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Head Injury or Brain Injury?Assessment & Management of Concussion
Christopher C. Giza, M.D.Pediatric Neurology and Neurosurgery
California Academy of PAsAugust 11th, 2017
San Diego, CA
45+10
Credit where credit deserved!
Basic ScientistsDavid Hovda, Ph.D.Fernando Gomez-Pinilla, Ph.D.Tiffany Greco, Ph.D.Neil Harris, Ph.D.Dejan Markovic, Ph.D.Mayumi Prins, Ph.D.Raman Sankar, M.D., Ph.D. Rich Sutton, Ph.D.
StudentAlan Grusky
Lab ManagersYan Cai, M.S.Sima Ghavim
Residents/FellowsAdam Darby, M.D.Josh Kamins, M.D.Julia Morrow, M.D.Beth Nakae, M.D.Doug Polster, Ph.D.Raj Rajaraman, M.D.
Nurse PractitionerKristina Murata
Clinical Investigators Robert Asarnow, Ph.D.Talin Babikian, Ph.D.Meeryo Choe, M.D.John DiFiori, M.D.Josh Goldman, M.D.Jason Lerner, M.D.Andy Madikians, M.D.Joyce Matsumoto, M.D.David McArthur, Ph.D., M.P.H.
www.uclahealth.org/brainsportcgiza@mednet.ucla.eduTwitter: @griz1
Clinical AssistantJanet Kor
Post-docsEmily Dennis, Ph.D.Annie Hoffman, Ph.D.Saman Sargolzaei, Ph.D.
Funded by: NIH NS27544, NCAA, Dept of Defense, Stan & Patti Silver, UCLA BIRC, UCLA Steve Tisch BrainSPORT, UCLA Easton Labs for Brain Injury,
Avanir, Neural AnalyticsAdvisor: LoveYourBrain, MLS, NBA, NCAA, USSF
Consultant: Neural Analytics, NFL NCP, NHLPA
Research Assistants Alma MartinezBriana MeyerSonal SinghZoey Wang
Program ManagementConstance JohnsonPhilip Rosenbaum
Graduate StudentsChaitali Biswas, Ph.D.Aditya Ponnaluri, M.Eng.
[Disclosures]
4 R’s of Sports Concussions
Recognize signs & symptoms.
Remove from play/risk of repeat injury
Recover
Return to play/activity
Objectives1. To assess acute concussion / mild traumatic brain
injury2. To determine the appropriate role of acute neuroimaging for
concussion / mild TBI3. To provide evidence-based initial management & education
for concussion / mild TBI4. To make sports safer
What is a Concussion?
• A biological process affecting the brain induced by physical forces
McCrory P et al., Concussion in Sport, (5th), Br J Sport Med 2017
Biomechanical event
Symptoms start quickly
Neurological symptoms occur but not only rarely unconsciousness
Gets better with time if you don’t get whacked again
[Symptoms not caused by something else]
“A Brain Movement Injury”
Acute Signs/Symptoms of Concussion
• Headache
• Dizziness
• Nausea and Vomiting
• Vacant stare (looks ‘out of it’)
• Slow to talk or do things
• Confusion and inattention
• Disorientation
• Slurred or incoherent speech
• Loss of coordination
• Emotions out of proportion
• Memory loss (amnesia)
• Any period of unconsciousness
Who Gets Sports Concussions?
Lincoln, et.al., Am J Sports Med 2011; Giza, Kutcher, et al., Neurol 2013
Football53%
Lacrosse, boys9%
Soccer, boys4%
Wrestling5%
Basketball, boys3%
Baseball1%
Soccer, girls7%
Lacrosse, girls4%
Basketball, girls6%
Softball2%
Field Hockey2%
Cheerleading5%
Concussions (% of total)
Sport Boys Girls
Football: HFootball: C
1.553.02
--
Ice Hockey: C 1.96 -
Soccer: HSoccer: C
0.591.38
0.971.80
Basketball: HBasketball: C
0.110.45
0.600.85
Baseball/Softball: HB/Sball: C
0.080.23
0.040.37
Concussions/1000 games
Girls have a higher rate of concussion than boys, particularly in similar sports
H=high schoolC=college
Recognize, Remove, Re-evaluate
Impact Event
STEP 1: Recognize:
Suspect Concussion?
Yes / No?
Concussion not suspected
Concussion suspected
STEP 2: Remove & EvaluateMechanism Symptoms
SCAT5ChildSCAT5
Concussion diagnosed
Concussionnot diagnosed or unsure
STEP 3: Re-
evaluate
Recognize & Remove• NO SINGLE test to diagnose concussion• Using SCAT5 - test conditions are important
• Quiet conditions• Minimum 10 minutes
• Helmet/impact sensors not for diagnosis
• Video may help?
Sport Concussion Assessment
ToolSCAT5
McCrory, et.al. Br J Sports Med, 2017
Sensitivity 0.64-0.89Specificity 0.91-1.0
Symptom Checklist
SCAT5-ChildSymptom Checklist
Davis, et.al. Br J Sports Med, 2017
Sensitivity ???Specificity ???
SCAT5 / SCAT5-ChildCognitive assessment:Standardized Assessment of Concussion (SAC) - Child
1. Orientation: month, date, day, year, time
2. Immediate memory: 5 words x 3 tries
3. Concentration: a. Digits backwards (2, 3, 4, 5, 6)b. Days/months in reverse order
4. Test Balance and Coordination
5. Delayed recall: same 5 words, one try.
Sensitivity ???Specificity ???
Balance assessment: Balance Error Scoring System (BESS)
4. Test Balance and Coordinationa. Double leg stance (20s)b. Single (non-dominant) leg
stance (20s)c. Tandem stance (20s)d. Upper limb coordination
Sensitivity ???Specificity ???
Sensitivity 0.80-0.94Specificity 0.76-0.91
Sensitivity 0.34-0.64Specificity 0.91
Remove: Avoid Repeat Concussion
Guskiewicz et al., JAMA 2003
A history of prior concussion was associated with a higher rate of subsequent concussion.
Of in-season repeat concussions, 11/12 (92%) occurred within 10 days of initial concussion
7.414.6 20
30
62.3 46.346.7
70
30.339 33.3
0
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3
>7 days
1-7 days
<1 day
Remove: Avoid Repeat Concussion
Athletes with repeated concussions take longer to recover – and miss more school
and more games.
Guskiewicz et al., JAMA 2003
% o
f con
cuss
ed a
thle
tes
# of concussions
Days to recovery
Computerized Cognitive Testing
Automated Neuropsychological Assessment Metrics (ANAM)
Objectives1. To assess acute concussion / mild traumatic brain injury2. To determine the appropriate role of acute
neuroimaging for concussion / mild TBI3. To provide evidence-based initial management & education
for concussion / mild TBI4. To make sports safer
Pediatric mild TBI >2 years old: Indications for CT scanning
Kupperman, et.al. Lancet, 2009
GCS=14Altered mental statusBasilar skull fracture
No
YesCT recommended
Observation or CTBased on:• Physician experience• Multiple vs isolated findings• Worsening signs/symptoms
after ED observation• Parental preference
4.3% risk of ciTBI
Loss of consciousness VomitingSevere mechanism of injury Severe headache
No
Yes
0.9% risk of ciTBI
CT NOT recommended
<0.05% risk of ciTBI
ObservationMainstay of management for mild TBIGenerally for a period of 12-48 hours after injuryObservation alone is reasonable after mild TBI with no LOC
Observation ± CT is reasonable after mild TBI with LOC
Homer and Kleinman, Pediatrics, 1999Schutzman, Barnes, et.al. Pediatrics, 2001
Nigrovic et al., Pediatrics, 2011
•Out of 40,000 subjects, 5,000 underwent observation before decision regarding CT. OR for CT in observed group was 0.53 [0.43-0.66].
•Rate of ciTBI was 0.75% vs 0.87% [NS].
CT imaging after mild TBI: Adults
Jagoda A, et al., Ann Emerg Med 2008
Noncontrast Head CTLevel A: Indicated after TBI with LOC or PTA only if ≥1 of the following:
Headache VomitingAge >60 y Drug or Alcohol IntoxicationShort-term memory deficit Physical trauma above claviclePost-traumatic seizure GCS < 15Focal neurological deficit Coagulopathy
Level B: Consider after TBI without LOC or PTA if there is:Focal neurological deficit VomitingSevere headache Age > 65 ySign of basilar skull fracture GCS < 15Coagulopathy Dangerous mechanism of injury
(MVA ejection, struck pedestrian,fall from >3 feet or 5 stairs)
Level C: None specified
Initial Clinical AssessmentABCsBrief history if possible
Mechanism of injuryProtective equipment (helmet, seatbelt, airbag, carseat)Loss of consciousness, Amnesia, SeizurePersistent neurological symptoms
(nausea, headache, visual disturbance, dizziness, etc.)
Physical examination of head and neck:Lacerations, depressions, tenderness
Raccoon Eyes
•Frontobasal skull fractureBattle Sign
•Temporal bone fracture
TBI Examination Pearls
CSF otorrhea Retinal hemorrhages
5. Examinationa. Head: hematomas, swelling, stepoffs, scalp lacerationsb. Skull: CSF leaks, hemotympanum, Battle sign, Raccoon eyesc. Eyes: fundi, retinal hemorrhagesd. Neck: cervical spine tenderness, deformatione. Neuro: Mental status, PERRL, EOMI, corneals, doll’s eyes, focal
weakness or numbness, reflexes, toes.
Hemotympanum•Temporal bone fracture•Hearing loss•Facial nerve palsy
•Abusive head trauma•Skeletal survey•Examine skin for bruising/burns/marks
Acute CT
Subdural
Epidural
Diffuse edema
Diffuse axonal injury
•Concave, crescent-shaped
•Crosses sutures•Usually venous
•Convex, lens-shaped•No crossing sutures•Usually arterial•Beware lucid interval
•Sulcaleffacement
•Unclear gray-white
•Small ventricles
•White matter hemorrhage
•Often multiple
Objectives1. To assess acute concussion / mild traumatic brain injury2. To determine the appropriate role of acute
neuroimaging for concussion / mild TBI3. To provide evidence-based initial management & education
for concussion / mild TBI4. To make sports safer
Recover: Acute Activity
Asken et al. J Athl Training 2016
Athletes with delayed removal from play after concussion take
longer to recover.
Eblin et al., Pediatrics 2016
Recover: Expect to Get Better
N=2141 HS athlete-exposuresN=136 concussions
Collins, et al., Neurosurgery 2006
70-75% of high school athletes with concussions get better in 14 days; 80-85% in 21 days.
Recover: Early Intervention-Adults
Brief psychological treatment alone provided a 16% reduction in post-concussive syndrome
Mittenberg W, et al, J Clin Exp Neuropsych 2001
1. Reassurance2. Education3. Cognitive restructuring –
teaching and instructing patient to return to activity (mental and physical) in a graded fashion.
Recover: Early Intervention-Kids
Ponsford et al. Pediatr 2001
0
0.5
1
1.5
2
2.5mTBI-Int
mTBI-no
Ctrl-int
Ctrl-no
*
**
Chi
ld B
ehav
ior
Che
cklis
t (C
BC
L)
46
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Pos
t-co
ncus
sion
sym
ptom
che
cklis
t (P
CS
C)
*
*
Reassurance, education & symptom management reduced impairment at 3 mos.
Recover: To Rest or Not to Rest?
Thomas DG, et al, Pediatrics 2015
Strict rest (5d) took 3d longer than usual care (1-2d rest) for 50% to
recover.
Brown, et al., Pediatrics 2014
Prospective; n=335; age=15y (8-23)
Only highest cognitive activity level predicted longer recovery.
Recover: Exercise as Treatment?
Leddy JJ, et al., Clin J Sport Med 2010
• Active exercise improves symptoms• Athletes may improve more rapidly• Exercise tolerance improves with training
Gagnon I, et al., Scand J Med Sci Sport 2015
Return: to Cognitive Activity?
REST
• 1-2 days• Limited/ no
work
BEGINNING RECOVERY
• Start cognitive effort• Partial return to
school• Monitor symptoms
GRADUAL ACTIVITY
• Increase cognitive effort
• Return to school• Monitor symptoms• May start non-contact
risk exercise
RETURN TO NORMALCY
• Return to normal school
• Monitor symptoms• Begin/ continue
return to play progression
Recover & ReturnWindow for physiological recovery may outlast clinical recovery.
Pre-injurybaseline
Concussive event
Acute• Symptomatic• Clinical dysfx• Physiol dysfx
Full recovery• Asymptomatic• Clinical normal• Physiol normal
Subacute• Asymptomatic• Clinical normal• Physiol dysfx
Clinical recovery
Physiological recovery
Clinical & Physiological recovery
“Buffer Zone”
Kamins J, et.al. Br J Sports Med, 2017McCrea, et al. Br J Sorts Med, 2017
Return: to Play/Physical Activity?
McCrory, et.al. Br J Sports Med, 2013, 2017
Athletes should NOT return to play the same day of injury
“Return to Play” only after “Return to Learn” starts
1. Symptom-limited rest (physical and mental rest)
24-48 hours for high school and younger
3. Sport-specific exercise (add balance, running, balance)
2. Light aerobic exercise (add aerobic, stationary bike, swim)
4. Non-contact training drills (add thinking, resistance training)
5. Full contact training (after medical clearance)
6. Return to competition (game play)
Pre-participation exam: Risk factor hx, comorbidities,
neuro, GSC, SAC, BESS, NPT
Approach to concussion management
Concussion suspected
Initial assessment
DefiniteConcussion
ProbableConcussion
PossibleConcussion
Not a concussion
Resolved concussion
Serial assessmentsManage activity
Symptom monitoring
Gradual return
to activity
Return to Participation
Diagnosed Concussion
Sit it Out!
Treat other condition:
• Hyperthermia• Migraine• Syncope• Anxiety• LD• Other
Kutcher & Giza, Neurol Continuum 2014
Outpatient Management: HeadachesMigraine
• Identify triggers and avoid where possible
• Keep simple headache log
• If <2-4 per month, abortive “STOP” therapy is indicated OTC analgesics
Triptans: Rizatriptan (Maxalt), Sumatriptan pill or nasal spray (Imitrex); Zolmitriptan (Zomig); others
Dihydroergotamine nasal spray (DHE)
• If >2-4 per month and missing school/work, also use prophylactic “PREVENT” therapy Anticonvulsants: Topiramate (Topamax) or Valproic acid (Depakote) qHS/bid,
Antidepressants: Amitriptyline qHS; SSRIs less effective
Propranolol (Inderal): avoid in asthma, DM, depression
Outpatient: Spells, cognitive, behavioral
Syncope/spells• If cardiac symptoms – ECG, Holter, echo; cardiology
consultation• If concern for seizure - EEG first, then CT/MRI second
unless focal neuro finding, neurology consultation • Other general tests – lytes, serum glucose, check for
orthostatic BP
Cognitive/behavioral symptoms• Inform school/work, short-term accommodations• Consider neuropsychological testing • Psychiatry/psychology consultation, cognitive
behavioral tx• Treat comorbid conditions – ADHD (stimulants-
amphetamine, dexedrine). Depression (TCAs, SSRIs), Anxiety (benzos, SNRIs)
Outpatient : Dizziness, PCS, Sleep
Post-concussion syndrome
Headache medicationControlled exercise
• Amantadine: Open trial• Fish oil, omega 3s: no clinical data
Sleep disturbance, insomnia
Sleep hygieneSleep study
• Melatonin • TCAs (amitriptyline, doxepin)
• Trazodone
Limited evidence for meds but these are used!
Dizziness / vertigo / vestibular• Treat confounders – good hydration, avoid hypoglycemia• Desensitization exercises• Vestibular therapy, physical therapy• Rarely medications – diphenhydramine, meclizine
Objectives1. To assess acute concussion / mild traumatic brain injury2. To determine the appropriate role of acute neuroimaging for
concussion / mild TBI3. To provide evidence-based initial management & education
for concussion / mild TBI4. To make sports safer
How can we improve youth sports safety?
Avoid unnecessary contact!
Use protective equipment properly!
Enforce rules consistently!
Identify and manage concussions properly!
Practice good technique!
Safety: CA Assembly Bill 25
L NUMBER: AB 25 CHAPTEREDBILL TEXT
CHAPTER 456FILED WITH SECRETARY OF STATE OCTOBER 4, 2011APPROVED BY GOVERNOR OCTOBER 4, 2011PASSED THE SENATE AUGUST 31, 2011PASSED THE ASSEMBLY SEPTEMBER 6, 2011AMENDED IN SENATE AUGUST 30, 2011AMENDED IN SENATE JULY 6, 2011AMENDED IN ASSEMBLY MAY 27, 2011AMENDED IN ASSEMBLY MARCH 25, 2011AMENDED IN ASSEMBLY JANUARY 31, 2011
INTRODUCED BY Assembly Member Hayashi(Coauthors: Assembly Members Buchanan, Conway, Fong, Hill,
Huffman, Ma, Nestande, John A. Pérez, and Smyth)(Coauthors: Senators Alquist, Padilla, Steinberg, and Strickland)
DECEMBER 6, 2010
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 49475 is added to the Education Code, to read: 49475. (a) If a school district elects to offer an athletic program, the school district shall comply with both of the following:
(1) An athlete who is suspected of sustaining a concussion or head injury in an athletic activity shall be immediately removed from the activity for the remainder of the day, and shall not be permitted to return to the activity until he or she is evaluated by a licensed health care provider, trained in the management of concussions, acting within the scope of his or her practice. The athlete shall not be permitted to return to the activity until he or she receives written clearance to return to the activity from that licensed health care provider.
(2) On a yearly basis, a concussion and head injury information sheet shall be signed and returned by the athlete and the athlete's parent or guardian before the athlete's initiating practice or competition.
(b) This section does not apply to an athlete engaging in an athletic activity during the regular schoolday or as part of a physical education course required pursuant to subdivision (d) of Section 51220.
Signed into lawby Governor BrownOctober 4, 2011
(1) An athlete who is suspected of sustaining a concussion or head injury in an athletic activity shall be immediately removed from the activity for the remainder of the day, and shall not be permitted to return to the activity until he or she is evaluated by a licensed health care provider, trained in the management of concussions, acting within the scope of his or her practice.
Safety: CA Assembly Bill 2127
• No more than 2 full-contact practices/week• No more than 90 min per full-contact practice• No full-contact practice in off-season
Signed into lawby Governor BrownJuly 21, 2014
Sum Up1. Concussion is a biomechanically induced syndrome with a range of
neurological signs & symptoms that include amnesia, headache, confusion, incoordination and disorientation.
2. Recognize: Concussion is a clinical diagnosis, there is no single test!
3. Remove: If in doubt, sit ‘em out! Protect from repeat injury.
4. CT imaging is generally not indicated for concussion. Obtain CT if you suspect something other than concussion.
5. Recover: Provide education, reassurance & activity/symptom management to facilitate recovery. Avoid prolonged inactivity.
6. Return: First return to school, then non-contact physical activity, then gradually return to contact risk.
7. There are many ways to decrease sports concussion risk, including practicing good technique, reducing contact, proper equipment, rule enforcement and managing concussions appropriately.
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