Concussion

Updated December 2011

A concussion is an injury to the brain that results in temporary loss of normal brain function. It usually is caused by a blow to the head. Cuts or bruises may be present on the head or face, but in many cases, there are no signs of trauma. Many people assume that concussions involve a loss of consciousness, but that is not true. In most cases, a person with a concussion never loses consciousness.

The formal medical definition of concussion is: a clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma.

People with concussions often cannot remember what happened immediately before or after the injury, and they may act confused. A concussion can affect memory, judgment, reflexes, speech, balance and muscle coordination. Paramedics and athletic trainers who suspect a person has suffered a concussion may ask the injured person what year it is or direct them to count backwards from 10 in an attempt to detect altered brain function.

Even mild concussions should not be taken lightly. Neurosurgeons and other brain-injury experts emphasize that although some concussions are less serious than others, there is no such thing as a "minor concussion." In most cases, a single concussion should not cause permanent damage. A second concussion soon after the first one, however, does not have to be very strong for its effects to be deadly or permanently disabling.

Prevalence and Incidence

According to the University of Pittsburgh's Brain Trauma Research Center, more than 300,000 sports-related concussions occur annually in the United States, and the likelihood of suffering a concussion while playing a contact sport is estimated to be as high as 19 percent per year of play. More than 62,000 concussions are sustained each year in high school contact sports, and among college football players, 34 percent have had one concussion and 20 percent have endured multiple concussions. Concussions often cause significant and sustained neuropsychological impairments in information-processing speed, problem solving, planning, and memory, and these impairments are worse with multiple concussions.

Reasonable estimates show that between four and 20 percent of college and high school football players will sustain a brain injury over the course of one season. The risk of concussion in football is three to six times higher in players who have had a previous concussion.

A study conducted by McGill University in Montreal found that 60 percent of college soccer players reported symptoms of a concussion at least once during the season. The study also revealed that concussion rates in soccer players were comparable to those in football. According to this study, athletes who suffered a concussion were four to six times more likely to suffer a second concussion. Research such as this has led to greater interest in developing protective headgear for soccer participants.

Concussions also are commonly caused by automobile and biking accidents, and by falls around the home, especially among toddlers and older adults.

Symptoms

Like concussions, mild injuries to the brain may not be observable in routine neurological examinations. Diagnostic tests typically will not show any changes. Therefore, diagnosis is based on the nature of the incident and the presence of specific symptoms, confusion being a primary one. The three principal features of confusion are:

The following are concussion symptoms:

If any of these occur after a blow to the head, a health-care professional should be consulted as soon as possible.

Concussions and Head Injuries

The brain normally floats inside the skull, cushioned gently by the surrounding spinal fluid. The brain consists of a gelatin-like substance and is vulnerable to outside trauma. The skull protects the brain against trauma, but does not absorb all the impact of a violent force.

An abrupt blow to the head, or even a rapid deceleration, can cause the brain to bounce against the inner wall of the skull. There is a potential for tearing of blood vessels, pulling of nerve fibers and bruising of the brain substance.

Sometimes the blow can result in microscopic damage to the brain cells without obvious structural damage visible on a CT scan. In severe cases, the brain tissue can begin to swell. Since the brain cannot escape the rigid confines of the skull, severe swelling can compress the brain and its blood vessels, and limit the flow of blood. Without adequate blood flow, the brain does not receive the necessary flow of oxygen and glucose. A stroke can occur. Brain swelling after a concussion has the potential to amplify the severity of the injury.

A blow to the head can cause a more serious initial injury to the brain. A contusion is a bruise of the brain involving bleeding and swelling in the brain. It can be thought of as a bruise of the brain tissue.

A skull fracture occurs when the bone of the skull breaks. A skull fracture by itself may not necessarily be a serious injury. Sometimes, however, the broken skull bones cause bleeding or other damage by cutting into the brain or its coverings.

A hematoma is a blood clot that collects in or around the brain. If active bleeding persists, hematomas can rapidly enlarge. Like brain swelling, the increasing pressure within the rigid confines of the skull due to an enlarging blood clot can cause serious neurological problems and even be life-threatening. Some hematomas are surgical emergencies. Hematomas that are small sometimes can go undetected initially, but may cause symptoms and require treatment several days or weeks later. The warning signs of a serious brain injury are:

Seek immediate medical attention if any of these warning signs occur.

Grading Concussions

There is no universal agreement on the grades of severity for a concussion. There are many different guidelines for concussion evaluation and return-to-play decisions in athletes. Most guidelines recognize three different grades of concussions and share similar recommendations for return to play.

The two sets of guidelines most followed in the U.S. were formulated by the American Academy of Neurology (AAN) and Robert C. Cantu, MD.

In 1986, Cantu formulated a set of guidelines that became widely used; these were subsequently adopted by the American College of Sports Medicine (ACSM). In 1991, the Colorado Medical Society Guidelines were formulated in response to several deaths related to head injuries in Colorado high school football players. These guidelines are more restrictive than previous versions and were subsequently adopted by the National Collegiate Athletic Association (NCAA). In March 2013, the AAN revised its guidelines again with new recommendations. Currently, there is no consensus within the sports medicine community as to which set of guidelines is the most appropriate.

Grading the concussion is a helpful tool in the management of the injury (see Cantu, below) and depends on: 1) presence or absence of loss of consciousness, 2) duration of loss of consciousness, 3) duration of posttraumatic memory loss, and 4) persistence of symptoms, including headache, dizziness, lack of concentration, etc.

Some team physicians and trainers evaluate an athlete's mental status by using a five-minute series of questions and physical exercises known as the Standardized Assessment of Concussion (SAC). This method, however, may not be comprehensive enough to pick up subtle changes.

The Centers for Disease Control (CDC) offers a Concussion Tool Kit. It also offers a Heads Up Concussion in Youth Sports online training course for coaches.

According to the Cantu Guidelines, Grade I concussions are not associated with loss of consciousness, and post-traumatic amnesia is either absent or less than 30 minutes in duration. Athletes may return to play if no symptoms are present for one week.

Players who sustain a Grade II concussion lose consciousness for less than five minutes or exhibit posttraumatic amnesia between 30 minutes and 24 hours in duration. They also may return to play after one week of being asymptomatic.

Grade III concussions involve post-traumatic amnesia for more than 24 hours or unconsciousness for more than five minutes. Players who sustain this grade of brain injury should be sidelined for at least one month, after which they can return to play if they are asymptomatic for one week.

Following repeated concussions, a player should be sidelined for longer periods of time and possibly not allowed to play for the remainder of the season.

NCAA Update

The NCAA's 2011-2012 Sports Medicine Handbook includes a section called "Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete," which notes that "In the years 2004 to 2009, the rate of concussion during games per 1,000 athlete exposures for football was 3.1; for men's lacrosse, 2.6; for men's ice hockey, 2.4; for women's ice hockey, 2.2; for women's soccer 2.2, for wrestling, 1.4; for men's soccer, 1.4; for women's lacrosse, 1.2; for field hockey, 1.2; for women's basketball, 1.2; and for men's basketball, 0.6, accounting for between four and 16.2 percent of the injuries for these sports, as reported by the NCAA Injury Surveillance Program by the Datalys Center." The NCAA defines concussion or mild traumatic brain injury as "a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces."

The handbook also states that "NCAA member institutions must have a concussion management plan for their student-athletes on file with specific components as described in Bylaw 3.2.4.16 (see Guideline 2i)." The plan:

The signs of a concussion, according to the NCAA, are as follows:

The NCAA handbook includes much more info on concussions starting on page 55 of http://www.ncaapublications.com/productdownloads/MD11.pdf. The NCAA also recommends viewing the National Athletic Trainers' Association's Heads Up video, which takes a closer look at the types of head injuries incurred and how they happen using footage from football games, for example.

Treatment

The standard treatment for concussion is rest. For headaches, acetaminophen (Tylenol) can be taken. Postconcussive headaches often are resistant to stronger narcotic-based medications.

Postconcussive Syndrome

People who suffer a head injury may suffer from side effects that persist for weeks or months. This is known as postconcussive syndrome. Symptoms include memory and concentration problems, mood swings, personality changes, headache, fatigue, dizziness, insomnia and excessive drowsiness. Patients with postconcussive syndrome should avoid activities that put them at risk for a repeated concussion. Athletes should not return to play while experiencing these symptoms. Athletes who suffer repeated concussions should consider ending participation in the sport.

Second-impact Syndrome

Second-impact syndrome results from acute, often fatal brain swelling that occurs when a second concussion is sustained before complete recovery from a previous concussion. This is thought to cause vascular congestion and increased intracranial pressure, which can occur very rapidly and may be difficult or impossible to control. The risk of second-impact syndrome is higher in sports such as boxing, football, ice or roller hockey, soccer, baseball, basketball and snow skiing.

The CDC reports an average of 1.5 deaths per year from sports concussions. In most cases, a concussion, usually undiagnosed, had occurred prior to the final one.

Head Injury Prevention Tips

Buy and use helmets or protective head gear approved by the American Society for Testing and Materials (ASTM) for specific sports 100 percent of the time. The ASTM has vigorous standards for testing helmets for many sports; helmets approved by the ASTM bear a sticker stating this. Helmets and head gear come in many sizes and styles for many sports, and must properly fit to provide maximum protection against head injuries. In addition to other safety apparel or gear, helmets or head gear should be worn at all times for:

Head gear is recommended by many sports safety experts for:

Sports Tips

General Tips

Additional Notes:

Sports-related neurosurgical injuries were the focus of the November 2011 issue of the Journal of Neurosurgery (http://thejns.org/toc/foc/31/5). It included the results of a study of 451 patients about the mechanisms and consequences of head injuries (http://thejns.org/doi/full/10.3171/2011.10.FOCUS11184), which references an anonymous survey that found that more than 46 percent of university soccer players experienced a concussion in just one fall season, and almost two-thirds of the same group experienced a concussion over the 12-month period while playing soccer. Another article described a new iPhone application designed to sideline concussion testing (http://thejns.org/doi/full/10.3171/2011.8.FOCUS11186).

Meanwhile, in September of 2011, the AANS issued a Powerpoint presentation entitled Concussion and Sports: Useful prevention and treatment information for your community from America's neurosurgeons" to help prepare and educate the public on this critical issue.