concussion 2013

Cathy O’Connor MD, FACS

Concussion 2013

Goals for today Update knowledge of injury and

neurologic sequelae How to screen children in school

setting for mTBI/concusssion Brain injured child in the academic

setting- what can we do What testing is available and how it

should be utilized

Why is this important to you?No spare brains available

Long lasting consequences if not managed properly in kids

Education and patience is the key

What is a concussion?

Forget what you were taughtWide range of presenting

symptoms–Immediate–Delayed

Kids vs adolescents vs adultsBe afraid….be very afraid….

Concussion since 1980 Used to be up to 17 different grading

scales- no agreement International Conference on

Concussion in Sport– First one in Vienna 2001– 2012 Zurich update due now

Military research with the wars NFL- the elephant in the room

What do we know? Disturbance in brain neurological

function following a physical insult– Short circuit, dog food can hits wall– Reality: disturbance in glucose

metabolism, blood flow, ion balance No gross structural damage

– May have axonal damage not unlike a neuropraxia type injury

How much force? Pick a number, any number Influence of genetics

– APO E2 Repetitive injuries Vectors of force

– Straight vs rotational vs combination– Translation from the body to the brain

Equipment – Helmets, mouthguards, head strap

Brain Metabolism is Related to Recovery◊ Over 200 High School Athletes Studied using fMRI◊ Hyperactivation predicts CLINICAL recovery time◊ Resolution of hyperactivation correlates with recovery

Time course of recovery

Collins, et al. Neurosurgery 58:275-286, 2006

Predicting the symptoms If direct blow:

– Location– Vector of force– Combination of forces

Transmission of force from body Whiplash of brain within skull Force waves

Right hemisphere

Processing multi-sensory input

simultaneously Visual spatial skills Memory stored in auditory, visual

and spatial modalities

Left hemisphere Sequential Analysis:

– Systematic, logical interpretation of information.

– Interpretation and production of symbolic information:language, mathematics, abstraction and reasoning.

– Memory stored in a language format

Cerebral cortex

– Outermost layer– Learn new info– Form thought– Make decisions– Memory function

Frontal lobe

– Recent memory– Emotions– Concentration– Ability to learn new

info and retain it– Storage of motor

patterns and voluntary activity

Parietal lobe

– Processing of sensory input

– Sensory discrimination

– Body orientation

Occipital lobe

– Processing of all visual input

Temporal lobe

– Expressed behavior: childish, irritable, agitated

– Information retrieval

– Receptive speech/auditory input processing

SymptomsPhysical

HeadachesFatigue/tirednessDizziness with movement or mental exertion

NauseaLight/noise sensitivityRinging in the ears

Sleep difficultiesTrouble falling asleepOvernight awakeningOversleeping/undersleepingFeeling tired in the morning despite long hours in bed

CognitiveInability to focusLimited concentrationInefficient short-term memory

Slowed thinkingFeeling mentally “foggy”Poor reading comprehension

Mood disruption IrritabilitySadnessNervousnessAnxietyDepression

COGNITIVE• Fogginess• Concentration• Memory deficits• Cognitive fatigue

MOOD DISRUPTIONIrritabilitySadnessAnxiety

SLEEP DYSREGULATIONFalling asleepFragmented sleepToo much/too little sleep

SOMATICHeadachesDizzinessLight/noise sensitivityTinnitus

Adapted from Camiolo Reddy, Collins & Gioia, 2008

– Wake up fatigued– Develop headaches sitting in class– Can’t fully grasp class material– Feel worse as the day wears on– Bothered by light/sound at school– Feel more exhausted after school– More symptomatic trying to do

homework– Upset and worried they are falling behind– Go to bed feeling worse

Second Impact Syndrome Second force to brain while still

recovering and SYMPTOMATIC from a first concussion

– Disrupts the autoregulation of blood flow to the brain- massive swelling

– 50% dead on the field– 50% permanent brain damage– Only seen in the adolescent under-22

Return to action Adolescents

– Not little adults– Longer recovery– Significant risk of long term academic

and behavioral issues if not managed well

Kids (6-10)– White paper from CDC by Dec 2013?– No research– No evidence based validated tools

What can you do Identify-new injury vs delayed What are their current issues Additional evaluation if needed Modification of home, work, school to

maximize recovery and minimize long term problems

Safe place in school, source of information for all parties

Advocate for the child

Questions?