Head Evaluation and Treatment

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Head Evaluation and Treatment
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Head Injury Background

• Skull - Hard casing with pudding like substance
  inside
• Protected by coverings
• Nutrients by rich blood supply
• Neural Components at base of skull

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Head Injury

• Mechanism
• Coupe
• Contra-Coupe
• These mechanisms can cause injury and swelling
• Concussion
• Epidural/subdural Hematoma

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Bleeding in the Brain
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Circle of Willis

• Two communicating links exist
• Posterior communicating artery links the
  posterior and middle cerebral arteries
• The anterior communicating artery unites the two
  anterior cerebral arteries

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Circle of Willis

• 1. Anterior Cerebral Arteries
• 2. Inter-Carotid Arteries
• 3/5. Middle Cerebral
• 4. Posterior Communicating Arteries
• 6/7.Posterior Cerebral Arteries
• 8. Basilar Arteries
• 9. Vertebral Arteries

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Where the Head Ends and Neck Begins

• Plane between the external occipital protuberance
  and inferior surface of the mandible
• Neck
• Anterior triangle is bordered by Mandible
  (above), Cervical midline(laterally) and
  Sternomastoid (anteriorly

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Arteries
Middle Meningeal Artery Main supply to the Dura
Matter Fast Bleed when Injured May be related to
Migraines (Hoskin et. Al, 1999)
Middle Meningeal Artery
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Assessing Head Injury

• Check
• Visual Acuity eye movement
• Facial movement
• Headache
• ringing in the ears
• Nausea
• Behavioral Changes (unlike normal personality)
• Amnesia (retrograde/ post-concussive)

• MUST SIT OUT 20 MINUTES AND REASSESS
• If symptoms increase send to emergency
• This is a limited list

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Head Injury

• First Degree
• No Concussion - Bell rung resolution of symptoms
  within Lucid Interval
• Second Degree
• Loss of Consciousness brief less than 15 seconds.
  No resolution within lucid interval

• Third Degree
• Loss of Consciousness more than 15 seconds
• increasing severity within lucid interval
• This is only one type of scale many variations

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Post-Concussive Syndrome

• Residual symptoms post concussion including
• Nausea
• Headache
• Tinnitus
• etc.
• These may occur with movement, daily activities,
  rising from bed etc.
• Must not participate during this period of time

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Second Impact Syndrome

• Injury while still recovering from initial
  concussion
• 100 morbidity
• Very important that post-concussive syndrome has
  resolved

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Decisions on Head Injuries

• MUST SEND TO EMERGENCY IF
• Blood out of ears /or nose (from blow to head)
• Any unconscious episode
• Symptoms increase during 20 minute waiting period
  or when activity resumes
• DO NOT RETURN TO ACTIVITY IF
• Symptoms are not resolved
• Activity exacerbates headache

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Blood Supply to the Brain

• CSF is main nutrition to the neural structures.
• Blood supply to the brain is via a paired
  arteriole system
• Two internal carotid arteries enter the brain
  through the neck

• Two vertebral arteries travel up the posterior
  aspect of the neck through the transverse foramen
  and at the level of the pons. This then becomes
  the basilar artery.
• The basilar will nourish the pons and the
  cerebellum along the way to the area of the
  midbrain where it will divide into the posterior
  cerebral arteries

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Athlete Return to Activity Colorado Guidelines

• First Concussion 1º
• 1 week post resolution of Symptoms
• Second Concussion or 2 º
• 1 month post resolution of symptoms

• Third Concussion or 3 º
• End of Season needs discussion of career
• Start with bike activity - if no symptoms
  increase functional activity before full return
• Above subject to Dr Discretion

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Assessment Tools

• Factors that influence the diagnostic usefulness
  of the tests are that concussion guidelines are
  ever evolving, and no strong scientific consensus
  exists about how to weigh various postconcussion
  symptoms, including cognitive symptoms, when
  grading concusssions. For example, prospective
  studies are finding that loss of consciousness
  isn't always a reliable indicator of head injury
  severity. (Cantu, 2005)

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Concussion Assessment Tools

• Computerized Testing Models computerized tests
  are still being validated against the full
  battery of neuropsychological tests that have
  traditionally been used to evaluate the effects
  of head injuries. (Cantu, 2005)
• Standardized Tools
• Sport Concussion Assessment Tool (SCAT)
• Balance Error Scoring System (BESS)
• Standardized Assessment of Concussions
• Neuropsychological Tests
• Oral Word Association, Hopkins Verbal Learning,
  Trail Making, Wechsler, Symbol Digit Modalities
  Test, Paced Auditory Serial Addition Test, Stroop
  Color Word Test

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SAC

• The SAC takes approximately 5 minutes to
  administer and includes measures of
• Orientation (month, date, day of week, year,
  time)
• Immediate memory (recall of 5 words in 3 separate
  trials)
• Neurologic screening
• Loss of consciousness (occurrence, duration)
• Post-traumatic Amnesia (PTA) (either retrograde
  or anterograde) (recollection of events pre- and
  post-injury)
• Strength
• Sensation
• Coordination
• Concentration (reciting numbers backwards months
  in reverse order)
• Exertional maneuvers (jumping jacks, sit-ups)
• Delayed recall (5 words)
• The SAC is available on pocket-sized cards

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The Balance Error Scoring System (BESS)

• The of the signs of a concussion is poor balance.
  An athlete's balance and equilibrium can be
  tested quickly on the sideline through use of the
  Balance Error Scoring System (BESS). The BESS
  consists of 3 tests lasting 20 seconds each,
  performed on two different surfaces, firm and
  foam The athlete first stands with the feet
  narrowly together, the hands on the hips, and the
  eyes closed (double leg stance). The athlete
  holds this stance for 20 seconds while the number
  of balance errors (opening the eyes, hands coming
  off hips, a step, stumble or fall, moving the
  hips more than 30 degrees, lifting the forefoot
  or heel, or remaining out of testing position for
  more than 5 seconds) are recorded. The test is
  then repeated with a single-leg stance using the
  non-dominant foot, and A third time using a
  heel-toe stance with the non-dominant foot in the
  rear (tandem stance). All three tests are
  performed on a firm surface (grass, turf, court),
  and again on a piece of medium-density foam (a
  piece of foam can easily be carried in a travel
  trunk or equipment bag for road games).

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Concussion Management Software Systems

• CogStatewww.cogstate.com Scoring and analysis of
  Reaction time, information processing, memory,
  attention, problem solving, decision makingmin
• HeadMinder www.headminder.com Reaction time,
  processing speed for high schools, 1,000 for colleges, 2,000 for
  professional teams
• ImPACT www.impacttest.com Attention, memory,
  reaction time, impulse control, visual processing
  speed and accuracy
• Immediate Postconcussion Assessment and Cognitive
  Testing (ImPACT) (www.impactest.com) Verbal,
  visual memory, Information Processing Speed,
  Reaction Time, Impulse control.
• Automated Neuropsychological Assessment Metrics
  (ANAM), jsb2_at_mhg.edu, Reaction, Memory, Spatial
  Processing,

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Postconcussive Treatment

• Increase in need for Glycogen Patient need for
  larger meals is normal post concussive injury
  (Hensen et.al, 1993, Hovda et al, 1991)
• Observation for next 24 hours to monitor symptoms
• Currently no medication based treatment is
  recommended.
• Omit wake-up routine
• Re-evaluation prior to return.