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 taught   Wide range of presenting symptoms – –Immediate – –Delayed   Kids vs adolescents vs adults   Be 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: , 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

Symptoms Physical   Headaches   Fatigue/tiredness   Dizziness with movement or mental exertion   Nausea   Light/noise sensitivity   Ringing in the ears

Sleep difficulties   Trouble falling asleep   Overnight awakening   Oversleeping/undersleeping   Feeling tired in the morning despite long hours in bed

Cognitive   Inability to focus   Limited concentration   Inefficient short-term memory   Slowed thinking   Feeling mentally “foggy”   Poor reading comprehension

Mood disruption   Irritability   Sadness   Nervousness   Anxiety   Depression

COGNITIVE Fogginess Concentration Memory deficits Cognitive fatigue MOOD DISRUPTION Irritability Sadness Anxiety SLEEP DYSREGULATION Falling asleep Fragmented sleep Too much/too little sleep SOMATIC Headaches Dizziness Light/noise sensitivity Tinnitus 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?