cerebral concussion

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Introduction

Minor head injury resulting in an immediate & transient impairment of neural function.

Classification

Concussion grading system (Colorado, 1991):

Etiology

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

Laboratory

Diagnostic procedures

Radiology

Complications

Management

  • 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]
  • repeated cognitive & neurologic assessment may be more important than grading[2]
  • outpatient followup computerized neurocognitive testing may identify persistent symptoms not detected by other clinical assessment
  • persistent symptoms lasting > 1 hour warrant medical observation[4]
  • grade 1 concussion allows a player to return to play in the same game[3][8]
  • 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
  • grade 3 concussion
    • remove from competition
    • if symptoms brief & examination findings normalize, may return home with family with observation
    • if prolonged symptoms. persistent abnormal examination, or prior concussion, emergency department evaluation with neuroimaging
    • player with brief symptoms should be asymptomatic for 1 week before returning to competition
    • player with prolonged symptoms should be asymptomatic for 2 weeks before returning to competition
    • player with second occurrence should be asymptomatic for 4 weeks before returning to competition[5][8]
  • return to work as per recommendations for return to play
  • no treatment expedites recovery or prevents long-term cognitive impairment[9]
  • post-concussion cognitive rest
    • limit activities requiring concentration[20]
    • adjust academic workload[12]
    • strict rest following concussion not helpful for children & adolescents[21]
    • most concussion symptoms improve within 3 weeks
    • persistence of symptoms longer than 3 weeks should prompt further investigation
    • students should return to baseline academic performance before returning to extracurricular activities, including sports[12]
  • 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]
  • moderate aerobic activity after sports-related concussion reduces time to recovery[47]
  • moderate-to-vigorous physical activity within 1 week is associated with lower postconcussion symptom burden[51]
  • patient education
    • telling patients that symptoms are common after concussion significantly changes their responses[28]

Notes

More general terms

More specific terms

Additional terms

References

  1. ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1076
  2. ↑ 2.0 2.1 Journal Watch 24(2):17-18, 2004 Guskiewicz KM et al Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA 290:2549, 2003 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14625331
    McCrea M et al Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA 290:2556, 2003 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14625332
  3. ↑ 3.0 3.1 3.2 3.3 Journal Watch 24(7):58, 2004 Lovell MR et al Grade 1 or "ding" concussions in high school athletes. Am J Sports Med 32:47, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14754723
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2018, 2021.
  5. ↑ 5.0 5.1 American Academy of Neurology Concussion (mild traumatic brain injury) and the team physician: a consensus statement. Med Sci Sports Exerc. 2006 Feb;38(2):395-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16531912
  6. ↑ Physician's First Watch, Nov 2, 2010 Massachessetts Medical Society http://www.jwatch.org American Academy of Neurology Position Statement On Sports Concussion http://www.aan.com/globals/axon/assets/7913.pdf
  7. ↑ 7.0 7.1 Cunningham J et al. Concussive symptoms in emergency department patients diagnosed with minor head injury. J Emerg Med 2011 Mar; 40:262. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19157755
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Meehan WP et al Computerized Neurocognitive Testing for the Management of Sport-Related Concussions Pediatrics, Published online November 30, 2011 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22129538 <Internet> http://pediatrics.aappublications.org/content/early/2011/11/28/peds.2011-1972.abstract
  9. ↑ 9.0 9.1 9.2 9.3 Giza CC Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommitted of the American Academy of Neurology. Neurology. March 18, 2013. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23508730 <Internet> http://www.neurology.org/content/early/2013/03/15/WNL.0b013e31828d57dd.full.pdf+html
    Alessi AG et al Protecting the brain in sports: What do we really know? Neurology. March 18, 2013. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23508729 <Internet> http://www.neurology.org/content/early/2013/03/15/WNL.0b013e31828d9c13.full.pdf+html
  10. ↑ Tator CH Concussions and their consequences: current diagnosis, management and prevention. CMAJ. July 22, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23877672 <Internet> http://www.cmaj.ca/content/early/2013/07/22/cmaj.120039
    Purcell L et al for the Canadian Concussion Collaborative Five things to know about ...Concussions CMAJ. July 22, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23877671 <Internet> http://www.cmaj.ca/content/early/2013/07/22/cmaj.120511
  11. ↑ Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology. 1997 Mar;48(3):581-5. PMID: https://www.ncbi.nlm.nih.gov/pubmed/9065530
  12. ↑ 12.0 12.1 12.2 Halstead ME et al Returning to learning following a concussion. Pediatrics. Oct 27, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24163302 <Internet> http://pediatrics.aappublications.org/content/early/2013/10/23/peds.2013-2867.full.pdf+html
  13. ↑ Insitute of Medicine Sports-Related Concussions in Youth: Improving the Science, Changing the Culture ( 2013 ) http://books.nap.edu/catalog.php?record_id=18377
  14. ↑ Mansell JL, Tierney RT, Higgins M et al Concussive signs and symptoms following head impacts in collegiate athletes. Brain Inj. 2010;24(9):1070-4. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20597635
  15. ↑ Brown NJ et al Effect of Cognitive Activity Level on Duration of Post- Concussion Symptoms. Pediatrics. January 6, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24394679 <Internet> http://pediatrics.aappublications.org/content/early/2014/01/01/peds.2013-2125.abstract
  16. ↑ 16.0 16.1 Shahim P et al Blood Biomarkers for Brain Injury in Concussed Professional Ice Hockey Players. JAMA Neurol. Published online March 13, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24627036 <Internet> http://archneur.jamanetwork.com/article.aspx?articleid=1846623
    Gatson J and Diaz-Arrastia R Tau as a Biomarker of Concussion JAMA Neurol. Published online March 13, 2014. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24627000 <Internet> http://archneur.jamanetwork.com/article.aspx?articleid=1846622
  17. ↑ 17.0 17.1 17.2 17.3 Eisenberg MA et al. Duration and course of post-concussive symptoms. Pediatrics 2014 Jun; 133:999 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24819569 <Internet> http://pediatrics.aappublications.org/content/133/6/999
  18. ↑ Ontario Neurotrauma Foundation Guidelines for Diagnosing and Managing Pediatric Concussion. First edition. June 2014 Recommendations for Healthcare Professionals. http://onf.org/system/attachments/257/original/GUIDELINES_for_Diagnosing_and_Managing_Pediatric_Concussion_-_RECOMMENDATIONS_FOR_HCP__June_19_FINAL.pdf
  19. ↑ 19.0 19.1 Kirschen MP et al Legal and ethical implications in the evaluation and management of sports-related concussion. Neuorology. July 9, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25008394 <Internet> http://www.neurology.org/content/early/2014/07/09/WNL.0000000000000613.full.pdf+html
    Deibert E Concussion and the neurologist: A work in progress. Neuorology. July 9, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25008391 <Internet> http://www.neurology.org/content/early/2014/07/09/WNL.0000000000000629.full.pdf+html
  20. ↑ 20.0 20.1 Sport Concussion Assessment Tool. 3rd edition. SCAT3 http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/JSM/A/JSM_23_2_2013_02_14_MCCRORYY_200872_SDC2.pdf
    Sport Concussion Assessment Tool for children ages 5-12 years Child-SCAT3. http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/JSM/A/JSM_23_2_2013_02_14_MCCRORYY_200872_SDC3.pdf
  21. ↑ 21.0 21.1 Thomas DG et al Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Published Online January 5, 2015 Pediatrics. vol 135, number 2, February 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25560444 <Internet> http://pediatrics.aappublications.org/content/early/2015/01/01/peds.2014-0966.full.pdf
    Meehan III WP, Bachur RG The Recommendation for Rest Following Acute Concussion. Published Online January 5, 2015 Pediatrics. vol 135, number 2, February 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25560439 <Internet> http://pediatrics.aappublications.org/content/early/2015/01/01/peds.2014-3665.full.pdf+html
  22. ↑ 22.0 22.1 Meier TB et al. Recovery of cerebral blood flow following sports-related concussion JAMA Neurol 2015 Mar 2; [e-pub] <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25730545 <Internet> http://archneur.jamanetwork.com/article.aspx?articleid=2173271
  23. ↑ 23.0 23.1 Dompier TP et al Incidence of Concussion During Practice and Games in Youth, High School, and Collegiate American Football Players. JAMA Pediatr. Published online May 04, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25938704 <Internet> http://archpedi.jamanetwork.com/article.aspx?articleid=2281575
  24. ↑ 24.0 24.1 Ransom DM et al Academic Effects of Concussion in Children and Adolescents. Pediatrics. May 11, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25963014 <Internet> http://pediatrics.aappublications.org/content/early/2015/05/06/peds.2014-3434
  25. ↑ 25.0 25.1 AMA News Room. June 9, 2015 New AMA Policy Aims to Reduce Risk of Concussion in Youth Sports.
  26. ↑ 26.0 26.1 26.2 Strain JF, Womack KB, Didehbani N et al Imaging Correlates of Memory and Concussion History in Retired National Football League Athletes. JAMA Neurol. 2015 May 18 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25985094
  27. ↑ 27.0 27.1 27.2 Comstock RD et al An Evidence-Based Discussion of Heading the Ball and Concussions in High School Soccer. JAMA Pediatr. Published online July 13, 2015. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26168306 <Internet> http://archpedi.jamanetwork.com/article.aspx?articleid=2375128
  28. ↑ 28.0 28.1 Iverson GL, Silverberg ND, Mannix R et al Factors Associated With Concussion-like Symptom Reporting in High School Athletes. JAMA Pediatr. 2015 Oct 12:1-9 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26457403
  29. ↑ 29.0 29.1 Fralick M, Thiruchelvam D, Tien HC, Redelmeier DA. Risk of suicide after a concussion CMAJ February 8, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26858348 <Internet> http://www.cmaj.ca/content/early/2016/02/08/cmaj.150790
  30. ↑ 30.0 30.1 Kerr ZY, Zuckerman SL, Wasserman EB et al Concussion Symptoms and Return to Play Time in Youth, High School, and College American Football Athletes. JAMA Pediatr. Published online May 02, 2016 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27135397
  31. ↑ 31.0 31.1 Arbogast KB, Curry AE, Pfeiffer MR et al. Point of health care entry for youth with concussion within a large pediatric care network. JAMA Pediatr 2016 May 31 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27244368 <Internet> http://archpedi.jamanetwork.com/article.aspx?articleid=2526071
  32. ↑ 32.0 32.1 FDA News Release. August 22, 2016 FDA allows marketing of first-of-kind computerized cognitive tests to help assess cognitive skills after a head injury. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm517526.htm
  33. ↑ 33.0 33.1 Elbin RJ, Sufrinko A, Schatz P et al Removal From Play After Concussion and Recovery Time. Pediatrics Aug 2016, e20160910 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27573089
  34. ↑ 34.0 34.1 Smith NA, Chounthirath C, Xiang H Soccer-Related Injuries Treated in Emergency Departments: 1990-2014 Pediatrics Sep 2016, e20160346 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27621412
  35. ↑ Novak Z, Aglipay M, Barrowman N et al Association of Persistent Postconcussion Symptoms With Pediatric Quality of Life. JAMA Pediatr. Published online October 24, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27775762 <Internet> http://jamanetwork.com/journals/jamapediatrics/article-abstract/2569451
    Polster DR, Giza CC, Babikian T. Health-Related Quality of Life After Concussion. How Can We Improve Management of Care? JAMA Pediatr. Published online October 24, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27775752 <Internet> http://jamanetwork.com/journals/jamapediatrics/fullarticle/2569449
  36. ↑ 36.0 36.1 Grool AN, Aglipay M, Momoli F et al Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504-2514 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27997652 <Internet> http://jamanetwork.com/journals/jama/fullarticle/2593568
    Chrisman SP, Rivara FP Physical Activity or Rest After Concussion in Youth. Questions About Timing and Potential Benefit. JAMA. 2016;316(23):2491-2492 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27997637 <Internet> http://jamanetwork.com/journals/jama/article-abstract/2593551
  37. ↑ 37.0 37.1 Stewart WF, Kim N, Ifrah CS et al Symptoms from repeated intentional and unintentional head impact in soccer players. Neurology Feb 1, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28148633 <Internet> http://www.neurology.org/content/early/2017/02/01/WNL.0000000000003657
    Lingsma H, Maas A Heading in soccer. More than a subconcussive event? Neurology Feb 1, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28148628 <Internet> http://www.neurology.org/content/early/2017/02/01/WNL.0000000000003679
  38. ↑ 38.0 38.1 Snook ML, Henry LC, Sanfilippo JS, Zeleznik AJ, Kontos AP. Association of concussion with abnormal menstrual patterns in adolescent and young women. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28672284 JAMA Pediatr 2017 Jul 3 http://jamanetwork.com/journals/jamapediatrics/fullarticle/2633491
  39. ↑ 39.0 39.1 Cusimano MD et al. Assessment of head collision events during the 2014 FIFA World Cup tournament. JAMA 2017 Jun 27; 317:2548 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28655000 <Internet> http://jamanetwork.com/journals/jama/article-abstract/2633899
  40. ↑ 40.0 40.1 Veliz P, McCabe SE, Eckner JT, Schulenberg JE. Prevalence of concussion among US adolescents and correlated factors. JAMA 2017 Sep 26; 318:1180. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28973604
  41. ↑ 41.0 41.1 Neidecker JM, Gealt DB, Luksch JR, Weaver MD. First-Time Sports-Related Concussion Recovery: The Role of Sex, Age, and Sport. J Am Osteopathic Assoc October 2017, Vol. 117, 635-642 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28973180 <Internet> http://jaoa.org/article.aspx?articleid=2656577
  42. ↑ 42.0 42.1 42.2 Johnson JJ, Loeffert AC, Stokes J et al Association of salivary microRNA changes with prolonged concussion symptoms. JAMA Pediatr 2017 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29159407
    Meehan WP 3rd, Mannix R. Promise of salivary microRNA for assessing concussion. JAMA Pediatr 2017 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29159406
  43. ↑ 43.0 43.1 Brooks M FDA Clears First Blood Test to Aid in Concussion Diagnosis. Medscape - Feb 14, 2018. https://www.medscape.com/viewarticle/892683
    FDA News Release. Feb 14, 2018 FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm596531.htm
  44. ↑ 44.0 44.1 DePadilla L, Miller GF, Jones SE, Peterson AB, Breiding MJ. Self-Reported Concussions from Playing a Sport or Being Physically Active Among High School Students - United States, 2017. MMWR Morb Mortal Wkly Rep 2018;67:682-685 https://www.cdc.gov/mmwr/volumes/67/wr/mm6724a3.htm
  45. ↑ Wasserman EB, Kerr ZY, Zuckerman SL, Covassin T. Epidemiology of Sports-Related Concussions in National Collegiate Athletic Association Athletes From 2009-2010 to 2013-2014: Symptom Prevalence, Symptom Resolution Time, and Return-to-Play Time. Am J Sports Med. 2016 Jan;44(1):226-33. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26546304
  46. ↑ Halstead ME, Walter KD, Moffatt K. COUNCIL ON SPORTS MEDICINE AND FITNESS. Sport-Related Concussion in Children and Adolescents. Pediatrics. November 2018. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/30420472 <Internet> http://pediatrics.aappublications.org/content/early/2018/11/08/peds.2018-3074
  47. ↑ 47.0 47.1 Leddy JJ, Haider MN, Ellis MJ et al Early Subthreshold Aerobic Exercise for Sport-Related Concussion. A Randomized Clinical Trial. JAMA Pediatr. Published online February 4, 2019. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30715132 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2723523
    Chrisman SPD Exercise and Recovery Time for Youth With Concussions. JAMA Pediatr. Published online February 4, 2019. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30715089 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2723516
  48. ↑ 48.0 48.1 Ault A Saliva Test a Potential Game Changer for Sports-Related Concussion? Medscape - Mar 24, 2021. https://www.medscape.com/viewarticle/948035
    Di Pietro V, O'Halloran P, Watson CN et al Unique diagnostic signatures of concussion in the saliva of male athletes: the Study of Concussion in Rugby Union through MicroRNAs (SCRUM) Brit J Sports Med. 2021. March 23 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33757972 Free article https://bjsm.bmj.com/content/early/2021/02/09/bjsports-2020-103274
  49. ↑ 49.0 49.1 George J Cognitive Effects Persist After Concussion At 1 year, poor cognitive outcomes were common in people with mild TBI. MedPage Today February 18, 2022 https://www.medpagetoday.com/neurology/headtrauma/97290
    Christman Schneider AL, Huie JR, Boscardin WJ et al Cognitive Outcome 1 Year After Mild Traumatic Brain Injury: Results From the TRACK-TBI Study. Neurology. 2022. Feb 16 PMID: https://www.ncbi.nlm.nih.gov/pubmed/35173018 https://n.neurology.org/content/early/2022/01/19/WNL.0000000000200041
  50. ↑ 50.0 50.1 NEJM Knowledge+
    Harmon KG, Clugston JR, Dec K et al American Medical Society for Sports Medicine position statement on concussion in sport. Br J Sports Med. 2019 Feb;53(4):213-225 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30705232
  51. ↑ 51.0 51.1 Ledoux A-A et al. Optimal volume of moderate-to-vigorous physical activity postconcussion in children and adolescents. JAMA Netw Open 2024 Feb 16; 7:e2356458 PMID: https://www.ncbi.nlm.nih.gov/pubmed/38363567 PMCID: PMC10873766 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2815228
  52. ↑ 52.0 52.1 Nowinski CJ et al Spontaneous Headshake after a Kinematic Event (SHAAKE): Evaluating the Utility of a Potential New Sign in the Diagnosis of Concussion. Diagnostics. 2024 14(20):2314 Oct 17
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