4/26/15 ¡ Concussion Overview Overview Overview of History Epidemiology Concussions Recognition Cumulative Injuries CSMS April 28th 2014 Imaging/Biomarkers David Wang MD, MS Treatment/Rehabilitation Elite Sports Medicine Prevention Director of Sports Medicine Quinnipiac University The thoughts about concussions have really changed in the past 20 years The Old Way The management of concussions has been understood for a long time before it was in vogue to talk about them. It is now much easier as a practitioner to care for them with the help of the media and legislation. Now with concussions we are also Currently dealing with: Overanalyzing We certainly are recognizing and caring for Confusion on concussions concussions much better. Liability Although there has been much progress we Chronic traumatic encephalopathy still see examples of mismanagement every day. School accommodations Return to sports/retirement 1 ¡
4/26/15 ¡ Concussion History Hippocrates made numerous comments on Let’s briefly look at where we brain injury. were 2500 years ago “In cerebral concussion whatever the cause, the patient becomes speechless, ...falls down immediately, loses their speech, cannot see or hear” Concussion History Sports Concussion History Not until the first century AD The main sports of the time did Rhazes describe were combative sports. concussion and differentiate Galen of Pergamon it from a more severe head documented numerous injury. gladiator injuries. He described concussion as Described several post an abnormal physiological accident symptoms such as state without gross traumatic dizziness. lesions of the brain. History of Concussion In the middle ages sports were not well organized but revolved Fairly close to where we are around jousts, duels, and fighting. today Physicians further documented: the faltering of speech, impairment of memory, dullness of understanding, and short lived symptoms of tinnitus and photophobia. 2 ¡
4/26/15 ¡ Definition Epidemiology Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain; induced by The CDC estimates there are biomechanical forces (Zurich 2012) 3.5 million sport related Several common features concussions per year. Concussions represent 10% Rapid onset of short lived neurologic symptoms. of all sports injuries No structural injury. sustained by high school athletes. Resolution of the clinical and cognitive symptoms typically follows a sequential course. Signs of Concussion Signs of Concussion Vacant stare Incoordination Delayed responses Nausea/vomiting Inattention Inappropriate emotionality Disorientation Memory problems Slurred/Incoherent speech Loss of consciousness Perseveration Headaches Pearl Top 10 Symptoms of Concussion Headache A key point when evaluating these patient’s is that there is Feeling slowed down more than one cause of headache in an athlete who has been Difficulty concentrating struck on the head. Dizziness Concussion Fogginess Inter-cranial bleed Fatigue Extra-cranial injury Blurry or double vision Sensitivity to light Cervical injury Memory problems Previous headache issues Balance problems 3 ¡
4/26/15 ¡ Concussion Symptoms Odd Symptoms after Concussion Voice changing Sweating Another way at looking at Right to left handed concussion symptoms is to Heart rate and blood pressure simplify them into 4 changes categories: Cognitive, Physical, Emotional, and Pseudo-seizure Sleep. Increased urination Better math skills Vestibular Symptoms Concussion and Vision 67% of the neural connections within the brain are involved with some aspect of vision. The vestibular system is a Such as visual input, visual critical system that is perception, and visual responsible for balance as integration. well as vision. Hence why visual changes are so common after concussion. Visual Issues from Concussion Accommodative Insufficiency Blurry Vision Convergence Insufficiency Double Vision Light Sensitivity Ocular-Motor Dysfunction Pursuit Pathway Reduced Visual Processing Speed 4 ¡
4/26/15 ¡ Visual Symptoms Balance and Concussion Ocular focusing and tracking are common concussion problems that affect school Balance deficits are participation. commonly seen after Reading concussion. In some cases these can be Writing severe requiring assistance Note taking with ambulation. Walking hallways Balance Measurements Dysautonomia Seen fairly commonly in the pediatric concussion population Tachycardia Orthostatic hypotension Hypertension Just recently “red hot ears” Post-Concussive Syndrome Injury Locations and Symptoms Underlying psychological issues “Bad” concussion vs. mTBI “Microscopic Macroscopic” head injury Genetics? Female Gender (neck, hormonal, other) Injury type (i.e. Overlapping Concussion Syndrome) Toledo, Neurosci Biobehav Rev. 2012 A missed diagnosis (vestibular, cervical, etc) 5 ¡
4/26/15 ¡ Cumulative Injuries Chronic Traumatic Encephalopathy Stage 1 - Headache and loss of attention Chronic Traumatic Encephalopathy (formerly Stage 2 - Depression, anger outbursts, and Dementia Pugilistica) short-term memory loss Stage 3 - Executive dysfunction and cognitive Overlapping Concussion Syndrome impairment Second Impact Syndrome Stage 4 - Dementia, aggression, and word finding difficulties CTE Pathology CTE Contributors Tau protein deposition around vessels (3R, 4R) . Genetics -Apoprotein E Occurs in the deep portions of the sulcus. Prion? Appears to start in the frontal lobes. Tauopathies (Just a few) Overlapping Concussion Syndrome • Alzheimer’s disease • Pick’s disease • Down Syndrome Charts from 615 patients were reviewed and 419 met criteria for analysis. • Creutzfeldt-Jakob disease • Tuberous Sclerosis 400 “normal” concussions and 19 OCS patients identified. • Prion protein cerebral amyloid angiopathy • Down Syndrome • Frontaltemporal dementia and parkinsonism linked to chromosome 17 6 ¡
4/26/15 ¡ Overlapping Concussion Syndrome Results Symptomatic patients in recovery but not resolved who suffer another blow to the head have a prolonged recovery course. In our concussion clinic 4.5% of the patients seen had OCS. Yet another reason to keep athletes who remain symptomatic from concussion out of harms way, even if they are improving. Other Insults Second Impact Syndrome Well documented yet rare event often There are other insults to a concussed patient that can resulting in death. worsen or prolong the concussion symptoms. Any types of physical or emotional stress can worsen Injury occurs after a second blow is received symptoms. while still symptomatic from a previous head injury. Things like elective surgery (even dental) or changes in family dynamics (divorce) can worsen symptoms. Loss of vasoregulation is felt to be cause of Stress from missing school work. cerebral swelling and brain herniation. Imaging Imaging fMRI measures brain function via blood flow and oxygenation. Has demonstrated lower CT scans do not show changes frontal cortex activity following concussion. MRI increased sensitivity for cerebral edema, Resting State Networks hemosiderin deposition, and cerebral contusion. Arterial Spin Labeling MRI can measure cerebral perfusion 7 ¡
4/26/15 ¡ Imaging Bioenzyme Markers MR Spectroscopy (N-Acetylaspartate levels S-100 associated with energy impairment) Neuron-specific enolase (NSE) MR Elastography (measures brain tissue Myelin basic protein (MBP) stiffness) GFAP DTI is used to measure white matter integrity Biomarkers Biomarkers SNTF (Brain enriched protein calpain-cleaved Tau proteins are also currently being alpha II-spectin N-terminal fragment) investigated as a biomarker in concussion. High levels of SNTF after brain injury Tau -C levels higher in post concussion corresponds to persistent symptoms after samples. Tau-A levels correlated with injury (axonal injury) duration of post concussive symptoms. Tested 1 hour to 144 hours after the injury (Shahim, J Neurotrauma 2015) (Simon, J Neurotrauma 2014) On the field first aid Treatment of Concussion for head injuries If concussion suspected remove from the game/practice. Do not allow to return even if athlete appears normal. Suggest evaluation by medical provider before return to sports. If athletes condition appears worrisome or is worsening then immediate medical treatment is indicated. If unconscious first evaluate for breathing and cardiac activity. If not breathing or pulseless then CPR/AED. Protect the neck of the unconscious athlete. Immediate medical treatment is indicated. 8 ¡
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