Concussion, CTE and what we don’t know

Monday, May 14, 2018

What we wish we knew about concussion and CTE would make life easier for athletes, their parents, coaches and league administrators. It’s tough to remember that concussion research is in its infancy and the final answers about the way the brain reacts to injury, both in the short term and long term is still a mystery. Regardless of the headlines, there are many things we don’t understand. What should be common sense, may or may not be true.

Diagnosis

The only way to diagnosis chronic Traumatic Encephalopathy is after death, by autopsy, and using special techniques to look for abnormal proteins in brain tissue. Tau proteins are located in the brain and help stabilize microtubules inside brain cells called neurons. Abnormalities of an enzyme may cause tau proteins to fold abnormally and clump into “neurofibrillary tangles”. Other brains cells may also be affected.

While the diagnosis of CTE may be suspected because of symptoms like depression, suicidal thoughts, confusion, and short term memory loss, there is no test available for patients to confirm the diagnosis while they are alive.

The pathology findings under the microscope suggest that there is a difference between Alzheimer disease and CTE based on where the tau tangles occur and the presence of amyloid plaque (a sticky protein) seen in Alzheimer.

Concussion

The relationship between head injury and CTE seems to be well established. Using boxing research, it may be the number of hits to the head that make a difference as opposed to whether a concussion occurred. Studies suggest that “punch drunk syndrome” leading to dementia pugilistica found that it was the number of rounds boxed that was the important factor in determining long term brain issues, rather than the number of concussion.

This presumes that we know how to make the diagnosis of concussion and the answer is that we don’t. There is no test to confirm that a concussion has occurred. We know a concussion when we see it: a player who is temporarily confused or knocked unconscious, has a brief seizure or has an abnormal neurologic exam is an easy diagnosis. Many times, the symptoms of concussion may be delayed by hours and those symptoms may be subtle, involving sleep disturbance, ability to concentrate or minor changes in personality.

A concussion may be caused by a direct blow to the head, face or neck or it may be caused when a force to another part of the body is transmitted to the head. Imagine a car wreck where the seat belt holds the body in place but the head whips back and forth.

Not only can we not diagnosis a concussion with certainty, we also do not know when the brain has healed itself from injury and has returned to “normal”.

Cause and Effect

Making the link between head injury, concussion and CTE seems to have occurred, but the question there are plenty of questions left to answer. Does CTE risk increase with the number of concussions or does is it the age of the brain when that first concussion occurs?  Contact sports increase the risk of head injury and the prevalence of CTE in NFL players has led to lawsuits to care for players who develop debilitating symptoms after their careers have ended.

In soccer, recent research suggests that heading the ball affects brain function more than head injury caused by collision. This supports the concept that the number of minor hits may be as important or perhaps more important than a single concussion.

Newer recommendations from research have suggested that concussed brains that are not fully developed are at higher risk for future behavior problems and decreased executive thinking, including initiating activities, problem solving, and planning and organizing. The suggestion is that between the ages of 10 and 12, the brain is undergoing major growth and development and may be particularly vulnerable to injury. Recommendations suggest that tackle football should be avoided before age 12.

Implications

The NFL and NHL rightly are concerned about the long-term consequences of head injury to their players. Those who make it to the pro level have played more games at a higher level and presumably with more exposure to violence than those who didn’t make it to the college level and beyond. A case study published this year found that an 18-year-old high school football player with multiple concussions had, on autopsy, already developed abnormal tau protein tangles in his brain.It may be that the die has been cast for the pro…what happens in the major leagues may be inconsequential as to the development of abnormalities in the brain that are associated with CTE…or, it’s those concessions that occur because of collisions with larger and faster opponents may be the culprit.

The bottom line is that research teaches us much as to the consequences of head trauma and the potential for long term brain dysfunction. It also reminds us that we don’t know what we don’t know.

Protecting players at all levels of competition is a reasonable approach, but that risk of concussion will never be zero, and because of that the risk of CTE will never be zero. Asking the NFL, NHL, NCAA and high school leagues to alter the game maybe appropriate, but there is no way to know whether it will actually make a difference.

We can’t make the diagnosis of concussion. We can’t make the diagnosis of CTE. We don’t know how many concussions it takes to develop CTE and we don’t know if the brain has the ability to fix itself if it has been hurt.welcome to the world of science.

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Random ER thoughts from the week

Friday, April 20, 2018

Random ER thoughts for the week

Carrie Underwood makes her new face debut months after falling, lacerating her face and needing a significant repair. There a couple teaching points.t:

  • The only reason to repair a wound is for its cosmetic results. Every cut will heal eventually.
  • The primary concern when caring for any wound is to prevent infection and make certain that the structures underneath the cut, like tendons, arteries and nerves, aren’t damaged.
  • Scars take time to mature. The timeline starts first with a raised,r ed healing ridge, followed by gradual flattening of the scar, and finally weathering and whitening. It may take 6 months or longer for the final outcome to be realized.

Justice Sonia Sotomayer falls at home and fractures her humeral head, the ball part of the shoulder joint. The fracture often heals on its own with a sling, but the bigger question we ask, especially of older people who fall, is why did the fall happen? Was it a trip on a rug or did the patient pass out and then fall.

Passing out is never normal and can be due to a variety of reasons and it takes detective work to find the cause.

  • Was it low blood sugar (hypoglycemia)? This is one of the complications of medications (including insulin) used to treat diabetics and the Justice has had hypoglycemic events in the past.
  • Was it dehydration or anemia (low red blood cell count)
  • How about a heart rhythm disorder, where the electrical system made the heart beat two fast or too slow?
  • Maybe a seizure?
  • And sometimes it’s normal physiology that runs amok, like a vasovagal episode where the vagus nerve is stimulated and causes the heart rate to slow and blood vessels to dilate, temporarily decreasing blood supply to the brain.

The fracture is a consequence of the fall and taking care of a broken bone is easy. The most important job in in the ER is to understand the why of the injury.

 

Kevin Love of the Cleveland Cavaliers hurts his hand and damages a ligament in his thumb, most likely the ulnar collateral ligament, which is responsible for keeping the thumb in place as it is used to grasp.

  • A completely torn ligament is a third-degree sprain and would require surgery for repair.
  • Fortunately for Mr. Love, his is not that severe and he is able to continue to play.
  • But injured ligaments can’t do their job as well and a partially torn ligament can completely rupture in the near future
  • With a sprained UCL, it’s tough to pinch the thumb and index together and make a powerful fist.
  • UCL tears are also known as Gamekeeper’s Thumb or Skier’s Thumb.

 

Minnesota Wild Zach Parise is done for the playoffs after fracturing his sternum or breastbone. It sounds like a terrible injury and it takes significant force as a direct blow for this to happen. Most often it’s in car wrecks or during sports.

  • Sternal fractures can be associated with other injuries and it’s important to look for those, including lung and rib damage.
  • While the heart sits right behind the sternum, it is usually not damaged An EKG is often done, looking for abnormalities that might be associated with a bruising of the myocardium (heart muscle).
  • The treatment is all about pain control so that the victim can take deep breaths and keep the lungs expanded.
  • Unfortunately, the healing time is measured in months not days and Mr. Parise is done till next season.

 

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