1. HEAD INJURY with Delayed Presentation in Football Wes Bailey, MD Moses Cone Sports Medicine Fellow SEACSM Annual Meeting February 5, 2011

2. Case  ID/CC  17 year-old male Varsity cornerback c/o left-side headache (HA).  HPI  HA began during a football game 5 days prior to presentation. HA started after he suddenly arose from the ground following a play. The player did not recall the details of the play. Player eventually pulled from the game when he could not remember a play call.

3. Case  Ensuing 4 Days - Not evaluated by trainer or MD.  Worsening headache severity.  Day # 4 (AM) - One episode of vomiting along with generalized fatigue.  Day # 4 (PM) - Head strike after return to practice. Blurred vision for ~5 minutes. Feet felt “asleep” for ~10 minutes.  Went to bed early 2/2 headache.  Day # 5  Brought by mother to SM office.  Decreased HA severity.  No mood lability or impaired concentration.

4. Physical Examination  Entire PE including neurological exam WNL.  Standard Assessment of Concussion (SAC)  Score: 24/30.  Deficits: Orientation – Date (1 point) Immediate memory (2 points). Delayed recall (1 point). Recitation of the months of the year backwards (1 point). Recitation of a six-number string in reverse order (1 point).

5. Panel/Audience Questions

6. Differential Diagnoses  Concussion.  Second Impact Syndrome.  Intracranial Bleed.  Post-Concussive Syndrome.

7. Panel/Audience Questions

8. Image Findings  Cervical Spine X-Rays  Normal.  Head CT  Thin extra-axial fluid collection on the left cerebral hemisphere without mass effect, midline shift, or hydrocephalus.

9. Final Working Diagnosis  Subdural Hematoma.  Concussion.

10. Treatment & Outcome  Referred to a local neurosurgeon on the day of presentation.  Managed non-operatively given stable medical condition and lack of mass effect, midline shift, or hydrocephalus.  Held from practice and physical education activities.  Instructed to f/u with the neurosurgeon for interim re- assessment and repeat head CT(s).

11. Treatment & Outcome  Instructed to avoid non-steroidal anti-inflammatory drugs.  Mother received emergency precautions and instructed to limited the player’s physical activities at home.

12. Treatment & Outcome  Slightly decreased size of the fluid collection. Head CT - 2 Days Later

13. Treatment & Outcome  Cleared subdural hematoma. Final Head CT - 3 Weeks Later

14. Treatment & Outcome  Headache resolved.  Resumed full-time academic activities w/o difficulty.  Returned to baseline without mood/behavior changes.

15. Treatment & Outcome  Held from sports and physical education activities for the remainder of the 2010 football season; for a period longer than 1 month.  Gradually resumed non-contact physical education activities at school.  Restricted from wrestling this season.  Cleared for unrestricted sports participation beginning in the summer of 2011 as long as he remains symptom-free.

16. Key Points  Head injury is the leading cause of death in football, and in sports in general 1.  Early communication is key.  Athletes with intracranial bleeding can have normal physical findings.  History is essential.  Individualized neurosurgical management with serial imaging. 1. Gerberich S et al. Concussion incidences and severity in secondary school varsity football players. Am J Pub Health. 1983; 73:1370-1375.

17. Key Points  No official guidelines wrt NSAID use.  No official guidelines wrt activity restrictions.  No physical activity for at least 1 month. Professional hockey player s/p craniotomy for parenchymal hemorrhage. Soccer & ice hockey players s/p sx for ant/post wall fractures of the frontal sinus. 16 y.o. female soccer player s/p drainage of large chronic SDH which communicated with an arachnoid cyst and caused a mass effect. RTP 1 year later. No interim incidents.

18. Panel/Audience Questions