normal exam..abnormal head ct

Tuesday, September 6, 2016

Concussion is supposed to be a football and hockey issue, but this weekend it was baseball that reminded us that head injury isn’t limited to “contact” sports. Angels pitcher Matt Shoemaker was hit in the heads with a line drive and though he was not knocked out and had a normal neurological examination, he was not immune from injury. In the real world that mechanism of injury is one of the indications to perform a CT and image the brain.

Mr. Shoemaker cut his forehead but otherwise walked off the field under his own power as he was attended to by the medical staff. Based on being hit by a ball hit at an estimated 105 mph, a CT was done, finding a skull fracture (usually not a big deal) and bleeding inside his head. Press releases weren’t specific about what type of bleeding, but blood in or near the brain is never good.

The skull is a solid box and is mostly filled with brain tissue. If there is swelling or bleeding, there is no place for it to go and the brain may get squashed, which it does not really like. Bleeding in the skull is categorized based on its location.

  • Epidural hematoma or blood clot is located between the brain lining and the skull. This is caused by torn arteries that line the skull
  • Subdural hematoma is located between the lining and the brain tissue and is due to tearing of the bridging veins that travel from the skull to the brain
  • Subarachnoid hemorrhage is located in the space where fluid bathes the brain
  • Intracerebral hemorrhage or hematoma is located within the brain tissue.

ic hematoma

Not all bleeding in the brain needs an operation. Regardless of whether Mr. Shoemaker had an epidural or subdural hematoma, he was watched closely in ICU and had repeated CT scans to monitor the amount of bleeding, whether the clots were enlarging and whether there was pressure being exerted on the brain. Within a few hours, bleeding had progressed and an operation was needed to fix the bleeding issue and prevent brain damage.

There are a variety of guidelines that help decide who might need a CT scan in the first place and who can just be watched. There are all sorts of caveats for each guideline and the purpose is to prevent too many CT scans and the potential radiation risk while not missing significant brain injury. It’s easy to decide to do a CT scan when a head injury victim is not acting normally or has an abnormal physical exam. But Mr. Shoemaker reminds us that one can act normally and still have brain issues. For that reason, “significant mechanism of injury” is an indication to get a CT scan. What is significant? The Ottawa CT head guidelines suggest a couple, including a pedestrian being struck by a motor vehicle, a passenger ejected from a car or falling more than 5 stairs. A 105 mph baseball probably qualifies.

While violent head injuries are self evident, too often injuries can’t easily be appreciated from the sideline and initial symptoms may be shortlived. This week, the NFL Players Association sent out information packets to all its players to teach them about concussion symptoms so that they can help check on their teammates. It’s about time; we called for this to happen in 2011.

And some final food for thought. Mr. Shoemaker has a significant head injury/concussion. Is one big blow enough to cause CTE in the future? Do you need to endure multiple “small” head injuries to cause future chronic brain disease? The joy of not being able to predict the future.




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a special type of neck injury

Monday, September 14, 2015

Football is a violent sport as witnessed by the length of the injury report every Monday morning. From torn ligaments and broken bones to cuts and scrapes, players accept a fair amount of risk to play a game that they love. Injuries to the brain are becoming less acceptable with concussion being front and center on the field and in the press.

Lorenzo Mauldin of the New York Jets was slow to get up after a play this past weekend, and when he eventually stood, collapsed to the ground, face down and didn’t move. Medical staff converged, finding him unconscious and not moving, and still not moving even after he wakened. There was fear of a head injury and the fear of a damaged spinal cord. The stadium was silent as Mr. Mauldin was immobilized on a board and taken from the field. The good news came after hours in the hospital. Mr. Mauldin had sustained a concussion but his neck was all right.

Most people understand the concept of concussion. The brain is shaken and briefly turns off and then gradually returns to normal. Symptoms may occur immediately or they may be delayed, Symptoms may be dramatic, like being knocked unconscious, or very subtle, like having difficulty concentrating or experiencing changing sleep patterns. Imaging the brain with CT scan or MRI does not usually find any damage.

People also understand broken necks and being paralyzed because of spinal cord injury. The neck attaches the head to the body and allows it to swivel and enjoy the world around it. It is also the conduit where the spinal cord runs inside the spinal canal, attaching the brain to the nerves in the rest of the body. The cervical spine is made up of seven interlocking vertebrae and held stable by a variety of ligaments and muscles. Even with broken bones, if the spinal canal is not compromised, the spinal cord can survived intact and undamaged with no symptoms. However, if the vertebrae fracture in such a way that the spinal canal is narrowed, the spinal cord can be injured and that results in badness. Football players can tolerate the risk of knee injuries but no so much that of being paralyzed.

And then there is SCIWORA: spinal cord injury without radiographic abnormalities. Most often seen in children and adolescents, but also in adults, it is a form of spinal cord injury, where there are signs or symptoms of weakness, paralysis or change in sensation without any evidence of fracture, dislocation, or misalignment of bones on X-ray or CT scan. The symptoms can be transient where the spinal cord stops working and then recovers, almost like the brain that has been concussed. But sometimes there can be permanent damage. SCIWORA was much more of a mystery before MRI but with these scans, some of these injuries may be explained by ligament damage or subtle bleeding into the spinal cord. Many victims though, have no obvious spinal cord injury, even though damage exists because the spinal cord has stopped working.

SCIWORA is a frustrating situation for doctors. Doctors like to make a diagnosis but they also like to fix things. But how can something be fixed, if there is nothing that can be done? The treatment is immobilizing the neck and observation, the watchful waiting to see what nature brings, just like a brain concussion. But when there are some agreement as to how long to keep a concussed player off the field, there is much more caution with the SCIWORA patient: “high risk” activity should be avoided for up to six months.

Mr. Maudlin was discharged from hospital after an overnight stay having suffered “only” a concussion and hopefully his brain will recover quickly. The inability to actually see an injury of the brain or spinal cord remains a frustration for the medical community. The patient knows that it’s there. The doctor knows that it’s there. And the treatment options are the same as in the time of Hippocrates, who wrote: “Healing is a matter of time, but it is sometimes also a matter of opportunity”

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