Concussions-Exam 3

CTE

A disease entity with a distinctive neuropathology; associated with repetitive blows to the head, sub concussions and concussions

First confirmed case of CTE was found in what year?

1954

CTE can occur after just ______ episode(s) of brain trauma

1

Who is the doctor that addressed CTE in professional sports

Dr Bennett Omalu

How does CTE present clinically?

Occurs after a prolonged latent period as a composite syndrome of mood disorders and neuropsychiatric impairment, with or without sensorimotor impairment.

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Aka, symptoms don’t appear until later in life.

How does a doctor confirm CTE diagnosis

It is confirmed post mortem. Done after direct tissue histochemical and immunohistochemical analysis. This reveals lesions occuring in the brain.

Common symptoms of CTE

* Memory loss
* loss of language and incoherence
* loss of executive functioning
* Deterioration of job performance, investing performance
* Loss of socioeconomic status
* Bankruptcy
* Paranoia
* Exaggerated responses to stressors
* depression
* Restlessness

PTE

Non-neurodegenerative and not progressive. It is a syndrome that temporarily follows brain trauma and is induced by focal or diffuse destruction of brain tissue.

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Key difference: PTE is not a protein issue, it is a structural issue

PTE Symptoms

Contusions

lacerations

Compression of the brain

Necrosis/ brain tissue loss

CTE is a _____ disease

Standalone, does not relate to alzheimer’s or parkinson’s

Consequences of CTE discovery

Long-term risks of concussions are appreciated much more

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Clear need for improved diagnostics

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How does this relate to future studies?

Subconcussion

Cranial impact that does not result in known or diagnosed concussion on clinical grounds.

Greatest effect of sub concussions

Through repeated occurrances

Risk measures of subconcussive forces

* Age at exposure
* Type and magnitude of exposure
* Recovery periods
* Differential rates of recovery
* Genotype
* Individual vulnerability

TBI is thought to be ___ __and__ ______ injury phase

primary, secondary

Tertiary phase of TBI’s

Involves ongoing abnormalities in glucose usage and cellular metabolism

Animal studies on TBI’s

* Repeat injuries were associated with impairments of complex spatial learning and cognitive impairment
* Changes in brain protein and increase vulnerability
* Changes to CNS, no behavioral changes
* Injury may be greater in occurred in a shorter time frame

Effects of a single sub concussive force

\*Tearing of axons with no change in level of consciousness or respponsiveness

\*No difference in behavioral or axonal injury but the subconcussed rates showed increase in immune activation and reactive astroglial activity

Broglio study on 95 football players

* 652 iimpacts during a 14 week season
* Linemen greates number, tight ends next, running backs, and linebackers
* high acceleration and rotational acceleration
* Found that concussions occurred due to a wide range of impact forces

Cerebral Contusion

A contusion that results in inner-cerebral bleeding

* frequent
* happen in similar fashions to concussions

Contusions represents an area of brain injury that consists of:

* hemmorhage
* cerebral infarction
* necrosis

Progression of contusions take place over:

24-48 hours

Symptoms of cerebral contusions

* Frontal and temporal lobe damage
* Headache
* Confusion
* Neurological deficits that manifest to neurological deterioration

Imaging item used for contusion

CT Scans

Lesion

A traumatic intracerebral hemorrhage

Subarachnoid hemorrhage

Bleeding into fluid filled space around the brain.

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Usually not life threatening.

Subdural hematoma

Collection of blood below the dura of the brain. Increases the intercranial pressure which deteriorates intra-cranial matter.

True/False: Subdural hematoma is the most common form of serious and lethal brain injuries in athletics.

true

Causes of Subdural Hematoma

* Tearing of surface of bridgin veins secondary to rotational acceleration-deceleration during violent head motion
* Laceration leading to surrounding subdural accumulation of blood

Skull Fracture

Common if no helmets are worn.

Skull Fx types

Linear- usually clean, no depression. Does not require intervention and heal over several months/years

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Depressed- CSF leak or infection may occur, treatment is needed

Epidural Hematoma

Arterial bleed where a skull fx will lacerate the vessels in the epidural area.

\*common in sports where helments aren’t required

Skull fx is present in ____ of Epidural hematoma

75%

Presentation of Epidural hematoma

* period of LOC
* Arousal to normal LOC
* “Lucid period”

Epidural hematoma symptoms

\*Pupillary dilation

* Hypertension
* Respiratory distress
* Death

Arterial Dissection

The layers of blood vessels separate from each other, secondary to trauma. Reported in almost every sport besides american footbal

Arterial Dissection cause

Flexion or rapid rotation of the neck can tear the carotid or vertebral arteries

Fatalities in sport

Sports are mostly safe. Unpredictable risk of sudden death in sport; mostly tied to cardiovascular causes

Second impact syndrome

Fatal, malignant and uncontrollable increase in intracranial pressure caused by diffuse cerebral edema that occurs after head impact has been sustained before complete recovery from a previous head trauma

Second impact syndrome symptoms

Rapid dilating pupils, loss of eye movement evidence of respiratory failure.

Frequency of Second Impact syndrome

unknown

Return to Play- Concussions

* Never allow an injured brain to return to the same game or practice
* Symptom onset, severity, type and duration are factors to management of concussions
* You MUST have a robust and qualified concussion management strategy
* Important to have neurological assessment, initial action plan, and determination of disposition.

History of RTP

\*Each situation is individualized

* Contact vs. Collision?

Current recommendations for RTP

* No activity either cognitive or physical
* Light aerobic exercise
* Sport specific exercise
* Non-contact drills
* Full contact practice

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\*\*\* Do not move till the next step till the one before is complete

Symptom checklist

* headache
* dizziness
* visual or balance disturbances
* diminished job performance
* MRI changes

RTP contradictions

* Increasing symptoms
* Persistent post concussion symptoms
* Space occupying brain mass
* Hydrocephalus
* Cranial hemorrhage
* Second impact
* Needs to be individualized

Season Retirement

* Prolonged concussion syndrome
* 3 or more concussions in a season
* 2 or more major concussions in a season
* Diminished academic performance
* Diminished athletic performance
* MRI scan abnormality

Career retirement

* intracranal hemorrhage
* academic or cognitive abilities
* prolonged concussion
* lowered threshold
* 3 or more major concussion
* CT MRI structural brain injuries
* non resolving mri or fmri scan