August is here, and football and soccer are underway at virtually every school and college. While these sports may not cause the majority of head injuries, undoubtedly the coming months will bring an increase in the incidence of concussions and brain injuries among children, adolescents and young adults. Consequently, many healthcare providers are likely to see greater numbers of patients presenting with complaints following a head injury, leading to many questions on behalf of patients and their families as well as those professionals who are responsible for treating them.
The term concussion is often used both colloquially and professionally as synonymous with mild traumatic brain injury (mTBI). Concussion is quite common. For example, in football alone, an estimated 10% of college and 20% of high school players in the United States sustain brain injuries each season.
A concussion occurs with head injury due to contact that results in acceleration or deceleration forces. It is typically defined as mild by a Glasgow Coma Scale (GCS) score of 13-15, measured approximately within 30 minutes of the injury. A concussion may or may not involve a loss of consciousness (LOC). However, LOC (if present) and its duration are critical as it is used as one of the indices of the severity of the injury.
Symptoms of Concussion
Concussion typically results in a very rapid onset of neurologic dysfunction which tends to resolve spontaneously. In some cases, symptoms and signs may evolve over a number of minutes to hours, so a person who suffers a concussion may present as lucid and cogent immediately after the injury, only to experience decline at a later time. For this reason, it is essential that individuals suspected of having a concussion be carefully observed over the next 12-24 hours following discharge to ensure their condition does not deteriorate. Usually this responsibility falls to family and friends. It’s important to ask if a patient lives alone so the individual can make arrangements to ensure they are not alone over the next day or so.
The hallmark acute symptoms of concussion include confusion and amnesia, which manifests as a temporary loss of memory for events immediately prior to and/or following the concussion. These symptoms may be apparent immediately after the head injury or may appear several minutes (or even hours) later.
Athletes, family members and medical providers need to recognize an alteration in mental status can occur without LOC. In fact, the majority of concussions in sports occur without LOC. Consequently, most concussions often go unrecognized and undiagnosed, and why many sports programs are implementing policies to recognize and assess possible concussion.
Other signs and symptoms of concussion include headache, dizziness, nausea and vomiting. Additional symptoms which often develop in the hours and days afterward include moodiness, irritability, sensitivity to light and noise and sleep disturbances. One reason that a thorough assessment is so important following suspected concussion is the possibility of second-impact syndrome (SIS). SIS occurs when an individual sustains a second concussion while still symptomatic from an earlier concussion. While rare, this condition is often fatal and makes accurate diagnosis of any concussion all the more important.
Testing and Diagnosis
Neuroimaging is largely unremarkable following concussion/mTBI, as the acute clinical symptoms largely reflect a functional disturbance rather than structural injury. Therefore, patients who are being seen in the emergency department (ED) may have neuroimaging (e.g., CT/MRI) that is reported as normal.
The acute evaluation of an individual with concussion includes mental status testing and a neurologic assessment. Significant warning signs include prolonged unconsciousness, persistent mental status alterations (e.g., prolonged amnesia), or abnormalities on neurologic examination. If these symptoms are present, urgent neuroimaging and neurosurgical consultation may be warranted. One of the most common sequelae reported by patients following concussion is a general slowing of mental processing speed.
While acute symptoms represent one area of concern, medical providers should be alert for any patient who is reporting a history of multiple concussions. Inquiring about any cognitive deficits they are experiencing is important to determine if a more comprehensive neuropsychological evaluation is warranted. Complaints of memory loss, concentration and attention difficulties, and decline in academic performance would likely provide a compelling basis for further evaluation. Mood symptoms are also a common complaint, as concussions can contribute to emotional labiality, depression, irritability and impulsivity.
When a patient’s symptom complaints persist beyond what would be expected following an uncomplicated head injury (e.g., several weeks and months post-injury), medical providers should suspect the possibility of post-concussion syndrome (PCS). PCS typically involves a symptom complex that includes headache, dizziness, neuropsychiatric symptoms and cognitive impairment.
PCS is controversial, especially when symptoms are protracted over several months. A number of empirical studies have identified a psychogenic contribution to PCS, with a much greater prevalence of preexisting psychiatric symptomatology including depression and anxiety. Iatrogenic effects following treatment can also contribute to the emergence and maintenance of complaints following concussion.
This is an area in which neurocognitive and psychological testing can provide additional diagnostic clarification and inform treatment through appropriate intervention strategies, leading to improved long-term outcomes. In fact, neuropsychological assessment has been considered the “gold standard” in concussion assessment for some time, due in large part to the persistence of cognitive deficits in the absence of focal neurologic dysfunction.
A great deal of interest and increasing attention continues to be given to the effects of concussions. The high-profile suicides of many professional athletes and literature linking contact sports with neurodegenerative conditions such as chronic traumatic encephalopathy (CTE) have raised concern among many. As a result, healthcare providers are likely to encounter increasing numbers of patients and family members who are concerned about the effects of head injuries and what assessment and treatment options are available. Recognizing the acute and chronic symptoms of concussion will lead to more favorable outcomes in the future.
Dr. Baker earned his Bachelor of Science degree from Northern Michigan University prior to attending the University of Cincinnati where he obtained his Ph.D. in clinical neuropsychology. He completed his pre-doctoral internship at Patton State Hospital in San Bernardino, California and his two-year postdoctoral residency in clinical neuropsychology at the Louis Stokes VA Medical Center in Cleveland, Ohio. His clinical expertise and experience includes adult neuropsychological assessment. He works with individuals with a wide range of neurocognitive disorders, including but not limited to differential diagnosis of dementia, brain injury, and a host of other medical/neurological conditions.
Dr. Baker’s current practice also includes forensic neuropsychological assessment of adults. These evaluations include, but are not limited to, independent medical examinations, disability/return-to-work, guardianship, and intellectual/ developmental disability.
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