Concussion

When is a “bump on the head” a concussion?  Someday we may all know the answer to this question.  At the moment what we have is more questions:   How did it happen? Did the person pass out, or seem “dazed,” and importantly, for how long? Any nausea, or vomiting? How old is the patient? And what was their health status before the bump? The one thing most anyone who suffers a concussion wants to know is when they will feel “normal” again.  The answer to that depends entirely on the answers to the questions just posed. Symptoms of concussion vary widely from person to person but generally includes headache, a vague sense of not “being right” often described as fogginess, vision changes, vertigo, restlessness, a change in mood, fatigue, loss of coordination, and amnesia for the traumatic event that caused the concussion.

The symptoms may appear immediately or be delayed.  As our focus for the past several years has been on concussions sustained in the course of athletic activity whether by professionals or amateurs, one of the concerns that arises is how soon is medical attention sought.   It happens that the desire to continue the activity that led to injury is given undue precedence and the activity is resumed prematurely.  This is a dangerous situation as another concussion when the symptoms of the first episode have not yet resolved can lead to the potentially fatal consequence of Second Impact Syndrome.  The resulting brain swelling can quickly lead to death.

A concussion results from a sudden acceleration or deceleration of the brain. As the brain is gelatinous, it is well cushioned within the skull by cerebrospinal fluid.  But sudden changes in the state of motion can cause the brain to strike against the inside of the skull.  Depending on the velocity of the strike unconsciousness may result.  An episode of loss of consciousness lasting longer than 30 seconds requires immediate medical attention.  Imaging of the brain in the emergency department may disclose bleeding.

More often patients are seen for evaluation of concussion when there had been no apparent loss of consciousness.  In these situations the evidence for concussion becomes apparent when symptoms evolve hours or days after the injury.  Excessive somnolence, fatigue, and a foggy feeling become prominent.  Rarely, seizures occur days or weeks after a concussion.  It is difficult to know who may develop seizures in this case, but it seems reasonable to expect that a prior seizure or a strong family history likely are predisposing factors.

Certain activities carry a higher risk for concussion. Whether the activity is a contact sport, biking, or riding on a motorcycle, it is imperative to have proper protective gear.  In the case of motorcycles, and specifically in Delaware the law requires that a helmet be on the bike.  There is no requirement that it actually be on the rider’s head.  Children and young adults involved in contact sports must always be supervised, and must have protective headgear when playing hockey, football, boxing, rugby, or other contact sports.  A prior concussion is a significant risk factor for another one.

How long the symptoms last is open ended.  It can be six months or longer.  Treatment traditionally has relied heavily on the older class of anti-depressants.  They have been effective in children and adults but present risks to the older patient.  Often a proper assessment of symptoms and risk factor for re-occurrence may be sufficient to allay the anxieties a diagnosis of concussion may raise.  Medical intervention if the symptoms are mild and are resolving may be deferred.  Recurrence of concussion in an older individual should raise the suspicion of physical (elder) abuse.  Likewise anyone at any age presenting with recurrent concussion must be assessed for the possibility of abuse.

Chronic Traumatic Encephalopathy (CTE) is an area of active research, and much controversy.  Anyone subjected to repeated traumas to the head can be expected to  develop significant behavioral and cognitive difficulties.  Mentation is slowed and over time incoordination leads to an appearance resembling to some degree Parkinson’s. Beginning in the 1920s evidence was presented for a condition then termed Dementia Pugilistica.  Whether this is distinct from CTE is not clear.  And are repeat concussions the pathway to CTE? The answer to this will have significant ramifications for professional sports.

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