Head injuries constitute the most frequent cause of death in sports-related events and accidents.
Ten percent of college football and 20 percent of high school football players suffer from significant head injuries and/or concussions. Approximately 85 percent of deaths in football are a result of significant head or neck injuries. Modification of tackling techniques has decreased head injuries. Despite proper equipment and technique, however, significant head injuries do occur. Head injuries must be fully evaluated on the sideline by trained personnel. Inappropriate return to play with a reinjury can result in the sudden death of the athlete.
Head trauma and hockey are becoming common sports news items. In the recent past, the news has reported the cases of Tony Granato and his brain surgery resulting from a head trauma suffered playing hockey; the mandatory retirement of Brett Lindros from five concussions over a one-and-a-half-year period; the retirement of Pat Lafontaine because of repeated head trauma; Paul Kariya’s concussion after a cross-check to his head; Eric Lindros’s career-interrupting concussions after being checked into the boards; and the playoff-ending concussion of Ron Francis.
The brain is certainly one of the most delicate structures in the body and one of the most critical. Hence, it has been carefully protected by the surrounding bony structure of the skull. A thick covering called the dura surrounds the brain. The brain floats in a lake of cerebrospinal fluid. This anatomic configuration offers maximal protection for the brain.
Mechanisms/Types of Brain Injury
Head injuries can occur as a result of a direct blow to the skull causing local trauma to the skull. This may manifest as a contusion or fracture and cause injury to the brain. A sudden acceleration or deceleration, without a direct blow to the head, can make the brain strike against the surrounding hard skull causing a brain injury. A player can receive a blow to one side of the head but actually sustain a brain injury on the opposite side of the head. In this type of trauma, the brain will strike the opposite side of the skull and result in a brain injury on the side opposite the direct blow. This is known as a contra-coup injury. Another type of brain injury is called a diffuse axonal injury. Rotary forces, or tangential forces, cause a shearing effect in the deep substance of the brain causing confusion or bleeding within the brain.
A concussion is an alteration of mental status or mental function as a result of trauma to the brain. It may be the result of a direct blow, acceleration and deceleration forces, or a contra-coup injury. The hallmark signs of a concussion are confusion and amnesia. An athlete does not have to have loss of consciousness to have a concussion.
Classic Characteristics of a Concussion
The classic characteristics of a concussion include the following: blank stare; delayed verbal response to questions; delayed ability to follow instructions; inability to focus attention; apparent distraction by the patient; inability to follow a conversation; disorientation; walking (or skating) the wrong direction; loss of awareness of place, time, or date (not knowing who the opposing team is or at which rink they are skating); slurred speech; poor coordination with stumbling; poor balance; and inability to walk a straight line (drunk test or heel-to-toe test). More subtle signs include emotionality (i.e., crying for no apparent reason), memory loss, and poor intellectual function.
Early complaints by the athlete with a concussion may include headaches, dizziness, lack of awareness of surroundings, nausea, and vomiting.
Later complaints include persistent low-grade headaches, light headaches, inability to concentrate, memory dysfunction, excessive fatigue, irritability, intolerance to bright lights, intolerance to loud noises, or ringing in the ears. Some of these symptoms may develop that were not present during the early complaint stage. As an example of this, the newspapers reported that Tony Granato’s headaches were becoming intolerable. He arose from bed due to pain from the headaches. As he walked around downstairs, he looked at framed photographs of family and friends, which were placed on the piano. Tony did not recognize half of the people in the photographs and realized that he was in trouble. Tony was lucky to recognize his deficit. Many times, the athlete with the concussion is completely unaware of his or her deficits.
Classification of Concussion
There is not an absolute standard of grading and managing concussions. However, there are three guidelines that are referenced most frequently. The first is the American College of Sports Medicine (ACSM) Guideline, which is sometimes referred to as Cantu’s Guideline. The second is somewhat more conservative and is known as the Colorado Guideline. The third is the American Academy of Neurology (AAN) Guideline. I will refer to the AAN Guideline. Concussions are defined as mild (grade I), moderate (grade II), or severe (grade III). I also utilize my own clinical experience in neurosurgery, so at times my opinions may be even more conservative.
• Grade I Concussion. A grade I concussion is the most common type of concussion and is certainly the most difficult to recognize and diagnose. The athlete does not have any loss of consciousness or amnesia but has a brief period of confusion. The confusion can present as inattention or as the inability to maintain a coherent stream of thought and carry out goal-directed movements. Most players who have a grade I concussion refer to this as having their “bell rung.” There may be minimal evidence for the grade I concussion. It is only after careful observation and questions to the athlete by sideline medical personnel that this diagnosis will be evident. The symptoms usually resolve in 15 minutes.
• Grade II Concussion. A grade II concussion will also exhibit transient confusion and amnesia but will not have loss of consciousness. The patient may have amnesia for the events following the injury (post-traumatic amnesia or anterograde amnesia) or amnesia for events that preceded the injury (retrograde amnesia). A thorough neurological evaluation must be performed. The player may not return to the game.
• Grade III Concussion. Any loss of consciousness will automatically be defined as a grade III concussion. Loss of consciousness even for only a few seconds is still considered a loss of consciousness according to the AAN Guideline. A grade III concussion requires immediate removal from the game, and the athlete must be transported to a hospital for evaluation. A CT scan or MRI of the brain must be performed on any athlete rendered unconscious for any period of time.
AAN Guidelines for Return to Competition Following a Concussion
• Grade I Concussion. An athlete must be removed from the game and examined immediately and every five minutes for postconcussion-syndrome symptoms. If the athlete is symptomatic, he may not return to the game. Symptoms may include headache, dizziness, impaired orientation, impaired concentration, or memory problems. In order to return to play, symptoms must resolve while at rest and with exertion. Exertion or provocation testing is usually done on the sidelines in football and may be done in the locker room/training room for hockey. Again, return to play is allowed after a grade I concussion only if amnesia does not appear and the athlete is asymptomatic (without symptoms) during rest and exertion within 15 minutes.
If the player has a second grade I concussion in the same contest, this player is eliminated from competition for the day. A CT scan or MRI scan is recommended in all incidences in which a headache persists. These players should be given a head injury precaution information sheet for them to follow at home. The patient should be evaluated over the next 24 hours for signs of evolving intracranial problems. The family needs to have explicit, written information about warning signs and instructions to follow if the athlete becomes worse. The patient is removed from contact sports until he or she is asymptomatic for one week at rest and with exertion. A CT scan or MRI is recommended for those who have headaches or symptoms for more than one week. The AAN recommends that after a second grade I concussion, the player should be pulled from contact sports and returned only after having been asymptomatic for one week. I believe that it is not inappropriate to wait even longer for return to play, perhaps at least one month, and termination of the season should be considered. There is a problem known as second-impact syndrome that needs to be avoided if possible. I believe that termination of the season is mandated after a third grade I concussion. The athlete with three grade I concussions in a season must have a formal neurological evaluation before being considered for return to play.
• Grade II Concussion. The player with the grade IT concussion may not return to play, and frequently repeated reexaminations in the locker room need to be performed. The athlete needs to be examined the following day. I believe that a CT scan should probably be performed. Two grade II concussions in a season keep the player out until the athlete is asymptomatic for two weeks. I would consider terminating the season for the player, and he or she should have a follow-up MRI or CT scan. The player should have a complete neurological examination prior to returning to play the next season.
• Grade III Concussion. Any loss of consciousness necessitates removal from the game, transfer to a hospital, neurological examination, and CT scan or MRI of the brain. The AAN Guideline indicates an athlete should be held from contact sports until he or she is asymptomatic for two weeks after a grade III concussion. I believe it would not be inappropriate to wait one month or to terminate a season.
A second grade III concussion requires the athlete to be asymptomatic at least one month and perhaps longer, based on the physician’s opinion. It is never wrong to err in the conservative direction, so it would not be unreasonable to terminate the season for a second grade III concussion. The player must have a full neurological exam prior to the next season.
Sideline Evaluation of Concussions
1. Check the orientation of the athlete to person, place, time, and purpose. For example, ask the athlete these questions: What is your name? Where are you? Why are you here? Whom are you playing? A few years ago, one NHL player scored a game-winning goal in overtime against the Calgary Flames. Two days later, he received head trauma while playing the Edmonton Oilers. He was removed from the game. His teammates reported that in the locker room after the game, when he was asked where he was, he replied, “We’re in Calgary and I just scored the game-winning goal.” This player lost two days of memory preceding the trauma (retrograde amnesia).
2. Concentration may be evaluated with a counting test such as counting backward or naming the months of the year in reverse order, or a memory test such as naming the president of the United States or remembering three words or objects right away and five minutes later.
3. Ask the athlete about the events in the game and his or her own trauma.
1. Check the pupils for asymmetry and reaction to light.
2. Test coordination by asking the athlete to walk heel-toe (drunk-driving test) or to rub one heel up the opposite shin. This also helps determine if the athlete can follow directions.
3. Ask the athlete to touch his or her finger to the nose with eyes dosed.
4. Ask the athlete to hop on one foot.
If the athlete passes these tests and does not have headaches or dizziness and has clear mental function, then this is a grade I concussion. The examiner should test the athlete with exertional movements. An easy battery of exertional tests in a training room for a hockey player could include five sit-ups, five push-ups, five knee bends, and a short (few steps) maximum sprint effort. If a headache, nausea, dizziness, or other mental changes reappear, the athlete may not return to play.
The following covers other terms that those involved in trauma sports such as hockey should be familiar with.
Diffuse Axonal Injury (DAI)
Diffuse axonal injury takes the form of a prolonged traumatic brain coma with loss of consciousness lasting more than six hours. Residual neurological, psychological, or personality deficits often result because of the structural disruption of numerous axons in the white matter of the cerebral hemispheres and brain stem.
Postconcussive syndrome refers to the constellation of signs and symptoms that characterize the period of recovery from acute brain injury. Headache, dizziness, tinnitus, memory disturbance, and difficulty with concentration are hallmarks described by most victims. While these sequelae invariably follow moderate or severe brain injury, they have also been shown to result from minor head trauma. Willberger reported that more than half of high school football players complained of fatigue, dizziness, poor attention, or memory disturbances after minor head injury. Approximately 8 percent of the athletes suffered mild head injuries identified by the team physician or head trainer over the four-year testing interval. Only 4.7 percent of the injuries involved a positive loss of consciousness, none longer than five minutes. The head-injured players had more complaints of headache and dizziness than their middle-age-matched controls at one and five days after injury, while complaints of difficulty with memory persisted to ten days posttrauma.
Intracerebral Hematoma and Contusion
Intracerebral hematoma and contusion occur in patients with a significant intracerebral (within the brain) pathologic condition who have not suffered loss of consciousness or focal neurologic deficit but who do have persistent headache or periods of confusion after head injury and posttraumatic amnesia. As with any patients who have suffered head injuries, athletes with such symptoms should undergo a CT scan to permit early differentiation between solid intracerebral hematoma and hemorrhagic (bleeding) contusion with surrounding edema (swelling).
Epidural hematoma results when the middle meningeal artery tears as a result of a skull fracture. Because the bleeding in this instance is arterial, accumulation of dot continues under high pressure and, as a result, serious brain injury can occur. The classic description of an epidural hematoma is that of loss of consciousness at the time of injury, followed by a recovery of consciousness in a variable period after which the patient is lucid. This is followed by the onset of increasingly severe headache, decreased level of consciousness, dilation of one pupil, and decerebrate posturing and weakness.
Acute Subdural Hematoma
Acute subdural hematoma raises the image of a large collection of clotted blood in the intracranial cavity, compressing the brain substance and causing compromise due to the space occupied by the hematoma. This is not an infrequent consequence of closed head trauma, but this type of subdural hematoma is more common in adults who have a degree of cortical atrophy. Athletic head injuries result from inertial loading, which is lower than that of serious head injuries caused by vehicular accidents or falling from heights. Patients with an acute subdural hematoma typically are unconscious, mayor may not have a history of deterioration, and frequently display focal neurological findings. It is necessary to obtain a CT or MRI scan to diagnose an acute subdural hematoma.
Multiple injuries have been noted to increase the duration and magnitude of postconcussive syndromes. It was found that headache, dizziness, and memory deficit persisted longer in head trauma victims with a history of previous concussions. Many isolated case reports detailing malignant brain swelling following relatively minor blows in the setting of recent mild head injury have been documented. The pathophysiology of this entity is believed to involve subclinical brain swelling from a traumatic insult that makes the brain more susceptible to further injury. It is postulated that the first insult disturbs the brain’s autoregulatory mechanisms, with consequent vascular congestion and poor brain compliance.
Emergency Management of Head and Cervical Spine Injuries
Although all athletic injuries require careful attention, the evaluation and management of injuries to the head and neck should proceed with particular consideration. An intracranial hemorrhage may initially present with minimal symptoms yet follow a significant downhill course, whereas a less severe injury, such as a neuropraxia of the brachial plexus (“stinger”) that is associated with alarming paresthesias (tingling and numbness) and paralysis may resolve swiftly and allow for quick return to activity.
Individuals responsible for athletes who may sustain injuries to the head and neck should consider several principles:
1. The team physician or trainer should be designated as the person responsible for supervising on-the-field management of the potentially serious injury. This person is the “captain” of the medical team.
2. Prior planning must ensure the availability of all necessary emergency equipment at the site of potential injury. At a minimum, this should include a spine board, stretcher, hard collar, and equipment necessary for the initiation and maintenance of cardiopulmonary resuscitation (CPR).
3. Prior planning must ensure the immediate availability of a properly equipped ambulance as well as a hospital equipped and staffed to handle emergency neurological problems.
4. Prior planning must ensure immediate availability of a telephone for communicating with the hospital emergency room, ambulance, and other responsible individuals in case of an emergency.
Managing the unconscious or spine-injured athlete should not be done hastily or haphazardly. Being prepared to handle this situation is the best way to prevent actions that could convert a repairable injury into a catastrophe. A means of transporting the athlete must be immediately available in high-risk sports such as hockey and football and “on-call” in other sports. Having the proper equipment is essential! A spine board is necessary and is the best means of providing a supporting splint. By splinting the body, the risk of aggravating a spinal cord injury is reduced.
Properly trained personnel must know who is the person in charge; CPR; proper procedures for movement and transportation of the injured athlete; how to use emergency equipment; and procedures for activating the emergency support system.
Prevention of further injury is the single most important objective. Do not take any action that could possibly cause further injury. The first step should be to immobilize the head and neck by supporting them in a stable position. If the victim is breathing, maintain the airway. If not, the airway must be established. If the athlete is facedown when the ambulance arrives, change his or her position to faceup by log-rolling him or her onto a spine board. Once the athlete has been moved to a faceup position, quickly evaluate the breathing and the pulse. The jaw-thrust technique is the safest first approach to opening the airway of a victim with a suspected neck injury. If the jaw thrust is not adequate, the head tilt-jaw lift should be substituted. The transportation team should be familiar with handling a victim with a cervical spine injury, and they should be receptive to taking orders from the team physician or trainer. It is extremely important not to lose control of the care of the athlete; therefore you should be familiar with the transportation crew being used. Lifting and carrying the athlete requires five individuals: four to lift and the leader to maintain immobilization of the head. The leader initiates all actions with clear, loud verbal commands.
In summary, any athlete who has suffered loss of consciousness from head injury for more than one minute, or who has persistent headache with confusion or any disorientation that persists longer than one hour after trauma, or who has had more than one episode of unconsciousness, however momentary, during anyone playing season, should be referred for neurological examination and a CT scan.
New data are always emerging on the management of concussions. Research presented at a medical conference by Dr. Hovdaa, neurophysiologist at UCLA, involving PET (positron emission test) scans indicated that complete rest may be the most effective method to manage a significant concussion case. PET scans revealed that there was decreased uptake of glucose (blood sugar) in the area of the brain that received the concussion. Studies with rats that were given concussion revealed that if they were kept physically active, the recovery was delayed.
So, the concept of preventing deconditioning in the concussion athlete may be erroneous.