Concussion Lecture Flashcards
True or false: concussions can result from blows to areas other than the head
True
Are concussions a functional disturbance, or a structural injury? What, then, are the usual imaging findings?
Functional disturbance (normal imaging)
What is the most common reason for not reporting concussions? Second most common?
- Did not think it was serious enough
2. Did not want to leave the game
What is the pathophysiology of concussions?
Increased levels of K probably activate ATP-dependent Na/K pumps, creating a need for more glucose and adding to the metabolic stress (fuel need/ fuel delivery mismatch)
What happens to glutamate with concussions?
Increases extracellularly, and may contribute to the increase K flux
What is the major excitatory neurotransmitter in the CNS? Inhibitory?
Glutamate
GABA
What are the metabolic disruptions that occur with concussions?
Brain’s need for glucose increases acutely, and cerebral blood flow and oxidative metabolism are reduced
What causes the regional reduction of cerebral blood flow in a concussion?
Increase in intracellular Ca
What is the role of APO-E?
APO-E genes encode for apolipoprotein production, which is responsible for lipid transport in the brain, maintaining neuronal structural integrity, and recovery after neurological injury
What is the role of APO-E epsilon 4 in the pathophysiology of concussions?
Risk factor for alzheimer’s–inhibits neurite growth
What is the most common risk factor for concussions?
h/o previous concussions
What is the most common area of the head that is hit with concussions?
Temporal region
Where do concussions come from with soccer?
Head to head contact–not head to ball
What happens to head velocity with concussed athletes?
Increased velocity
Where is the most risky area of the head to be hit in? Why?
Top of the head–Allows max force through the head and neck
Is there an association between the degree of amnesia and prognosis?
No
When are seizures particularly bad post concussion?
Later on–immediately after generally do not carry a bad prognosis
What is the role of grading systems in concussions? Why?
Have fallen out of favor–not useful, and recovery is very patient-dependent
What is in the ddx for concussion?
-Subdural hematoma
-
What are the s/sx of subdural hematomas?
- Decreased LOC
- HA
- Pupil inequality
- Motor deficits
Pupil inequality = ?
More serious than a concussion
What are the s/sx of epidural hematomas?
- Decreased LOC followed b a lucid interval
- other concussive syndromes
- Late onset ipsilateral dilated pupil
What are the s/sx of subarachnoid hemorrhage?
- Worst ever HA
- Photophobia
- n/v
- Neck stiffness
What is the work up of subarachnoid hemorrhages?
head CT
Fundoscopic exam
LP
Which lobes are most commonly affected with intracerebral hemorrhage?
Frontal lobes
What is the mortality rate of intracerebral hemorrhages?
Low if pt presents conscious before intervention
What are the immediate problems with intracerebral hemorrhages?
- ABCs
- Evaluate for C-spine
- move if pt is conscious and without c-spine injury
Should the helmet be removed with head injuries?
Hockey–yes unless goalie
Football–no
What is the role of orientation questions (person, place, time) in checking for concussions?
Not as useful as memory questions
What are the cognitive assessments immediate post concussion?
- 3-5 word repetition
- Serial 7’s
- Months of year backward
What are the findings of a pronator drift test with concussive pts?
More like romberg than actual pronator drift
How do you prevent athletes from reentering the game?
Take away helmet
What is the sideline test that can be performed for concussive pts?
SCAT 3
What are the current recommendations with concussions?
No return to play same day, regardless of symptoms
What is the management for concussions?
Physical and cognitive rest
Why should there be physical rest post concussion?
Increased blood flow overloads area that is trying to heal, and irritation of the brain
What should be avoided post concussion?
No fun (no music, no screens, no videogames/tv)
What is the step-wise process to returning to play? (6)
- Rest
- Light aerobic exercise
- Sports specific
- Non-contact drills
- Full contact
- Game play
How much time should take place between steps of returning to play?
24 hours
What happens when HAs / s/sx occur along the continuum of return to play?
Drop them a level for 24 hours
Does taking medication still count in the stepwise return to play?
Anything that is not at baseline is not allowable
Concussion s/sx lasting longer than how long require further workup?
Weeks
Why should waking up a post concussive patient be avoided?
REM sleep is healing
Why are NSAIDs contraindicated with post-concussive s/sx?
Inhibit platelet function and increases bleeding risk
What is second impact syndrome?
Rapid brain swelling and herniation following a second head injury in an athlete still recovering
What is the prognosis for second impact syndrome?
- 50% mortality
- If no, significant neurological symptoms
Who gets SIS?
Young people d/t developing brain
What is post concussive syndrome?
Concussion s/sx persist weeks later
What are the medications that may be useful in post-concussive syndrome?
Anti-depressants
What causes posttraumatic seizures?
Traumatic depolarizations of neurons
Do immediate post concussive seizures usually require anti-epileptic seizures? How about ones that occur a week later?
No
Little before or after a Week later = need long term antiepileptic seizures
What are the s/sx of CTE?
CNS dysfunction–parkinosnianism, ataxia, and behavioral changes
What is the protein that is implicated in the pathogenesis for CTE?
Apolipoprotein epsilon 4
Do helmet prevent concussions?
No–it is used to prevent other forms of head trauma
Do mouthgaurds protect against concussions?
No–reduce dental trauma
What is the problem with the Virginia tech study?
Based on hypothesis of some arbitrary velocity to cause concussions
What is the best way to prevent concussions in sports?
Change rules to reduce injuries
What is the role of neuropsych testing?
Tests measure a broad range of cognitive function–very expensive and not reliable
