concussions

Traumatic Brain Injury

A brain injury that is caused by an outside force

• Forceful bump

• Blow

• Jolt to the head or body

• From an object entering the brain

types of TBI

• direct impact injury

• acceleration - deceleration injury

• shock wave injury

two broad types of TBI

penetrating

non-penetrating

penetrating TBI

• open TBI

• happens when an object pierces the skull (e.g., a bullet, shrapnel, bone fragment, etc.) and enters the brain tissue

non penetrating TBI

• (closed head injury or ”blunt TBI”)

• caused by an external force strong enough to move the brain within the skull

  Causes include falls, motor vehicle crashes, sports injuries, blast injury, or being struck by an object

TBI risk factors

• adults >65

• men

top 4 causes of TBI (sports)

football

basketball

bicycles

soccer

concussion

trauma-induced brain dysfunction without structural injury on neuroimaging and symptoms include headache, dizziness, confusion, drowsiness, nausea, amnesia, irritability, and transient loss of consciousness

concussion is a considered a

traumatically induced transient disturbance of brain function

• mild TBI

highest percentage of concussions in female athletes

soccer

• twice as often as males in the same sport

acute symptoms of concussion

• due to functional disturbance rather that structural damage

• negative MRI, CT

neurochemical and neurometabolic events after mTBI

• acute axonal injury via disruption of neurofilament organization

• release of electrolytes through ion channel depolarization leads to a release of neurotransmitters and subsequent neurologic dysfunction

• changes to glucose metabolism with decreased cerebral blood flow

• Mitochondrial dysfunction

diffuse axonal injury (DAI)

• most common brain injury

• widespread damage

• Can disrupt and break down communication among nerve cells in the brain

• Can also lead to the release of brain chemicals that can cause further damage

neuron following concussion

• metabolic dysfunction results in energy crisis (may last for up to 10 days)

• massive release of neurotransmitters interferes with cell communication

cellular crisis: potassium flows out of the neuron, soium and calcium flow in

• trigger voltage gated channels throughout brain

• widespread neuronal depression

• primes cells for barrier dysfunction

• inability to clear debris, resolve inflammation, and release trophic factors to repair neuronal connections

cell attempts to restore homeostasis via membrane ionic pumps

• pumps require energy, which is quickly exhausted

• The ability to deliver energy, via ATP, to the cell is also impaired after a concussion, resulting in an “energy crisis”

• a high demand for energy to restore homeostasis (i.e. ionic pumps) paired with the simultaneous decreased ability to deliver energy (i.e. altered cerebral blood flow)

mitochondrial dysfunction

•due to the increased calcium present with the cell, worsening the mismatch between demand for energy and the ability to produce or deliver energy

concussion baseline

• clinical history (including any symptoms)

• physical and neurologic evaluations

• measures of motor control (eg, balance)

• neurocognitive function

concussion evaluation

brief concussion-evaluation tool (e.g., Standardized Assessment of Concussion [SAC]) should be used in conjunction with a motor-control evaluation and symptom assessment to support the physical and neurologic clinical evaluation

Most important component is the medical history

•What happened

•Was trauma involved

•Any recent head-trauma events or prior concussions

•Any loss of consciousness

•Most patients (greater than 90%) diagnosed with a concussion do not have an associated loss of consciousness

•loss of consciousness is an important sign of a potentially serious head injury

emotional concussion s/s

irritability

changes in mood

cognitive concussion s/s

confusion/ disorientation

Amnesia

Mental fogginess

Difficulty concentrating

physical/ somatic concussion s/s

Headache

Dizziness

Difficulties with balance

Visual changes

sleep concussion s/s

Drowsiness

Sleeping less than usual

Sleeping more than usual

Difficulty falling asleep

most commonly reported concussion s/s 1-7 days post injury

1. headache

2. difficulty concentrating

3. fatigue

4. drowsiness

5. dizziness

6. foggy

7. feeling slowed down

8. light sensitivity

9. balance problems

10. difficulty with memory

concussion physical exam

• hed and neck for structural injury

• neurologic exam

• cognitive fxn

• emotional state

neurologic exam

• assessment of strength

• sensation

• reflexes

• ocular asessment (saccades and nystagmus)

• balance and vestibular

SCAT6

• standardized tool used by medical professionals and qualified health care professionals to aid in evaluation of athletes suspected of having sustained a concussion

• can also be used to obtain baseline data among health athletes for future reference

• > 13 years

SCAT6 components

An immediate/on-field assessment tool and an off-field assessment tool

on field SCAT6 assessment

•Taking note of red flags

•Checking for observable signs of concussion

•Memory assessment using Maddock's questionnaire

•Examining the level of consciousness using the Glasgow Coma Scale

•Cervical spine assessment

SCAT6 off field assessment

•Taking a comprehensive history of the player’s condition

•Symptom evaluation

•A cognitive screen (measures orientation and immediate memory)

•Spell first name backwards, recite months of the year in reverse order

•A measure of concentration

•A neurological screen

•Delayed recall (reciting 3 words that were clearly stated minutes earlier)

Child SCAT6

designed as a standardized tool to screen for concussion with children aged from 5 to 12

• It is to be used exclusively by a physician or licensed healthcare professional

• Immediate or On-Field Assessment

• Symptom Evaluation

• Cognitive Screening

• Neurological Screen

• Delayed Recall

• Decision