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PubMed2001

Base rate of post-concussion symptoms among normal people and its neuropsychological correlates.

OBJECTIVE: To explore the base rate of symptoms similar to those of post-concussion symptoms (PCS) among a group of participants without head injury. The effect of subjective complaints upon cognitive functioning was also examined. DESIGN: A cross-sectional study. PARTICIPANTS: A total of 85 participants without head injury, other identifiable neurological diseases or psychiatric diseases were recruited. OUTCOME MEASURES: These included Rivermead Post-concussion Symptoms Checklist, Cognitive Failures Questionnaire, Colour Trails Test, Stroop Word-Colour Test, Paced Auditory Serial Addition Test, Symbol Digits Modality Test, Word Fluency Test, Design Fluency Test, Digits Forward and Backward Span Test, and Modified Six Elements Test. RESULTS: A relatively high proportion of the participants reported symptoms similar to those of patients with PCS. These included longer time to think (65.9%), forgetfulness (58.9%), poor concentration (58.9%), fatigue easily (53.5%), and sleep disturbances (50.6%). Gender effect was not significant for either the individual item or the total score of the Rivermead Post-concussion Symptoms Checklist. Moreover, there was no difference found between low symptom reporters and high symptom reporters in terms of attention, working memory, mental fluency, and strategy allocation. CONCLUSION: The base rates of symptoms were consistent with previous studies among the nonclinical groups. However, persons reporting a high score of concussion-like symptoms did not perform less well than those reporting a low score of symptoms in attention, working memory, mental fluency and strategy allocation.

Adult↗
PubMed2006

Bench to bedside: evidence for brain injury after concussion--looking beyond the computed tomography scan.

The emergency management of cerebral concussion typically centers on the decision to perform a head computed tomography (CT) scan, which only rarely detects hemorrhagic lesions requiring neurosurgery. The absence of hemorrhage on CT scan often is equated with a lack of brain injury. However, observational studies revealing poor long-term cognitive outcome after concussion suggest that brain injury may be present despite a normal CT scan. To explore this idea further, the authors reviewed the evidence for objective neurologic injury in humans after concussion, with particular emphasis on those with a normal brain CT. This evidence comes from studies involving brain tissue pathology, CT scanning, magnetic resonance image (MRI) scanning, serum biomarkers, formal cognitive and balance tests, functional MRI, positron emission tomography, and single-photon emission computed tomography scanning. Each section is accompanied by technical information to help the reader understand what these tests are, not to endorse their use clinically. The authors discuss the strengths and weaknesses of the evidence in each case. These reports make a compelling case for the existence of concussion as a clinically relevant disease with demonstrable neurologic pathology. Areas for future emergency medicine research are suggested.

Axons↗
PubMed2004

Duration of cognitive impairment after sports concussion.

OBJECTIVE: We sought to determine the duration of cognitive impairment after sports concussion. METHODS: We conducted a study with a prospective design in which 729 athletes underwent preseason baseline testing by being administered a computerized neuropsychological test battery, followed by retesting at regular intervals after they sustained sports-related concussions. A control group consisting of nonconcussed athletes drawn from the same baseline population underwent testing at parallel intervals. RESULTS: Cognitive impairment in this primarily American Academy of Neurology Grade II sample of boxing concussions was apparent on the day of injury and at 1 to 2 days postinjury. Recovery of cognitive performance occurred during the 3- to 7-day interval. Comparison with control subjects showed that absent or attenuated practice effects, in addition to frank deterioration from baseline, were indications of recent concussion. CONCLUSION: The present findings of recovery during the 3- to 7-day interval postinjury are consistent with the American Academy of Neurology Grade II return-to-play practice parameters suggesting a 1-week time-out from participation in contact sports.

Adolescent↗
PubMed2004

Concussion in professional football: neuropsychological testing--part 6.

OBJECTIVE: The National Football League (NFL) neuropsychological testing program is reviewed, and neuropsychological test data are presented on various samples of NFL athletes who sustained concussion (mild traumatic brain injury, MTBI). METHODS: This study evaluated post-MTBI neuropsychological testing of NFL players from 1996 to 2001. All athletes completed a standardized battery of neuropsychological tests and underwent postinjury neuropsychological testing within a few days after concussion. Test scores were compared with baselines using analysis of variance for athletes having on-field memory dysfunction, three or more concussions, or 7+ days out from practice and play. RESULTS: The MTBI group did not display significant neuropsychological dysfunction relative to baseline scores within a few days of injury. However, a subsample of the injured athletes who displayed on-field memory dysfunction performed significantly more poorly on two of the memory tests. The neuropsychological test results of a group of athletes with a history of three or more MTBIs did not differ significantly compared with a group who had fewer than three concussions or compared with league-wide normative data. The neuropsychological performance of athletes who were out from full participation 7+ days was not significantly different from the group who returned to play within 7 days or the norms. CONCLUSION: Neuropsychological testing is used within the overall medical evaluation and care of NFL athletes. Players who experience MTBI generally demonstrate rapid recovery of neuropsychological performance, although poorer neuropsychological test results were related to on-field memory dysfunction. NFL players did not demonstrate evidence of neurocognitive decline after multiple (three or more) MTBIs or in those players out 7+ days. The data show that MTBI in this population is characterized by a rapid return of neuropsychological function in the days after injury.

Athletic Injuries↗
PubMed2006

Gait stability following concussion.

INTRODUCTION: The need to identify functional impairment following a brain injury is critical to prevent reinjury during the period of recovery. However, little is known about the effect of concussion on dynamic motor function. PURPOSE: The purpose of this study was to examine the effect of concussion on a dynamic motor task under conditions of divided and undivided attention over the course of 28 d. METHODS: Fifteen subjects with concussions (CONC) and 15 uninjured controls (NORM) were observed while walking with undivided attention and while concurrently completing simple mental tasks. The CONC were assessed within 48 h of injury and again at 5, 14, and 28 d postinjury. The NORM were evaluated at the same time intervals. Whole-body motion data were collected to examine displacement and velocity of the center of mass (COM) and the maximum separation between the COM and center of pressure (COP). Three-way repeated-measures mixed-design ANOVA and Tukey post hoc tests were completed to determine differences between group, task, and testing day (P<0.05). RESULTS: Several aspects of gait stability were compromised in the CONC group for up to 4 wk after injury. CONC were found to walk significantly slower during dual tasks on all testing days when compared with the uninjured controls. The injured subjects were also found to have greater sway and sway velocity than controls when attention was divided for up to 28 d postinjury. CONCLUSION: The findings of this study suggest that concussion may have long-term observable and measurable effects on the control of gait stability.

Adult↗
PubMed1999

Early prediction of persisting post-concussion symptoms following mild and moderate head injuries.

OBJECTIVES: King (1996) reported that a combination of emotional, organic and neuropsychological measures taken at 7-10 days following mild and moderate head injury may significantly help predict patients most likely to suffer persisting post-concussion symptoms (PCS) at three months post-injury. This study investigated a cross-validation sample (N = 57) to determine whether the results would be replicated for the early prediction of longer-term sufferers (i.e. those with persisting symptoms at 6 months post-injury). DESIGN: Multiple regression analyses were used in which scores on the Hospital Anxiety and Depression Scale, Impact of Event Scale, Short Orientation Memory and Concentration Test, Rivermead Post-Concussion Symptoms Questionnaire and Post-Traumatic Amnesia taken at 7-10 days post-injury were the independent measures. Scoring on the Rivermead Post-Concussion Symptoms Questionnaire taken at 6 months post-injury was the dependent measure. METHODS: Sixty-six consecutive patients admitted to any trauma ward in Oxfordshire with a mild or moderate head injury were recruited from a largescale randomized controlled sample. The assessment measures were administered at 7-10 days post-injury and the Rivermead Post-Concussion Symptoms Questionnaire at 6 months post-injury. Nine patients were unable to be followed up, leaving an active sample of 57. RESULTS: The cross-validation data confirmed that a similar combination of measures to that found in the original study best predicted persisting PCS but that the strength of prediction diminished for the longer term prediction (i.e. 6 months post-injury). CONCLUSIONS: The Hospital Anxiety and Depression Scale, Impact of Even Scale and Post-Traumatic Amnesia in combination are recommended as useful prognostic screening instruments for predicting persisting PCS, but great caution is required if they are used to aid predictions beyond 3 months post-injury.

Adolescent↗
PubMed1992

Cerebral concussion in sport. Management and prevention.

This article explains the various stresses (tensile, compressive, and shearing) that can affect the brain, and how they may produce the different types of brain injury. The biomechanical forces and dynamics that produce coup versus contra coup injury are covered, as are the common intracranial athletic head injuries, i.e. concussion and the various intracranial haematomas (epidural, subdural, subarachnoid and intracerebral). Though less common in occurrence, because their outcome is so catastrophic, space is also devoted to the recognition, the treatment and (especially in the latter case) the prevention of the malignant brain oedema syndrome of the adolescent and the second impact syndrome of the adult. A major emphasis of this paper is the recognition of the 3 grades of cerebral concussion and the delineation of clear guidelines as to when it is safe to return to collision sports after sustaining such injuries, for the first, second or third time during a given season. Clear guidelines are also presented as to when to discontinue collision sport competition for the remainder of the season after multiple concussions. Because of the concern for the second impact syndrome, the requirement to never allow an athlete with postconcussion syndrome symptoms to return to competition is emphasised. Also covered is the prevention of head injuries, which sports are at greatest risk, and the need for additional research on the cumulative effects of concussion.

Athletic Injuries↗
PubMed1998

Concussive convulsions. Incidence in sport and treatment recommendations.

Concussive convulsions (CC) are nonepileptic phenomena which are an immediate sequelae of concussive brain injury. Although uncommon, occurring with an approximate incidence of 1 case per 70 concussions, these episodes are often confused with post-traumatic epilepsy which may occur with more severe structural brain injury. The pathophysiological mechanism of CC remains speculative, but may involve a transient traumatic functional decerebration with loss of cortical inhibition and release of brainstem activity. The phenomenology of the CC is somewhat akin to convulsive syncope, with an initial tonic phase occurring within 2 seconds of impact, followed by a clonic or myoclonic phase which may last several minutes. Lateralising features are common during the convulsions. There is no evidence of structural or permanent brain injury on clinical assessment, neuropsychological testing or neuroimaging studies. Long term outcome is universally good with no evidence of long term epilepsy and athletes are usually able to return to sport within 2 weeks. The correct management of these episodes centres on the appropriate management of the associated concussive injury and the exclusion of other cerebral injury by medical assessment. The CC requires no specific management beyond immediate onfield first aid measures such as protection of the airway. Antiepileptic therapy is not indicated and prolonged absence from sport is unwarranted. These episodes, although dramatic, are relatively straightforward to manage and all team physicians and those involved in athlete care need to be aware of this condition.

Adult↗
PubMed2005

Management of sport-related concussion in young athletes.

Sport-related head injuries are a common clinical problem. Most head injuries in young athletes are mild traumatic brain injuries or concussions. The highest number of sport-related concussions has been reported in American football. In addition to the well described physical and psychosocial growth, there is ongoing neurocognitive development of the brain during childhood and through adolescence. This developmental process has direct implications in the assessment and management of head injuries in young athletes. Research on the management and long-term outcome following brain injuries in young athletes is limited. Traditionally, the assessment of concussion has been based on clinical history and physical and neurological examination. Increasingly, neuropsychological testing, especially computerised testing, is providing objective measures for the initial assessment and follow-up of young athletes following brain injuries. Numerous guidelines have been published for grading and return to play criteria following concussion; however, none of these have been prospectively validated by research and none are specifically applicable to children and adolescents.

Acute Disease↗
PubMed1977

Exerimental head injury in the rat. Part 2: Regional brain energy metabolism in concussive trauma.

A standardized model of acceleration concussion in the rat was used for the study of cerebral energy metabolism during the acute concussive reaction. Impact velocities of 7 and 9 m/sec were used, and the cerebral metabolic state was determined 1, 4, and 15 minutes after the impact. A concussive response could be sustained with a normal energy state in the tissue, but with the more intense reaction to a 9 m/sec impact, energy depletion usually occurred. At 1 minute these changes were most pronounced in the brain-stem regions. At 4 minutes the reactions were more varied but a progression usually occurred during this time, while at 15 minutes restitution was indicated. Hypoxia due to neurogenic pulmonary edema aggravated the state. The findings are compatible with a high metabolic rate during concussion, but progressive changes indicate the rapid appearance of complicating factors, including hypoxemia and probably also ischemia.

Adenine Nucleotides↗
PubMed1977

Experimental head injury in the rat. Part 3: Cerebral blood flow and oxygen consumption after concussive impact acceleration.

Cerebral blood flow (CBF) and oxygen consumption (CMRO2) were determined during timmediate posttraumatic period in rats subjected to concussive impact acceleration. According to previous studies an impact of 9 m/sec velocity elicited typical and marked symptoms of experimental concussion and often a prolonged comatose state, accompanied by cerebral metabolic signs of energy failure. During the immediate concussive response there was an increase of the CBF, followed within the next few minutes by a decrease to about one-third of normal flow, and then by a tendency toward normalization of flow 20 to 40 minutes posttrauma. Simultaneous measurements of cerebral oxygen extraction indicated an increase of the CMRO2 during the first minute. During the ischemic phase oxygen extraction increased but the lowest CBF values were only partially compensated for, and normal oxygen availability could not be maintained. The combined data, including cerebrospinal fluid pressure measurements, indicated primary cerebrovascular effects of the concussive trauma. These vasomotor effects may induce critical cerebral ischemia and thus profoundly influence posttraumatic cerebral function, and cause irreversible damage.

Animals↗
PubMed1977

Rate of cerebral energy consumption in concussive head injury in the rat.

The metabolic rate was determined in the rat brain during the immediate concussive response to standardized impact accelerations of 7 and 9 m/sec velocity. In one series, the metabolic state was determined in freeze-clamped cortical and brain-stem tissue 20 seconds after the impact. The metabolic rate was calculated from the rate of energy depletion in the adjacent unclamped tissue during 10 seconds of total ischemia. The freeze-clamping procedure per se was shown to enhance the metabolic rate probably by inducing mechanical excitation. In another series, in situ freezing was used for tissue sampling in the same situation. A 10-second period of heart standstill induced a standardized period of ischemia. During the acute concussive response to impact acceleration at 7 m/sec velocity, there was an increase of the metabolic rate in the brain stem. A more intense concussive impact at 9 m/sec velocity further enhanced this reaction and also involved the cortex. It is concluded that the basis of the immediate concussive response is a mechanically elicited neuronal excitation. This may lead to energy depletion unless the increased metabolic demands are met.

Adenine Nucleotides↗
PubMed2005

The prevalence, course and clinical features of post-concussion syndrome in children.

OBJECTIVE: To investigate the clinical features and the prevalence of symptoms of post-concussion syndrome in children with mild traumatic brain injury, and to evaluate their changes over time. MATERIAL AND METHODS: The research involved two groups of 4-16 year-old children: the case group of 301 children who had experienced a single mild traumatic brain injury, and the control group of 301 children who had sustained any other mild body injury without head trauma. Groups were matched according to gender, age, and the date of admission to hospital. In total, 102 matched pairs were analyzed. The period between the date of the trauma and the examination was one to five years (median-27 months). Standardized questionnaires were sent by post to parents from both groups. Parents were asked about the health state as well as symptoms of post-concussion syndrome, their character and frequency. The respondents were inquired about the presence of the symptoms prior to the trauma, shortly after the trauma, and during the last year and the last month before the inquiry. RESULTS: The prevalence of headache, irritability, fears, sleep disorders, learning difficulties, as well as concentration and memory problems did not differ significantly between children with mild traumatic brain injury and the control group when the results of the last year before examination and the last month before the examination were compared. We have investigated how the period of time between the date of the trauma and the date when the questionnaire was filled in influenced the results. The comparison of the questionnaires that were filled a year (but less than two years) after the trauma to those that were filled in 2-5 years after the trauma revealed significant differences in the prevalence of a number of symptoms of the post-concussion syndrome. In children with mild traumatic brain injury, there was a significant decrease in the prevalence of learning difficulties soon after the trauma (p=0.032), headaches before (p=0.026) and soon after the trauma (p=0.01), and irritability the last month before the examination (p=0.043). In children from the control group, there was a significant decrease in the prevalence of concentration problems the last year before examination (p=0.023) and the last month before examination (p=0.036). CONCLUSIONS: More than one year after the trauma, the prevalence of the symptoms of the post-concussion syndrome is not significant higher in children with mild traumatic brain injury, compared to children with other mild body injuries, and is comparable by the changes over time.

Adolescent↗
PubMed1991

[Evaluation of SPECT with N-isopropyl [I-123]-p-iodoamphetamine (IMP) or technetium-99m [99mTc]-d,l-hexamethylpropyleneamine oxime (d, 1-HM-PAO) in cerebral concussion].

123I-IMP and Tc-PAO SPECT were performed in 20 cases of cerebral concussion ranging in age from 4 to 20 years old, including six cases of the juvenile head trauma syndrome (JHTS). The SPECT findings were divided into two main types: six cases in the normal group with no blood flow abnormalities, and 14 cases in abnormal group showing reduced blood flow, mainly in cerebellum and occipital lobe except in one case. In 10 cases with reduced blood flow which could be analyzed, calculation of the blood flow ratio in the temporal and occipital lobes and the cerebellum with the frontal lobe taken as 100 showed values of 93.5% for the temporal lobe, 82.7% for the occipital lobe and 76.8% for the cerebellum. A statistically significant reduction in blood flow occurred in the occipital lobe and cerebellum. In blood examination, abnormally high values of white blood cell counts were observed transiently in 94% of cerebral concussion cases. Abnormalities in brain stem and hypothalamus appeared to cause these abnormal WBC values. From these findings, it was suggested that the blood flow regions of the basilar and posterior cerebral arteries, i.e., the brain stem and hypothalamus are closely connected with the lesions responsible for cerebral concussion. It also appeared that the JHTS occurs in cerebral concussion cases where recovery of the abnormal blood flow in these regions in poor.

Adolescent↗
PubMedDate not supplied

Concentration of biogenic amines and their metabolites in different parts of brain after experimental cerebral concussion.

The levels of biogenic amines and their metabolites were determined in different parts of brain or cerebral-spinal fluid 0.5, 1, 6, 12 or 24 h after experimental cerebral concussion. Cerebral concussion in the rat leads within 6 h to an increase in 5-hydroxytryptamine and a decrease in dopamine utilization in the striatum. That imbalance between the functional state of serotoninergic and dopaminergic neurons may partly explain the development of vasospasms, ischemia and edema brought about by the brain mechanical trauma. Moreover, after cerebral concussion an evident decrease in NA level in discrete brain areas and a decreased DA release in the whole brain occur. In conclusion it is suggested that the alterations of catecholamine and 5-hydroxytryptamine utilization in discrete brain areas, especially in the striatum are the characteristic feature of disturbances after experimental brain concussion.

3,4-Dihydroxyphenylacetic Acid↗
PubMed1984

Cerebral concussion in children: assessment of injury by electroencephalography.

An examination was made of 967 initial and follow-up electroencephalograms of 371 children with clinically diagnosed cerebral concussion to determine whether the EEG could provide an objective measure of injury. For each patient, the degree and distribution of EEG abnormalities, as well as their rate of resolution, were correlated with the severity of clinically assessed injury. A close relationship was found between the severity of both initial and longitudinal EEG disturbances and the clinically suspected grade of concussion. Serial EEGs of individual patients showed a similar relationship between time elapsed since injury and degree of abnormality. The rate at which the sequence of EEG resolution took place varied in direct relation to the severity of concussion. It was concluded that the initial EEG and the rate and degree of resolution of EEG abnormalities, together with the time elapsed since injury, can provide objective and reliable information to the clinician for the establishment of the diagnosis and assessment of severity of cerebral concussion in children.

Adolescent↗
PubMed1980

Attitudes to concussion in young New Zealand men.

Sixty-three men aged 17 to 48 who had been concussed were asked 90 days later if it had affected them, if they knew of others who had been affected, and if they would take action to prevent further injury. Twenty percent still had symptoms, mostly impairment of intellectual function. Sixty percent expressed concern about the injury, though only 19 percent intended realistic measures to prevent recurrence, such as giving up football or selling their motorcycle. Concern was commoner after sports than road accidents. Sixty percent had friends who had been concussed, and a third of these had given up sport because of the effects. It is concluded that there is considerable awareness, particularly amongst sportsmen, of the effects of concussion, and that sports administrators would find considerable support for rules to reduce the risk of brain damage from repeated concussion.

Adolescent↗
PubMed1995

Inappropriate discharge instructions for youth athletes hospitalized for concussion.

OBJECTIVE: To evaluate the medical care, especially the discharge instructions regarding return to participation, received by youth athletes hospitalized for a closed head injury. METHODS: We examined the records of all patients admitted over a 5-year period (1987 through 1991) to The Children's Hospital of Alabama for a sports-related closed head injury. Descriptive information was recorded and discharge instructions reviewed. Injury severity was graded according to guidelines current during the study period, as well as those outlined most recently by the Colorado Medical Society, which have been endorsed by a number of organizations including the American Academy of Pediatrics. Discharge instructions recorded for each patient were then compared with those recommended in the guidelines. RESULTS: We identified 33 patients with sports-related closed head injuries. Grade 1 concussions (least severe) occurred in 8 patients (24.2%), grade 2 in 10 (30.3%), and grade 3 (most severe) in 15 (45.4%). Overall, discharge instructions were appropriate for only 10 patients (30.3%), including all with grade 1 concussions, but only 2 with a grade 2 (20.0%) and none with a grade 3 concussion. CONCLUSION: All who care for youth athletes must become familiar with the guidelines for management of concussion to provide appropriate care and counseling and to avoid a tragic outcome.

Adolescent↗