More about concussions. Not everything becomes apparent after closed head injury!

In this post I shall dwell on the important issue of concussion. A concussion usually refers to loss of consciousness following a closed head injury. By closed head injury I mean that nothing penetrates into the brain. The skull is usually intact. The duration of loss of consciousness is frequently used to grade the severity of closed head injury/ concussion into mild, moderate and severe. However this grading is quite arbitary and other factors have to be borne in mind such as the age of the patient, the mechanism of injury, the force of injury, presence of pre-existing neurological disease such as dementia and whether protective head gear was worn by the person (such as a helmet).

Concussions are common and can occur in many common day to day activities contrary to common belief that concussions only occur in the setting of a motor vehicle accident (MVA) in the case of civilian life or on the battlefield. Concussions are commonly sustained during sports. Indulgence in some sports especially contact sports such as boxing, ultimate fighting (mixed martial arts), American football, rugby, soccer and wrestling to name only a few are more likely to result in a concussion.

So concussions are common and hence the recent heightened concerns about the short term and long term impact of concussions on the brain. Some of you may be well aware of terms such as chronic traumatic encephalopathy (CTE), boxers encephalopathy, dementia pugilistica and “punch drunk syndrome”.  They all imply that concussions do have a significant adverse effect on the brain. There is now ample evidence to indicate that multiple concussions (sustained in a person’s lifetime) cause memory and other cognitive problems. They may also predispose to dementia and a secondary Parkinsonian syndrome.

So it is imperative that concussions be recognized early so that the patient can receive adequate medical attention. This is expecially true on the playing field (whether it is a school, college or a professional sport arena). The fear is that many concussions go undetected and the player is allowed to return to play prematurely and risk a second (at times fatal) concussion. For concussions to be recognized in a timely fashion parents, coaches, personal trainers and other team officials need to be trained to identify concussions. A cursory examination is NOT enough and there is a recent thrust to have every player be examined by a physician. The physician after examining the player and considering the mechanism of injury and whether the player has sustained a prior concussion (in that game itself or in the recent past) shall then determine when the player can return back to play.

So not everything is apparent after a closed head injury. If you or any of your loved ones has sustained a concussion, bring them to the attention of a qualified physician. A big onus remains on parents who should demand more close supervision in school during play.

Nitin Sethi, MD

Bumps to the head: minor concussion and post concussive symptoms

Recently I have seen a few patients in my office with minor concussions. They all pressented with post concussive symptoms and hence that shall be the focus of my post on this gorgeous June day.  So what is a concussion and what is a “minor” concussion? Concussion is usually a closed head injury with temporary loss of brain function or rather loss of consciousness. By closed head injury, I mean that nothing penetrated the brain. Example of a penetrating head injury shall be a gun shot wound to the head.  Do not get me wrong here-obviously a penetrating head injury shall likely result in loss of consciousness and temporary or permanent loss of some brain function.

That said the word concussion is more commonly used for closed head injuries. Let me give you a few prime examples of concussion.  I am a big fan of boxing and the UFC. Anyone who watches these sports has seen a concussion. Boxer A walks into a stiff jab thrown by Boxer B. Down he goes and is out for the count. The ringside doctor jumps into the ring to examine him. Flips his eyes open and flashes a light into both of them.  After a momentary loss of consciousness, our fallen boxer comes to. Open his eyes but has a dazed look. He is able to answer the ringside doctors questions (show me two fingers with your left hand). He struggles to his feet but his legs are wobbly.  The referee consults the doctor and decides to halt the fight.  So what happened to our boxer? He just sustained a concussion.

Concussions can be graded into mild, moderate and severe. This is quite arbitrary. If the loss of consciousness is more than half an hour the concussion is graded as severe. Minor concussions, which shall be the focus of our talk henceforth, are usually associated with either no or momentary loss of consciousness.  Let me give you a few examples of minor concussions. Walking into a door, bumping your head against a low lying ceiling or a car door are all examples of minor closed head injury with or without concussion.  Majority of patients walk away from such an injury and never seek any medical attention because they experience no ill-effects. A few though  are not so lucky and post the head injury are plagued by headache (post concussive headache), problems with memory and concentration (especially when they are multi-tasking) and a myriad of other complaints such as subjectively feeling off balance, difficulty with sleeping and mood changes such as irritability. All these symptoms after a closed head injury/ concussion are included under the umbrella of post concussive symptoms.

In my next post, I  shall discuss post concussive syndrome and its treatment.

Nitin Sethi, MD

Epidural hematoma: when a “minor” head injury may prove to be fatal

Epidural hematoma: when a “minor” head injury may prove to be fatal

 

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Many of you must have read about the tragic demise of actress Natasha Richardson from blunt (closed) head trauma she sustained after falling on a ski slope. While exact details about the extent and nature of her injuries are unclear, it drew attention to blunt (closed) head trauma. I shall discuss about the same here.

Broadly speaking head injuries can be of two types: penetrating head injuries and closed head injuries. An example of a penetrating head injury is a gun shot wound to the head or when a person is involved in a motor vehicle accident with significant polytrauma (including fracture of the skull and bleeding into the brain). Penetrating head injuries are usually easily identified by first responders (emergency medical services such as the ambulance crew responding first to the call). Usually there is an obvious scalp laceration and blood is seen oozing from the site of the injury. Later when the patient is transferred to the hospital, the extent of the injury can be better documented. For this usually a CT scan of the brain is done (at times a MRI brain may be carried out). Penetrating head injuries vary depending upon the mechanism of injury (example velocity, trajectory and size of the bullet in the case of gun shot wounds to the head). Patients with penetrating head trauma are critical and require urgent stabilization usually in an intensive care setting.

It is the closed head injuries though which can be a little deceiving and that is where I shall like to steer this discussion. The mechanism of closed head injuries is usually blunt trauma to the head (example a fall, a blow to the head while boxing and so on). One special type of closed head injury is a concussive injury from an improvised explosive device (IED). These IED related injuries have become the signature injury in the battlefields of Iraq and Afghanistan. But moving away from the battlefield, closed head injuries are frequent. Most of them are mild as the ones sustained while playing contact sports like football or boxing or when you get up in the middle of the night to go get a glass of water only to bump your head against a door. One “sees stars” for a while but is none the worse for wear apart from a bruised head and maybe ego (especially if you are like me and love to box). But can seemingly innocuous looking closed head injuries prove to be fatal? Can a “minor” fall or blow to the head kill you?

Well yes and this brings us to epidural hematomas. Let us assume you suffer a “minor” closed head injury. What you may ask exactly is “minor” closed head injury. Well it usually refers to an injury in which there is no prolonged loss of consciousness (example is a concussion after a blow to the head or a fall). As the scalp is not lacerated there is no obvious external bleeding. The patient may suffer a minor black out (loss of consciousness for a few seconds to minutes) but soon is awake and seems alert and able to answer questions.

 Imagine a boxer, who walks into a straight right. BOOM!!! Down he goes. The referee counts him out. It is a KO. The ring side doctor rushes in. The boxer eyes are glazed but he is coming around and slowly is able to get up and walk out of the ring unassisted. Nothing but a bruised ego and a black eye. He shall live to fight another day you may say as a spectator but the next day you read in the papers that the boxer was found dead in his bed. What happened here? Well the answer is simple. Even though the boxer seemed to have a suffered a “minor” closed head injury, a far more sinister injury process started silently in the brain. The blow to the head caused one of the small arteries (usually a branch of the middle meningeal artery) to start leaking blood. This blood starts collecting in the potential space between the brain and the skull (we call this the epidural space and hence a collection of blood in this space is called an epidural hematoma). As the leak is small, the patient seemingly recovers and looks fine. He may answer questions appropriately and hence may decide not to seek further medical attention. This interval where the patient (in our case our boxer) looks fine and seems to have recovered from the head blow is called the LUCID INTERVAL (the patient is lucid, makes sense and looks normal). But things are already starting to go wrong. The small leak from the ruptured blood vessel leads to progressive accumulation of blood in the epidural space. When the epidural hematoma becomes large, it has no place to expand (remember there is a rigid bony skull which prevents the blood from coming out). So the underlying brain starts getting squashed. This leads to a depression in the level of consciousness as the pressure inside the brain increases. If the elevated intracranial pressure is not brought down urgently the patient may die (we call this herniation of brain due to elevated intracranial pressure).

Could our boxer have been saved? Yes by all means. If he had been kept under observation (sometimes we like to observe patients with closed head trauma overnight in the hospital), then the first signs of raised intracranial pressure would have been picked up. Usually this is a change in the level of consciousness (the boxer would have become drowsy or hard to wake up, may have complained of headache). An urgent CT scan would have revealed the epidural collection of blood and neurosurgical evacuation of the blood would have been carried out (the skull is opened and the blood is drained out. The bleeding vessel is identified and cauterized to achieve homeostasis).

So what are the take home points from our boxer’s story?

-some “minor” looking closed head injuries can indeed prove to be fatal.

-patients should be observed after a closed head injury. If the decision is made not to go to the hospital, have a friend or family member check on the patient at multiple points.

-the earliest change in the patient’s level of consciousness warrants a stat transfer to the nearest hospital and further investigations.

Concussion during sports and return to play decisions

                                      Concussion during sports and return to play decisions

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

I recently read an article in the Archives of Neurology ( Vol 65, Sep 2008) by Dr. Lester Mayers about return to play (RTP) criteria after athletic concussion. As concussions are relatively common sport related injuries (especially in contact sports like football, rugby and boxing) I thought it would be a good idea to review some of the salient points of the article in this forum.

Concussion is a common type of traumatic brain injury and has been referred to by other names such as mild traumatic brain injury, mild head injury and minor head trauma. No good defination for concussion exists though it is frequently described as head injury with transient loss of brain function (usually a short period of loss of consciousness occurs).

Let me explain with the help of an example. I love to box (true one of the few neurologist who actually likes boxing). Lets assume I am going a couple of rounds in the ring with another guy.  A southpaw with a mean right hand. First round here we go!!!. I got my right and left combinations going. Hmmm feeling good and then it happens. I walk into his right. BOOOOOM!!! My knees give in and I hit the canvas. I see stars shining and birds twittering. The referee is asking me “Are you okay? Are you okay?” I look dazed and then slowly come around and answer I am fine. I am helped out of the ring, the fight is over!!! THERE I JUST HAD MY FIRST CONCUSSION!!!

Can I return to play/ box after a 10 mins break?

 Or rather should I return to play after a break?

Is it safe?

 Am I okay?

All these questions are addressed by Dr. Mayers in his review. Traditionally return to play decisions are made by the field side by the team physician or in the case of boxing by the doctor at the ringside. This is usually a clinical judgement with doctors relying on the documentation of resolution of symptoms at rest and during exertion to provide an estimate of the appropiate time for the athletes to resume practice and play (return to play).

A stepwise process was outlined by the Canadian Academy of Sports Medicine:

Step 1: no activity, no play and complete rest till asymptomatic and with a normal neurological examination–if your clear this then Step 2: light aerobic exercise permitted, no resistance training–if you clear this then Step 3: can return to sports specific training and resistance training—if patient remains asymptomatic then can be cleared for Step 4: non-contact training can begin–if patient remains asymptomatic then he is cleared for Step 5: full contact training —if he still remains asymptomatic then he is cleared for Step 6-full play!!! (As you can imagine these criteria are for professional atheletes but also apply for others)

As you can see there are steps to be followed before return to play can be allowed. If you fail one step you go back to the previous step and remain there till you feel better and are ready to proceed further.

Why is this important? Studies have shown that even simple concussions cause cerebral dysfunction (reflecting damage to the brain at the celluar level) and that it takes a minimum of 4 weeks for the brain to revert back to normal. If RTP occurs earlier, the athlete is at risk for a recurrent concussion and further brain damage. Even death can occur (we have all heard of boxers who die during or shortly after a bout).

Learning points from Dr. Mayers review:

1) Concussions are common.

2) Concussions can be serious and even fatal.

3) Concussions lead to cerebral dysfunction and damage to the brain at the cellular level.

4) Return to play decision should be made by a doctor skilled in this task.  A postconcussion RTP interval of at least 4 weeks is imperative (Dr. Mayers takes pain to point out that even more time may be needed to permit complete brain healing and recovery).

My advise to you:

1) Treat a concussion with respect and see a doctor if you suffer one.

2) You may feel you are okay but you are not. The brain takes time to heal completely from a concussion.

3) Do not return to play. See a doctor and get his advise. Let him decide what the return to play interval should be.

Post Concussive Syndrome

In this post I thought I would talk a little about what is called post concussive syndrome (PCS). Before we discuss PCS, we need to understand just exactly what is a concussion. Unfortunately though there has been realms of data generated on this, the word concussion still remains quite ill-defined in the medical literature. Basically it refers to a brief loss of consciousness. Lets use an example. You are in the ring against Iron Mike. You have your right and left going but walk into one of Iron Mike’s jabs. Boom your legs give away under you and you are on the mat unconscious seeing “stars”. You are “out” for a few seconds and then boom you come out and are looking up at the referee to ask “where am I? what happened to me?”

Concussion may then also be referred to as a minor head trauma or rather a minor closed head trauma accompanied by brief loss of consciousness. Closed since there is no breach in the skull. The head injury occurs but nothing penetrates the skull. Concussions are thus common and they may occur during a MVA, sports related concussions are common (injuries during football, ice-hockey, boxing and other contact sports where blows to the head may occur). The exact mechanism why there is that bried period of unconsciousness which then resolves and the person wakes up is not fully elucidated. The thinking is that during the concussion, the brain is subjected to mechanical and kinetic forces which “shake” the brain inside the rigid cranium. The brain though is free to move inside the skull, it is attached by the brainstem which is relatively immobile. So as the brain turns on its axis, there is transient dysfunction of the brainstem and this leads to loss of consciousness and the person blacks out.

Concussions are usually not life threatening and the patient comes around in a few seconds to a few minutes. Those associated with a prolonged period of unconsciousness though need to be evaluated in the hospital to make sure there is nothing serious or structural such as an intracranial hemorrhage (bleed) into the brain or outside the brain but inside the skull (epidural hematoma).  There are guidelines with respect to sports related concussion injuries and usually the doctor at the side of the play field makes a decision whether it is safe for the player to play again during that game or should he sit out the rest of the game. Multiple concussive injuries increase the risk of sudden death (no one quite knows by what exact mechanism) and hence concussive injuries in professional players like those who play football do deserve special attention.

Let us now turn to what is called PCS. Again there has a lot which has been written about PCS but this syndrome is ill-defined and its etiology is far from clear. Patients who have suffered a concussion frequently complain of memory problems following the concussion. Apart from memory difficulties these patients may complain of mood changes been too irritable or short tempered, balance problems and unsteady gait, dizziness, headaches, fatigue and lack of energy. This constellation of signs and symptoms with a preceeding history of concussion is what has been referred to as PCS. When these patients present to neurologists, we investigate them but most of the time all the tests come back as “normal”. Their imaging studies like CT scan head and MRI brain are normal.

PCS is usually treated symptomatically. If headache is the major complain we treat the headache. If dizziness is the major complaint we treat with an antivertigo drug. At times low dose antidepressants may be helpful. The natural history of this condition is good and most patients recover in due course and are able to go back to their day to day life.

Nitin Sethi, MD