concussion spectrum

Monday, September 7, 2015

Making a diagnosis can be tough, especially when a disease can present in many different ways. Fortunately, technology can help sort out the complicated patient. EKGs and blood tests can help sort out a heart attack even if the patient complains of indigestion instead of chest pain. A CT can help diagnose appendicitis when the abdominal pain presents totally unlike it says in the textbooks. Unfortunately, that is not always the case and the spectrum of concussion symptoms was on full display this past weekend.

Wisconsin’s Michael Caputo makes a tackle on the first play of the game and is next seen confused, wandering on the wrong side of the line of scrimmage. Even without slow motion instant replay that shows him taking a knee to the head, it’s evident that something is not quite right but it took Alabama players pointing to him to get the attention of the referees. Trainers escorted him off the field and took away his helmet. Within seconds, television cameras show him walking on the sideline, appearing rather normal. We understand that a major blow to head can cause concussion.

On the other end of the spectrum is Eugenie Bouchard, a pro tennis player who slips on a wet floor in the locker room and perhaps hit her head on the floor. She begins to develop headaches, photophobia (dislike of bright lights) and phonophobia (dislike of loud sound). After a late night visit to the ER, she decides to withdraw from the US Open… after a slip on the floor. Who hasn’t tripped and bumped or shaken their head? Who hasn’t stood up quickly, only to bump their head on a table or a cabinet? A few stars, a rub of the head and you’re good to go. The headache that showed up a day or two later couldn’t be connected to the ding on the cabinet corner, could it? Can a concussion happen when nobody is there to see it happen?

It seems reasonable to go to the emergency room to get checked out but often the visit is less than satisfying. People fear for bleeding in the brain but most often that catastrophe can be eliminated clinically without the use of technology. Some patients, and parents especially, are not thrilled that a CT scan won’t be necessary, as long as the Canadian or New Orleans Head imaging criteria have been met. They require a normal neurologic exam but with that normal, the diagnosis of concussion can only be made by the patient’s complaints or the witnessing of transient abnormal behavior, like with Mr. Caputo. Otherwise, there is no magic test. There can be screening tests for concussion, often used on the playing field, but making the diagnosis is more art than science. If the patient adamantly refuses to admit headache, vision issues, problems concentrating or any other complaint, how can the doc make the diagnosis?

Concussion symptoms may resolve within seconds or may be delayed and not appear for many hours. For that reason, the brief, on field-testing now being used in the NFL and FIFA soccer may be more for show than for player protection. It would seem that if symptoms can be delayed, then any clinical concern for potential concussion should mandate immediate disqualification. That same thinking should filter down to colleges, high schools and community sports.

Brains that might be shaken need to be protected even if there is no “solid” initial evidence that brain function and anatomy has been compromised. A couple of reasons: First, brains that are irritated need to be rested to allow healing. People who suffer migraines understand that rest, quiet and sleep are some of the mainstays of treatment. Similarly, in head injury, avoiding overstimulation seems to make a difference; a tough treatment especially for kids because it means removing videos, computers and cellphones. Second, and perhaps more importantly may be much rarer but can be catastrophic. A concussed brain may not be able to protect itself against another blow should it occur shortly after the first. Second impact syndrome describes a brain that begins to swell, and with no room to expand in the solid skull, can lead to death.

Michael Caputo was removed from the game, not because he couldn’t or didn’t want to play, but because he was putting himself at risk. Eugenie Bouchard removed herself because her head symptoms prevented her from playing. While it would seem that the mechanisms of injury were markedly different, they both caused the brain to rattle inside the skull. One would think that the major hit on the football field would cause more long-term symptom consequence than a slip on a wet floor. It just goes to show that the brain isn’t very logical and medicine doesn’t really understand how to figure it out.










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