Sports-Associated Traumatic Brain Injury

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Sports-AssociatedTraumatic Brain Injury

• David W. Wright, M.D.

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CASE

• You are volunteering as a team physician at your
  local community league hockey game.
• JR approaches the net for a score when two
  opposing team players hit him from behind and
  slam him into the boards.

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Case continued

• He was slightly off balance when his head hit the
  brick stepwall.
• As he hit the ice his body stiffened. His arms
  stretched outward for a moment before he roused.
• Finally, he pulled himself up, shook his head and
  returned to the bench.

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Case continued

• The next period, JR gets slammed into the corner
  post of the goal along with the goalie.
• When he gets up and skates to the bench, he is
  dazed.
• You notice a glassy stare as the coach yells at
  him to pay attention.

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Case continued

• You convince the coach to sit the player out for
  the period.
• Immediately after the incident, he is dazed and
  has minimal recollection of the last period.
• His physical and basic neurological evaluations
  are normal except for the mini-mental status
  exam.
• He is slow to answer, cannot calculate serial
  sevens, and remembers only 1 word of the five you
  asked him to remember.

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Case continued

• Fifteen minutes later the coach is screaming to
  get him back into play. The player adamantly
  argues to you that he is fine and feels normal.
• You decide to reexamine his mini-mental status.
  He improves his score and is able to remember
  four out of five words, but still cannot do more
  than 3 serial sevens and still does not recall
  any details immediately surrounding the ding.

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Sports Head Injuries

• 300,000 sports related concussions per year
• Head injuries account for 65-85 of all sport
  related fatalities
• 1 out of 20 athletes will get a concussion
• 10 of college and 20 of high school athletes
  will have a concussion
• Younger athletes are at higher risk
• Effects of concussions are cumulative
• Costs to society of sports head injury unknown,
  but overall head injury costs are estimated at
  56 billion annually.

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Consequences of Concussions

• Immediate
• Cognitive impairment (attention, memory, slowed
  reaction time)
• Somatic problems Sensitivity to light,
  dizziness, headaches, etc.
• Life Threatening
• Second Impact Syndrome
• Long term
• Post concussive syndrome (cognitive impairment,
  personality changes,language difficulties, etc.)

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Sports head injuries

• Ice Hockey one of highest incidence of any
  sport
• 0.27 2.24 per 1000 athlete-exposures1,2,3
• Skiing
• 1.27 per 1000 visitor-exposure
• 12,700 per year in US3
• Leading cause of death in Skiing injuries
• Head injuries account for 14 of all injuries in
  adults and 22 in children (lt16 yo) 3

1Cantu, et al 2CIUAU NCAA 3U.S. Consumer
Product Safety Commission
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Sports head injuries

• Snowboarding
• Unknown rate, but head injury increasing from
  1000 in 1993 to 5,200 in 19973
• Beginners have higher incidence of head injury
• Tobogganing, acrobatic freestyle skiing and
  tubing also account for high incidence of head
  injury rate unknown
• Number of concussions that do not seek medical
  attention under-reported and therefore unknown.

Ellison, et al Clancy et al Johnson et al
Murray et al Scharplatz et al. U.S. Consumer
Product Safety Commission
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Are there permanent and long-term sequelae of
mild concussions?

• Bogdanoff et al. - structural changes in brains
  of boxers after concussions.
• Casson et al. Atrophy and chronic encephalopathy
  after repeat concussions in boxers.
• Lampert et al. - morphological changes in the
  brains of boxers.
• Seroni et al. signs of early dementia in young
  boxers

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Are there permanent and long-term sequellae of
mild concussions?

• Erlanger et al long-term cognitive deficits
  after concussion.
• Cantu et al. - second impact syndrome from mild
  concussion

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Neuropsychological Deficits

• Warden et al, 2001
• 14 concussions during boxing out of 483 military
  cadets
• Persistant slowing of Simple Reaction Time at 4
  days

• Lovell et al, 2003
• Some Grade 1 concussions or Dings have
  cognitive deficits for at least 6 days

Warden et al, 2001
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Long Lasting - ?Permanent?Post Concussion
Syndrome

• Symptoms at 3 months in 20-75
• Rutherford et al.
• 145 patients with mTBI
• 51 with persistent symptoms 6 weeks
• after their injury

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Post Concussion Syndrome

• Can last weeks to months
• Symptoms
• Fatigue
• Headaches
• Equilibrium disturbances
• Difficulty with concentration
• Nausea
• Memory complaints
• Blurred vision

• Light sensitivity
• Depression
• Sleep disturbances
• Loss of appetite
• Anxiety
• Hallucinations

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Are Concussions Cumulative?

• In addition to the structural changes listed
  previously, each concussion can take its toll on
  cognition.Freidman et al. Jordan et al
  Erlanger et al Collins et al Kelly et al Cantu
  et al Drew et al Gaetz et al Mrazik et al
  Gronwall et al Bailes et al.
• Athletes with gt 3 concussions suffer worse after
  symptoms with subsequent. Collins et al.
• There is a six times risk for repeat concussion
  if had one previously.
• Kelly et al.

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Can mild head injury be lethal?

• Second impact syndrome (SIS)
• First described in 1973 by Schneider
• Onset usually causes rapid neurological demise,
  brain swelling, and death.
• Inciting factor is second impact prior to
  recovery of initial mild concussion.

Cantu, et al.
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Second Impact Syndrome

• Incidence in Football
• 1980-1993
• 35 probable cases
• 17 confirmed
• 10 others likely

Cantu, et al.
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Second Impact Syndrome - Facts

• Young athletes more susceptible.
• Second impact may be very mild and not even to
  the head.
• Over 35 reported in football alone.
• Not limited to football, documented in ice
  hockey, skiing, etc.

Cantu, et al.
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Second Impact Syndrome - Etiology

• Malignant brain swelling and marked increased
  intracranial pressures.
• Due to cerebrovascular congestion, or loss of
  cerebrovascular auto-regulation
• Rapid onset high mortality gt50, morbidity
  nearly 100

Cantu, et al.
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Do Helmets Make a Difference?

• 44 of head injures in adult skiers (7,700
  annually) could be prevented with helmets.
• 53 of head injures in childen skiers (2,600
  annually) could be prevented with helmets.

U.S. Consumer Product Safety Commission
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Sports - Helmets Underutilized

• 19/26 ski resorts had helmets for rent1
• None included in standard package1
• Only 1 - 8.6 rented helmets1
• In one study of ER visits for skiing related head
  injuries, 1/350 was wearing helmet2

1Hennessay et al 2Levy et al.
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Helmets Save Brain
HEAD AND CERVICAL SPINE FATALITIES FOR
COLLEGIATE FOOTBALL17

• Football dramatic reduction in head injuries
  after new rules about spearing (1976) and helmet
  use (1978). Mueller et al.

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Definition Concussion

• Concussion is a
• trauma-induced alteration in mental status

Confusion and amnesia are key
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Diagnosing

• Recognition difficult
• Variety of signs and symptoms
• Signs can be subtle
• Athletes reluctant to report
• Awareness of problem limited among health
  professionals
• No specific diagnostic tool

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Clinical Signs of Concussion

• Vacant stare
• Delayed verbal and motor response
• Inability to focus attention
• Disorientation
• Slurred or incoherent speech
• Gross observable incoordination
• Emotional disturbances
• Memory deficits
• Any Loss of Consciousness

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Clinical Symptoms of Concussion

• Early
• Headache
• Dizziness or vertigo
• Lack of awareness of surroundings
• Nausea and Vomiting
• Late
• Persistent headache
• Lightheadedness
• Poor attention and memory dysfunction
• Emotional, irritable and frustrated
• Intolerance to bright lights or sounds, blurred
  vision, ringing in ear
• Anxiety and depressed mood
• Sleep disturbances

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Mental Status Testing in the Field

• Orientation
• Time, place, situation
• Concentration
• Digits backwards (3-1-7)(4-6-8-2)(5-3-0-7-4)
• Months of the year in reverse order
• Memory
• Recall of 3 words and objects at 0 5 minutes
• Recent news events, details of the contest
• Neuro exam
• Strength, sensation, coordination and agility
• Exertional Provocation Tests
• 5 push-ups, 5 sit-ups, 5 knee bends, 40 yard
  sprint

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Classification of TBI
General Overview of TBI

• Mild (GCS 13-15)
• Moderate (GCS 9-12)
• Severe (GCS 3-8)

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Primary Secondary Injury
Most common locations of brain contusions after
trauma
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• Lacerations
• Contusions
• Fracture
• Coup
• Contrecoup
• Herniation
• Gliding
• Intermediary

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Secondary Insults
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Neuron Destiny
Injured
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Secondary Insults at the Neuronal Level

• Excitatotoxic amino acids
• Glutamate
• Glycine
• Receptors
• NMDA
• AMPA/KA
• Othera

Massive calcium influx starts a cascade of
deleterious events within the cell subsequently
leading to cell necrosis or apoptosis.
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Structural and Physiological Changes in Response
to Brain Injury

• Events Immediately Following Trauma
• Disruption of the integrity of the tissue
• Disruption of the blood-brain barrier
• Increase in neurotransmitter levels
• Development of edema
• Initiation of inflammation
• Release of free radicals

• Events Hours to Days Following Trauma
• All of the above
• Development of secondary edema
• Hyperplasia and hypertrophy of glial cells
• Activation of inflammatory cells
• Release of neurotrophic factors
• Expression of receptors for neuropeptides
• Accumulation of free radicals and lipid
  peroxidation
• Apoptosis and trans-neuronal degeneration

David W. Wright, M.D.
Stein, et al.
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Secondary Insults at the Macroscopic Level

• Brain Ischemia
• Hypotension
• Hypoxemia
• Anemia
• Intracranial hemorrhages
• Edema
• Elevated ICP
• Metabolic insults

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Subdural Hematoma
Epidural Hematoma
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Edema

• Recognize
• Dilated pupil
• Posturing
• Worsening neurological status
• CT
• Treatment
• ABCs
• Mannitol
• Hypertonic Saline

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Intracerebral Hypertension

• Recognize
• Dilated pupil
• Posturing
• Worsening neurological status
• CT
• ICP monitor
• Treatment in Emergency Department
• ABCs
• Mannitol
• Hypertonic saline
• Moderate hyperventilation (pCO2 30-40)
• Rapid neurosurgical consult

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Future

• Better tools for Sideline Assessment
• Serum Markers of Neuroinjury
• Better diagnostic tools for PCS
• Pharmacological interventions
• Improved understanding of the mechanisms and who
  is at risk.

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Case Follow-Up

• JRs memory deficits seemed to resolve. Under
  the pressure of the coach, he returned to the
  game despite your vigorous discouragement. You
  had no authority to demand he stay out. During
  the last period, JR was checked from behind. The
  impact was hard but he did not lose his balance.
  He continued to play for approximately 5 minutes
  when suddenly he collapsed on the ice. You found
  him unresponsive. His pupils were initially
  responsive to light and equal in size. His vital
  signs were O2 sat 99, BP 130/palp, HR 76, RR 24.
  When you called for the ambulance to transport
  him to the ER, you noticed his respirations
  became slower and more labored, and he seemed to
  extend his arms. A recheck of his pupils found
  the left one 4 mm and the right 2 mm. A recheck
  of the vital signs in the ambulance were O2 sat
  98, BP 160/palp, HR 55, RR 8.

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Case Follow-Up Continued

• Because you appropriately suspected secondary
  impact syndrome and Cushings response (due to
  increased intracranial pressure), you intubated
  JR using the rapid sequence technique and
  hyperventilated him. Normal saline was started at
  KVO though a large bore IV. No other drugs were
  available in the ambulance. JR was rushed to the
  emergency department. In transport he began
  having seizure activity and was given 5 mg of
  diazepam. Evaluation in the ER included proper
  placement of the airway, oxygenation at 95, and
  repeat exam and vitals signs. The repeat VS
  were O2 sat 99, BP 210/70, HR 45, RR 16
  (ventilated). JR was still extending his arms
  and had a GCS of 3t (E1VtM2).

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Case Follow-up continued

• Mannitol was initiated and Neurosurgery was
  consulted immediately. JR was whisked to the CT
  scanner where diffuse cerebral edema, slit-like
  ventricles, and mild uncal herniation were seen
  on the CT monitor. He was transferred to the
  neuro intensive care unit and an intracranial
  pressure monitor was inserted. The monitor
  consistently displayed ICPs in the 40-50s
  despite mannitol, sedation, and barbiturates. JR
  subsequently died later that evening.

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Questions?