± 2.1

  Dazed or            23.8            2.6 ± 1.8
 Confused
Dizziness or          20.8            2.5 ± 1.8
  Balance
  Problems
   Trouble            18.7            3.4 ± 2.1
Concentrating
       Duration of Symptoms
• Meehan WP, d’Hemecourt P, Comstock RD.
  High School Concussions in the 2008-2009
  Academic Year: Mechanism, Symptoms, and
  Management. AJSM Preview, August 17, 2010.
• 544 concussed high school athletes
• 15.1% had symptoms > 1 week but <1 month
• 1.5% had symptoms > 1 month
   Post-Concussion Syndrome
• ICD-10
  – Head trauma w/LOC precedes symptoms by  4 weeks
  – Three or more symptoms categories:
     •   HA, dizziness, malaise, fatigue, phonophobia
     •   Irritable, depression, anxiety, emotionally labile
     •   Subjective concentration, memory, or intellectual difficulties
     •   Insomnia
     •   Reduced alcohol intolerance
     •   Preoccupation with symptoms and fear of brain damage with
         hypochondriacal concern and adoption of sick role
   Post-Concussion Syndrome
• DSM-IV:
  – 3 or more of the following occur shortly after trauma
    and last at least 3 months:
     •   Fatigued easily
     •   Disordered sleep
     •   Headache
     •   Vertigo or dizziness
     •   Irritable or aggressive with little/no provocation
     •   Anxiety, depression, or affective lability
     •   Personality changes
     •   Apathy or lack of spontaneity
               Does PCS Exist?
• Plenty of experts say no:
   –   Depression
   –   PTSD
   –   Litigation, Worker’s Compensation
   –   Chronic Pain
• What are we asking?
   – Self-reported questionnaires
   – Structured Clinical Interview/Sx assessments
   – Neuropsychological testing
• When are we asking?
    Attentional Deficits in PCS
• Categorization of PCS patients:
  – Mild sustained attentional deficits
     • Sustained Attention to Repsonse Task
     • Younger, better educated
  – Selective and divided attentional deficits
     • Best on SART; Stroop Word-Color, PASAT,
       Symbol Digits Modality Test impaired
  – General attentional deficits
     • Poor on everything
     • Disproportionately female
          Risk Factors for PCS
• Preexisting psychiatric   • Violent injury
  condition                   mechanism
• Comorbid psychiatric      • Dizziness
  diagnosis                 • Prior head injury or
• Alcohol                     CNS disorder
• Litigation                • Education
• Age                       • Learning disability
• Female gender             • Academic success
                              (GPA)
    Post-Concussion Syndrome
• Emotional disturbance and secondary gain
  are true confounders of PCS
• Controlled studies reveal objective findings
  of cognitive dysfunction in PCS
• Functional neuroimaging and electro-
  physiology studies can support diagnosis
         Episodic Symptoms
• Tucker (1986) described 20 cases with
  episodic changes in cognition, mood,
  hallucinations
• Abnormal EEG but not epileptiform
• Poor response to antipsychotics, lithium, or
  tricyclics (lower seizure threshold)
• Improved with anti-epileptic medications
         Episodic Symptoms
• Tinnitus             •   Staring spells
• Head pain            •   Anger episodes
• Memory gaps for      •   Dizziness
  experiences          •   Vertigo
• Déjà vu              •   Micropsia (funnel of
• Automatisms of           light)
  walking and speech
                   MIND
• Multiple authors describe similar cases
• Epilepsy Spectrum Disorder (ESD)
• Multiple Intermittent Neurobehavioral
  Disorder (MIND)
• No clear etiology
  – Hippocampal, brainstem, multifocal cortex-
    white matter junction lesions
• Differential: intermittent explosive disorder;
  personality disorder; mood disorder
                    MIND
• Typical neuropsychological profile:
  –   Mild to moderate attentional problems
  –   Short-term and long-term memory problems
  –   Focal NP deficits matching gross lesions
  –   Frontal lobe dysfunction (olfactory)
  –   Executive dysfunction
        Medications for MIND
• No randomized, controlled trials
• Most experience with carbamazepine and valproic
  acid
   – Both are good for partial seizure disorders
   – Carbamazepine used in mood control: rage
   – Valproic acid used in mood control: anxiety
• Iowa experience – 95% positive response to CBZ
• Second-line antiepileptics phenytoin and
  gabapentin with less experience
     Post-Concussion Syndrome
• For athletes, multiple concussions are a significant risk
  factor.
• While many symptoms of PCS overlap with other
  diagnoses, subscales of symptoms specific for cognitive
  function may delineate true cases of PCS.
• Neuropsychological testing can provide objective data for
  diagnosis, follow-up comparisons, and information to
  assist in reintegrating the injured person to work, school,
  and/or athletics.
• If objective neuropsychological findings support the
  diagnosis of MIND, a trial of antiepileptic medications
  may prove useful.
        Multiple Concussions
• 2002 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
• 2008 J Ath Train Covassin et al
  – ≥3 concussions = significantly slower recovery
    of verbal memory and reaction time
  – No significant change in symptom scores 5
    days after the concussion
        Pediatric Concussion
• Zurich guidelines appear applicable down to
  age 10
• For younger athletes, need different
  evaluation tools, teacher/parent input
• Longer recovery
• Cognitive rest
• “Diffuse cerebral swelling”
• Modifiers may apply even more
     Second Impact Syndrome
• Rare, controversial diagnosis
• Results when a second head injury occurs
  before resolution of first injury
• Rapid progression to altered sensorium,
  seizures, coma, brain death
• Abnormal or immature autoregulation of
  cerebral blood flow causes swelling,  ICP
  and cerebellar herniation (2-5 minutes)
    Chronic Traumatic Encephalopathy
•   “Punch-drunk” boxers – Martland 1928
•   Dementia pugilistica
•   Psychopathic deterioration of pugilists
•   Progressive neurodegeneration clinically
    associated with memory disturbances,
    behavioral and personality changes,
    parkinsonism, and speech and gait
    abnormalities.
                     CTE
• 48 cases proven by microscopic evaluation
  reported in the literature
• Cerebral and medial temporal lobe atrophy,
  ventriculomegaly, enlarged cavum septum
  pellucidum, and extensive tau-
  immunoreactive pathology
  – Tau-reactive neurofibrillary tangles (NFT) very
    similar to Alzheimer’s disease
                     CTE
• Football players’ history different from
  boxers –
  – Younger at age of death (44 yo versus 60 yo)
  – Shorter duration of symptoms (6 versus 20.6
    yrs)
• Head trauma linked with Alzheimer’s,
  suggesting a possible common pathway to
  chronic neuronal damage