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HEAD INJURY with Delayed Presentation in Football

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

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HEAD INJURY with Delayed Presentation in Football

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  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 Head CT - 2 Days Later • Slightly decreased size of the fluid collection.

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

  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 general1. • 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

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