1. CONCUSSION DR A.E NKUSI Department of neurosurgery Johannesburg hospital

2. Concussion Definition Grading Mechanism of injury Pathophysiology Concussion in sports Sequelae (post concussion syndrome ) 2 nd impact syndrome Management - Goals - Initial evaluation and treatment - Extended Observations VS Discharge home

3. Post concussion Syndrome Aetiology : organic & neurosis theories Symptoms Risk factors Diagnosis

4. Concussion/Confusion

5. Concussion/Teasdale

6. Concussion grading Mild Moderate Severe

7. Concussion PTA

8. Concussion GCS Severity of TBI Mild GCS 13-15 Moderate 9-12 Severe(Coma) 3-8 [Rimel et al 1981]

9. Concussion Grading Systems

10. Mechanisms Threshold of acceleration /deceleration forces Rotational or angular forces cause concussions - MVAs, falls, sport, assaults Translational or linear forces cause focal lessions.

11. Pathophysiology (Diffuse Axonal Injury-Concussion) Diffuse impact injury Acceleration of white matter Axonal strain Axonal shear White matter lesions

12. Brain Contusions and Haematomas (comparison) Local impact Coupe contra coupe Frontal/Temporal Extra cerebral Intra cerebral

13. Concussion in Sport Concussion in Sport very common South African Rugby Incidence 20% Prevalence 50% Horse riding Hockey Paragliding Soccer 120mph/1000s times Cricket Boxing Cycling

16. Concussion in Sport Minor Professional Athletes Returning to contact again Unstable post concussion state Cumulative effect Second impact injury When is safe to go back When to retire Development of grading systems and guidelines

17. Post concussion Syndrome

18. Post concussion syndrome (cont.) Controversies : - organic theory ; some believe that this syndrome is a result of the head injury. - Neurosis theory ; the proponents of this theory believe that the patients have psychological rather than organic. Incidence ; following mild head injury, 50% of patients have atleast 1 symptom and 25% of pts have headache.

19. Guidelines for return to play after first concussion

20. Guidelines for return to play after 2 nd 3 rd concussion

21. Traumatic Encephalopathy Cumulative Concussions Martland 1928 Boxers Punch drunk Tysvaer Soccer players 40% cognitive Symonds Gronwall MVAs

22. 2 nd Impact syndrome Schneider 1973 Saunders and Harbaugh 1984 “Catastrophic head injury” First concussion Post concussion symptoms still present Second Impact Minor/Mild Seconds to 5 minutes collapse Rapid deterioration due to brain swelling Incidence low/35 cases in 13y US football players Seen in non sport concussion as well M/M 50-100%

24. Management Concerns :3% mortality in minor head injury. Goals : early diagnosis and intervention. Initial evaluation : - clinical - neuroimaging - admission criteria - cost consciousness

25. Extended observation VS discharge Low risk group ; asymptomatic,headache, dizziness,soft tissue injuries. - Discharge on head injury chart. Moderate risk group ; history of changes of conscious level, increasing headache, intoxication, age <2yrs,unreliable history,PTA, seizures,skull fractures. - Close observation and CT brain.

26. High risk group ; decreasing level of consciousness, focal signs, penetrating injury. - do CT scan brain, admission and urgent neurosurgical consultation. SXR; Useless if normal,helpful if positive. CT brain : Non-contrast, 8-46% of patients with mild head injury have intracranial lessions. Need follow up CT ? Timing

27. Neuropsychological Assessment Objective assessment Important body of literature Validated results Still some concerns Not fully objective Depression Over diagnosing

28. Treatment Concussion is diagnosis of exclusion ; usually made confidently on basis of history and clinical findings. Patient education ; explain natural history,BE SUPPORTIVE,sympathetic and +ve in outlook. Drug therapy : Pharmacological treatment has been disappointing, dramatic improvement is uncommon.

29. Narcotic analgesic should be avoided. CDP(Cystidine Diphosphoryl Choline) was reported to have some effect on post traumatic symptoms. EEG : Where no improvement on or seizure suspected. Mainstay of treatment is supportive plus NSAIDS.

30. THANK YOU !