HEAD INJURY with Delayed Presentation in Football

HEAD INJURY with Delayed Presentation in

Football

Wes Bailey, MDMoses Cone Sports Medicine Fellow

SEACSM Annual MeetingFebruary 5, 2011

Case ID/CC

17 year-old male Varsity cornerback c/o left-side headache (HA).

HPI HA began during a football game 5 days

prior to presentation. HA started after he suddenly arose from the

ground following a play. The player did not recall the details of the play. Player eventually pulled from the game when

he could not remember a play call.

Case Ensuing 4 Days - Not evaluated by trainer or

MD. Worsening headache severity. Day # 4 (AM) - One episode of vomiting along with

generalized fatigue. Day # 4 (PM) - Head strike after return to practice.

Blurred vision for ~5 minutes. Feet felt “asleep” for ~10 minutes.

Went to bed early 2/2 headache.

Day # 5 Brought by mother to SM office. Decreased HA severity. No mood lability or impaired concentration.

Physical Examination Entire PE including neurological exam WNL. Standard Assessment of Concussion (SAC)

Score: 24/30. Deficits:

Orientation – Date (1 point) Immediate memory (2 points). Delayed recall (1 point). Recitation of the months of the year backwards

(1 point). Recitation of a six-number string in reverse

order (1 point).

Panel/Audience Questions

Differential Diagnoses Concussion. Second Impact Syndrome. Intracranial Bleed. Post-Concussive Syndrome.

Panel/Audience Questions

Image Findings Cervical Spine X-Rays

Normal.

Head CT Thin extra-axial fluid

collection on the left cerebral hemisphere without mass effect, midline shift, or hydrocephalus.

Final Working Diagnosis Subdural Hematoma. Concussion.

Treatment & Outcome Referred to a local neurosurgeon on the

day of presentation. Managed non-operatively given stable

medical condition and lack of mass effect, midline shift, or hydrocephalus.

Held from practice and physical education activities.

Instructed to f/u with the neurosurgeon for interim re-assessment and repeat head CT(s).

Treatment & Outcome Instructed to avoid non-steroidal anti-

inflammatory drugs. Mother received emergency precautions

and instructed to limited the player’s physical activities at home.

Treatment & Outcome

Slightly decreased size of the fluid collection.

Head CT - 2 Days Later

Treatment & Outcome

Cleared subdural hematoma.

Final Head CT - 3 Weeks Later

Treatment & Outcome Headache resolved. Resumed full-time academic activities w/o

difficulty. Returned to baseline without

mood/behavior changes.

Treatment & Outcome Held from sports and physical education

activities for the remainder of the 2010 football season; for a period longer than 1 month.

Gradually resumed non-contact physical education activities at school.

Restricted from wrestling this season. Cleared for unrestricted sports participation

beginning in the summer of 2011 as long as he remains symptom-free.

Key Points Head injury is the leading cause of death

in football, and in sports in general1. Early communication is key. Athletes with intracranial bleeding can

have normal physical findings. History is essential. Individualized neurosurgical management

with serial imaging.

1. Gerberich S et al. Concussion incidences and severity in secondary school varsity football players. Am J Pub Health. 1983; 73:1370-1375.

Key Points No official guidelines wrt NSAID use. No official guidelines wrt activity restrictions.

No physical activity for at least 1 month. Professional hockey player s/p craniotomy for

parenchymal hemorrhage.

Soccer & ice hockey players s/p sx for ant/post wall fractures of the frontal sinus.

16 y.o. female soccer player s/p drainage of large chronic SDH which communicated with an arachnoid cyst and caused a mass effect. RTP 1 year later. No interim incidents.

Panel/Audience Questions