1. Neurosurgical Red Flags in Sports-Related Head Trauma Christopher Bonfield, MD Assistant Professor Department of Neurosurgery Vanderbilt University Medical Center

2. Disclosures Unaffiliated Neurotrauma Consultant (UNC) for National Football League

3. Outline Sports-related concussions (SRC) Case examples Sports-related concussions with structural brain injury (SRCSBI) – Incidence – Which sports? Red flags Imaging

4. Sports-related concussions (SRC) Transient, trauma-induced physiological disruption of brain function Rapid onset of short-lived impairment of neurological function that resolves spontaneously with no abnormality seen on standard structural neuroimaging studies

5. Sports-related concussions (SRC) Vast majority of concussions do not require imaging Most resolve with first 2 weeks after injury

6. Case 15 yo M helmet to helmet hit on football field Immediate loss of consciousness, seizure? Intubated on field No movement L arm and leg Surgical decompression

7. Case 16 yo M collision on field Stumbled to sideline with head and neck pain Decrease in mental status Intubated Surgical decompression

8. Case 13 yo M unremarkable tackle while running with the ball Stumbled to sideline Decrease in mental status and seizure Intubated Improved left arm and leg weakness

9. Sports-related concussions with structural brain injury (SRCSBI) Subarachnoid hemorrhage (SAH) Subdural hemorrhage (SDH) Epidural hemorrhage (EDH) Malignant cerebral edema, second impact syndrome (SIS) Medical emergency

10. Sports-related concussions with structural brain injury (SRCSBI)

11. Incidence ~40 articles published – Most case reports and case series Spine incomplete recovery (football) 1977-2011: – 324 total, 0.53/100,000 high school, 1.37/100,000 college Brain incomplete recovery (football) 1984- 2011: – 164 total, 0.36/100,000 high school, 0.52/100,000 college Brain fatalities (football) – 128 1960’s, 77 1970’s, 42 1980’s, 37 1990’s, 32 2000’s Catastrophic head injuries (football) 1989-2002: – 7.23/year, 0.67/100,000 high school, 0.21/100,000 college – 80% subdural hematoma – 40% with symptoms from prior head injury

12. Which sports? Basketball Boxing Cycling Equestrian Football Golf Ice hockey Jump training Kickboxing Martial arts Pole vaulting Race walking Rugby Skateboarding Snow skiing Snowboarding Soccer Weightlifting

13. Which sports?

14. Red flags = Refer to emergency department Severe headaches or headaches that worsen Seizures Abnormal neurologic exam, focal neurologic signs Altered mental status, lethargy, difficult to arouse, syncope Repeated vomiting Slurred speech Increasing confusion or agitation Weakness or numbness in arm or legs Neck pain Clear drainage from nose or ear

15. Imaging CT is initial imaging study of choice – High availability (94% of ED with 24-hr access) – Speed – Depiction of bony detail for skull, face, spine fractures – High sensitivity for acute intracranial hemorrhage (epidural and subdural hematomas) – No screening parameters MRI may have role in subacute or chronic injuries

16. Conclusion Most concussions are mild Most do not require imaging or ED transfer Remember red flags (medical emergency) – Worsening or changing exam, focal neurologic deficit, seizure, repeated vomiting

17. References Boden BP, Boden MG, Peter RG, Mueller FO, Johnson JE. Catastrophic injuries in pole vaulters: a prospective 9-year follow-up study. Am J Sports Med. 2012 Jul;40(7):1488-94. Boden BP, Breit I, Beachler JA, Williams A, Mueller FO. Fatalities in high school and college football players. Am J Sports Med. 2013 May;41(5):1108-16. Boden BP, Tacchetti RL, Cantu RC, Knowles SB, Mueller FO. Catastrophic head injuries in high school and college football players. Am J Sports Med. 2007 Jul;35(7):1075-81. Forbes JA, Zuckerman S, Abla AA, Mocco J, Bode K, Eads T. Biomechanics of subdural hemorrhage in American football: review of the literature in response to rise in incidence. Childs Nerv Syst. 2014 Feb;30(2):197-203 McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, et al: Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med 43 (Suppl 1):i76–i90, 2009 Mueller FO, Cantu RC: Annual Survey of Catastrophic Football Injuries. 1977–2011. (http://www.unc.edu/depts/nccsi/FBCATReport2011.pdf) Report of the Quality Standards Subcommittee: Practice parameter: the management of concussion in sports (summary statement). Neurology 48:581–585, 1997 Yuh EL, Hawryluk GW, Manley GT. Imaging concussion: a review. Neurosurgery. 2014 Oct;75 Suppl 4:S50-63. Zuckerman SL, Kuhn A, Dewan MC, Morone PJ, Forbes JA, Solomon GS, Sills AK. Structural brain injury in sports-related concussion. Neurosurg Focus. 2012 Dec;33(6):E6: 1-12.

18. Thank you