Learning Objectives
- A concussion is diagnosed clinically
- Rest is an integral part of treatment
- Symptoms should resolve before return to normal physical activity, since earlier return correlates with longer lasting symptoms
History
A 19 year old soccer player accidentally collides with another player during a game. She does not lose consciousness, but she feels mild amnesia. She is taken out of the game and she is attended to by trainers. She says she feels fine, but she is asked to rest afterwards. The next day, she develops a diffuse, aching sensation in her head, which is worsened by physical effort. She has a poor appetite, nausea, and dizziness, she struggles to concentrate when she studies, and she feels irritable. When she does not recover with rest, she is sent to the clinic for further evaluation.
She has a history of seasonal allergies and a tonsillectomy procedure. She has no medicine allergies. She uses loratidine in the spring season.
There is no family history of headaches.
She reports she uses alcohol, but not for at least 2 weeks. She normally has at most 2 drinks per month. She does not smoke. She is a junior college student.
Review of systems indicates she has had no fevers, travel exposure, sick contacts, difficulty with the bowel or bladder function, rashes, joint pains, visual disturbance, coughing or chest pain.
Examination
Vital signs are temperature 98.7 F, pulse 68, blood pressure 112/66. She is a healthy-appearing person. She is wearing her soccer warm up clothes. Cardiovascular exam is normal. Pupillary and funduscopic exams are normal. She is not sensitive to light. Cognitive function, orientation and fund of knowledge are normal. There are normal eye motions, without nystagmus, normal hearing and facial sensation, normal facial expression, and normal head thrust. The strength and tone are normal, if not better than normal, in this athlete. Deep tendon reflexes and plantar stimulation are normal. Sensation to pin prick is normal. Finger nose finger and heel knee shin movements are normal, and no tremor is evident. She is able to tandem walk without difficulty and Romberg testing is normal.
Neuroanatomy and Localization
A concussion may occur by acceleration or deceleration of the delicate neural networks within the brain. It does not require a focal disturbance. Symptoms of a concussion may occur independent of any localizing exam or imaging finding. It is not known how many networks must be disrupted for concussion symptoms to occur.
Diagnosis
This is a young healthy patient who suffered a head collision and subsequently developed headaches, trouble with concentration and nausea afterwards. The examination is non focal. The differential diagnosis for the patient’s symptoms includes concussion / postconcussion syndrome, migraine headache, cerebral hemorrhage / hematoma, and neoplastic disease.
Although this patient is a young person with a headache, certain elements of the case suggest the diagnosis is not a migraine. The symptoms are a bit long in duration for a first time migraine. The localization of the headache is diffuse, not unilateral, and the quality of the pain is unlike that of a migraine. It may at times be difficult to distinguish migraine from other causes, as the clinical details may not support a single cause. Sometimes patients develop a tendency for migraines after an injury, such as a head to head collision of fall injury. So a history of trauma is not necessarily a key factor.
The patient is probably too healthy-appearing to consider hemorrhage and neoplasm as the cause of the symptoms. It is good to consider them for learning purposes. Both of these alternate illnesses can be identified by MRI and sometimes by CT testing. Evaluating these alternatives is more important for severe trauma or when symptoms are not improving as expected. Generally, hemorrhage and neoplasm will not deserve a high index of suspicion here because the symptoms started soon after mild trauma.
A concussion is a traumatic brain injury that results from sudden change in movement or with a direct blow to the head. The symptoms of concussion may include headache, nausea, decreased appetite, loss of consciousness, seizure, emotional irritability, fatigue, poor concentration or memory, altered vision, or regulation of sweating. The symptoms may last for hours, days, weeks, or sometimes months. Typically the headache is one of the longest-lasting symptoms, although this varies from person to person, and may depend on the patient’s history of headaches prior to the injury.
After a mild accident, there are standardized evaluation tools, such as checklists and questionnaires, available to team trainers and personnel to help diagnose a concussion. This should be sufficient for evaluation for mild cases. As the injury or symptoms becomes more significant, it is good practice to consult with health care providers and objective testing. Following a severe accident a CT scan should be done to be certain hemorrhage is not present. Traits of severe accidents include a first time seizure after injury, after a fall from a great distance, a significant car accident, or a prolonged loss of consciousness. A CT scan does not help to diagnose a concussion, as it should appear normal if concussion is the diagnosis.
What is a concussion? Networks of delicate nerve connections lie on the surface of and underneath the surface of our brain. These are fragile, biological structures, which can be disrupted by blunt force contact with the inside of the skull or by sudden change in direction or rotation. A concussion may occur with direct trauma to the head or by shaking the head. The pathological changes cannot be seen in a patient’s MRI or CT study. These changes are too small and subtle to be seen by these studies. Patients who have suffered many concussions may have changes in the brain consistent with disrupted cortical networks. This may appear as amyloid formation, tau protein, or nonspecific atrophy. In the setting of chronic traumatic encephalopathy, which is a condition related to numerous head injuries over many years, these changes are observed on microscopic examination of the brain during an autopsy.
Treatment
One way to treat a concussion is physical and mental rest. In this patient’s case, a long-lasting concussion syndrome may improve with a reduced course load for the school term. Reduced exercise intensity will also help. A gradual return to activities, starting with light exertion, is generally recommended to reduce the symptoms of a concussion.
Most physicians agree that significant signs of a concussion should resolve before a person returns to contact or physical exertion. Returning too early may expose a person to risk of a longer lasting symptom or re-injury, as healing tissue is more susceptible to injury, even with a trivial accident.
To diminish the risk of a recurrent injury, a health professional should help to determine that the symptoms of a concussion have resolved before returning to risky activities. The risk of prolonged symptoms is dependent on the risk of another injury. Activity with no risk of injury is felt to worsen symptoms, but not prolong them. Activities involving contact, such as tackling or wrestling, can compound concussion symptoms and cause them to last much longer. Patients with recurrent concussions may benefit from counseling regarding the risk of changes in behavior and cognitive decline, and take measures to protect themselves.
Headache symptoms may respond to rest, NSAID medication such as acetaminophen, tricyclic antidepressants, or gabapentin. Medicines such as ibuprofen and aspirin are sometimes avoided to reduce the risk of hemorrhage, but they may be safe if hemorrhage is proven not to be present.
Review Questions
- A concussion should be considered when:
a. the head has been injured by trauma
b. head injury leads to symptoms of headache, dizziness or altered cognition
c. head injury causes bleeding of the scalp
d. nausea, vomiting and loss of consciousness occur, without resolution
e. a person wakes up feeling a headache - The best first line care for a concussion is
a. rest
b. NSAID medications, such as acetaminophen
c. cognitive skill maintenance exercises
d. aerobic exercise 10 minutes each day
e. foods with a high salt content - Before returning to physical activity or risk of another head injury, a medical provider would be likely to recommend
a. that all symptoms of a concussion are resolved
b. to obtain an MRI study of the brain
c. neurogenic stress testing
d. neuropsychological testing
e. none of the above