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Head Injury or Brain Injury?Assessment & Management of Concussion

Christopher C. Giza, M.D.Pediatric Neurology and Neurosurgery

California Academy of PAsAugust 11th, 2017

San Diego, CA

45+10

Credit where credit deserved!

Basic ScientistsDavid Hovda, Ph.D.Fernando Gomez-Pinilla, Ph.D.Tiffany Greco, Ph.D.Neil Harris, Ph.D.Dejan Markovic, Ph.D.Mayumi Prins, Ph.D.Raman Sankar, M.D., Ph.D. Rich Sutton, Ph.D.

StudentAlan Grusky

Lab ManagersYan Cai, M.S.Sima Ghavim

Residents/FellowsAdam Darby, M.D.Josh Kamins, M.D.Julia Morrow, M.D.Beth Nakae, M.D.Doug Polster, Ph.D.Raj Rajaraman, M.D.

Nurse PractitionerKristina Murata

Clinical Investigators Robert Asarnow, Ph.D.Talin Babikian, Ph.D.Meeryo Choe, M.D.John DiFiori, M.D.Josh Goldman, M.D.Jason Lerner, M.D.Andy Madikians, M.D.Joyce Matsumoto, M.D.David McArthur, Ph.D., M.P.H.

www.uclahealth.org/[email protected]: @griz1

Clinical AssistantJanet Kor

Post-docsEmily Dennis, Ph.D.Annie Hoffman, Ph.D.Saman Sargolzaei, Ph.D.

Funded by: NIH NS27544, NCAA, Dept of Defense, Stan & Patti Silver, UCLA BIRC, UCLA Steve Tisch BrainSPORT, UCLA Easton Labs for Brain Injury,

Avanir, Neural AnalyticsAdvisor: LoveYourBrain, MLS, NBA, NCAA, USSF

Consultant: Neural Analytics, NFL NCP, NHLPA

Research Assistants Alma MartinezBriana MeyerSonal SinghZoey Wang

Program ManagementConstance JohnsonPhilip Rosenbaum

Graduate StudentsChaitali Biswas, Ph.D.Aditya Ponnaluri, M.Eng.

[Disclosures]

4 R’s of Sports Concussions

Recognize signs & symptoms.

Remove from play/risk of repeat injury

Recover

Return to play/activity

Objectives1. To assess acute concussion / mild traumatic brain

injury2. To determine the appropriate role of acute neuroimaging for

concussion / mild TBI3. To provide evidence-based initial management & education

for concussion / mild TBI4. To make sports safer

What is a Concussion?

• A biological process affecting the brain induced by physical forces

McCrory P et al., Concussion in Sport, (5th), Br J Sport Med 2017

Biomechanical event

Symptoms start quickly

Neurological symptoms occur but not only rarely unconsciousness

Gets better with time if you don’t get whacked again

[Symptoms not caused by something else]

“A Brain Movement Injury”

Acute Signs/Symptoms of Concussion

• Headache

• Dizziness

• Nausea and Vomiting

• Vacant stare (looks ‘out of it’)

• Slow to talk or do things

• Confusion and inattention

• Disorientation

• Slurred or incoherent speech

• Loss of coordination

• Emotions out of proportion

• Memory loss (amnesia)

• Any period of unconsciousness

Who Gets Sports Concussions?

Lincoln, et.al., Am J Sports Med 2011; Giza, Kutcher, et al., Neurol 2013

Football53%

Lacrosse, boys9%

Soccer, boys4%

Wrestling5%

Basketball, boys3%

Baseball1%

Soccer, girls7%

Lacrosse, girls4%

Basketball, girls6%

Softball2%

Field Hockey2%

Cheerleading5%

Concussions (% of total)

Sport Boys Girls

Football: HFootball: C

1.553.02

--

Ice Hockey: C 1.96 -

Soccer: HSoccer: C

0.591.38

0.971.80

Basketball: HBasketball: C

0.110.45

0.600.85

Baseball/Softball: HB/Sball: C

0.080.23

0.040.37

Concussions/1000 games

Girls have a higher rate of concussion than boys, particularly in similar sports

H=high schoolC=college

Recognize, Remove, Re-evaluate

Impact Event

STEP 1: Recognize:

Suspect Concussion?

Yes / No?

Concussion not suspected

Concussion suspected

STEP 2: Remove & EvaluateMechanism Symptoms

SCAT5ChildSCAT5

Concussion diagnosed

Concussionnot diagnosed or unsure

STEP 3: Re-

evaluate

Recognize & Remove• NO SINGLE test to diagnose concussion• Using SCAT5 - test conditions are important

• Quiet conditions• Minimum 10 minutes

• Helmet/impact sensors not for diagnosis

• Video may help?

Sport Concussion Assessment

ToolSCAT5

McCrory, et.al. Br J Sports Med, 2017

Sensitivity 0.64-0.89Specificity 0.91-1.0

Symptom Checklist

SCAT5-ChildSymptom Checklist

Davis, et.al. Br J Sports Med, 2017

Sensitivity ???Specificity ???

SCAT5 / SCAT5-ChildCognitive assessment:Standardized Assessment of Concussion (SAC) - Child

1. Orientation: month, date, day, year, time

2. Immediate memory: 5 words x 3 tries

3. Concentration: a. Digits backwards (2, 3, 4, 5, 6)b. Days/months in reverse order

4. Test Balance and Coordination

5. Delayed recall: same 5 words, one try.

Sensitivity ???Specificity ???

Balance assessment: Balance Error Scoring System (BESS)

4. Test Balance and Coordinationa. Double leg stance (20s)b. Single (non-dominant) leg

stance (20s)c. Tandem stance (20s)d. Upper limb coordination

Sensitivity ???Specificity ???

Sensitivity 0.80-0.94Specificity 0.76-0.91

Sensitivity 0.34-0.64Specificity 0.91

Remove: Avoid Repeat Concussion

Guskiewicz et al., JAMA 2003

A history of prior concussion was associated with a higher rate of subsequent concussion.

Of in-season repeat concussions, 11/12 (92%) occurred within 10 days of initial concussion

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Remove: Avoid Repeat Concussion

Athletes with repeated concussions take longer to recover – and miss more school

and more games.

Guskiewicz et al., JAMA 2003

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# of concussions

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Computerized Cognitive Testing

Automated Neuropsychological Assessment Metrics (ANAM)

Objectives1. To assess acute concussion / mild traumatic brain injury2. To determine the appropriate role of acute

neuroimaging for concussion / mild TBI3. To provide evidence-based initial management & education

for concussion / mild TBI4. To make sports safer

Pediatric mild TBI >2 years old: Indications for CT scanning

Kupperman, et.al. Lancet, 2009

GCS=14Altered mental statusBasilar skull fracture

No

YesCT recommended

Observation or CTBased on:• Physician experience• Multiple vs isolated findings• Worsening signs/symptoms

after ED observation• Parental preference

4.3% risk of ciTBI

Loss of consciousness VomitingSevere mechanism of injury Severe headache

No

Yes

0.9% risk of ciTBI

CT NOT recommended

<0.05% risk of ciTBI

ObservationMainstay of management for mild TBIGenerally for a period of 12-48 hours after injuryObservation alone is reasonable after mild TBI with no LOC

Observation ± CT is reasonable after mild TBI with LOC

Homer and Kleinman, Pediatrics, 1999Schutzman, Barnes, et.al. Pediatrics, 2001

Nigrovic et al., Pediatrics, 2011

•Out of 40,000 subjects, 5,000 underwent observation before decision regarding CT. OR for CT in observed group was 0.53 [0.43-0.66].

•Rate of ciTBI was 0.75% vs 0.87% [NS].

CT imaging after mild TBI: Adults

Jagoda A, et al., Ann Emerg Med 2008

Noncontrast Head CTLevel A: Indicated after TBI with LOC or PTA only if ≥1 of the following:

Headache VomitingAge >60 y Drug or Alcohol IntoxicationShort-term memory deficit Physical trauma above claviclePost-traumatic seizure GCS < 15Focal neurological deficit Coagulopathy

Level B: Consider after TBI without LOC or PTA if there is:Focal neurological deficit VomitingSevere headache Age > 65 ySign of basilar skull fracture GCS < 15Coagulopathy Dangerous mechanism of injury

(MVA ejection, struck pedestrian,fall from >3 feet or 5 stairs)

Level C: None specified

Initial Clinical AssessmentABCsBrief history if possible

Mechanism of injuryProtective equipment (helmet, seatbelt, airbag, carseat)Loss of consciousness, Amnesia, SeizurePersistent neurological symptoms

(nausea, headache, visual disturbance, dizziness, etc.)

Physical examination of head and neck:Lacerations, depressions, tenderness

Raccoon Eyes

•Frontobasal skull fractureBattle Sign

•Temporal bone fracture

TBI Examination Pearls

CSF otorrhea Retinal hemorrhages

5. Examinationa. Head: hematomas, swelling, stepoffs, scalp lacerationsb. Skull: CSF leaks, hemotympanum, Battle sign, Raccoon eyesc. Eyes: fundi, retinal hemorrhagesd. Neck: cervical spine tenderness, deformatione. Neuro: Mental status, PERRL, EOMI, corneals, doll’s eyes, focal

weakness or numbness, reflexes, toes.

Hemotympanum•Temporal bone fracture•Hearing loss•Facial nerve palsy

•Abusive head trauma•Skeletal survey•Examine skin for bruising/burns/marks

Acute CT

Subdural

Epidural

Diffuse edema

Diffuse axonal injury

•Concave, crescent-shaped

•Crosses sutures•Usually venous

•Convex, lens-shaped•No crossing sutures•Usually arterial•Beware lucid interval

•Sulcaleffacement

•Unclear gray-white

•Small ventricles

•White matter hemorrhage

•Often multiple

Objectives1. To assess acute concussion / mild traumatic brain injury2. To determine the appropriate role of acute

neuroimaging for concussion / mild TBI3. To provide evidence-based initial management & education

for concussion / mild TBI4. To make sports safer

Recover: Acute Activity

Asken et al. J Athl Training 2016

Athletes with delayed removal from play after concussion take

longer to recover.

Eblin et al., Pediatrics 2016

Recover: Expect to Get Better

N=2141 HS athlete-exposuresN=136 concussions

Collins, et al., Neurosurgery 2006

70-75% of high school athletes with concussions get better in 14 days; 80-85% in 21 days.

Recover: Early Intervention-Adults

Brief psychological treatment alone provided a 16% reduction in post-concussive syndrome

Mittenberg W, et al, J Clin Exp Neuropsych 2001

1. Reassurance2. Education3. Cognitive restructuring –

teaching and instructing patient to return to activity (mental and physical) in a graded fashion.

Recover: Early Intervention-Kids

Ponsford et al. Pediatr 2001

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Reassurance, education & symptom management reduced impairment at 3 mos.

Recover: To Rest or Not to Rest?

Thomas DG, et al, Pediatrics 2015

Strict rest (5d) took 3d longer than usual care (1-2d rest) for 50% to

recover.

Brown, et al., Pediatrics 2014

Prospective; n=335; age=15y (8-23)

Only highest cognitive activity level predicted longer recovery.

Recover: Exercise as Treatment?

Leddy JJ, et al., Clin J Sport Med 2010

• Active exercise improves symptoms• Athletes may improve more rapidly• Exercise tolerance improves with training

Gagnon I, et al., Scand J Med Sci Sport 2015

Return: to Cognitive Activity?

REST

• 1-2 days• Limited/ no

work

BEGINNING RECOVERY

• Start cognitive effort• Partial return to

school• Monitor symptoms

GRADUAL ACTIVITY

• Increase cognitive effort

• Return to school• Monitor symptoms• May start non-contact

risk exercise

RETURN TO NORMALCY

• Return to normal school

• Monitor symptoms• Begin/ continue

return to play progression

Recover & ReturnWindow for physiological recovery may outlast clinical recovery.

Pre-injurybaseline

Concussive event

Acute• Symptomatic• Clinical dysfx• Physiol dysfx

Full recovery• Asymptomatic• Clinical normal• Physiol normal

Subacute• Asymptomatic• Clinical normal• Physiol dysfx

Clinical recovery

Physiological recovery

Clinical & Physiological recovery

“Buffer Zone”

Kamins J, et.al. Br J Sports Med, 2017McCrea, et al. Br J Sorts Med, 2017

Return: to Play/Physical Activity?

McCrory, et.al. Br J Sports Med, 2013, 2017

Athletes should NOT return to play the same day of injury

“Return to Play” only after “Return to Learn” starts

1. Symptom-limited rest (physical and mental rest)

24-48 hours for high school and younger

3. Sport-specific exercise (add balance, running, balance)

2. Light aerobic exercise (add aerobic, stationary bike, swim)

4. Non-contact training drills (add thinking, resistance training)

5. Full contact training (after medical clearance)

6. Return to competition (game play)

Pre-participation exam: Risk factor hx, comorbidities,

neuro, GSC, SAC, BESS, NPT

Approach to concussion management

Concussion suspected

Initial assessment

DefiniteConcussion

ProbableConcussion

PossibleConcussion

Not a concussion

Resolved concussion

Serial assessmentsManage activity

Symptom monitoring

Gradual return

to activity

Return to Participation

Diagnosed Concussion

Sit it Out!

Treat other condition:

• Hyperthermia• Migraine• Syncope• Anxiety• LD• Other

Kutcher & Giza, Neurol Continuum 2014

Outpatient Management: HeadachesMigraine

• Identify triggers and avoid where possible

• Keep simple headache log

• If <2-4 per month, abortive “STOP” therapy is indicated OTC analgesics

Triptans: Rizatriptan (Maxalt), Sumatriptan pill or nasal spray (Imitrex); Zolmitriptan (Zomig); others

Dihydroergotamine nasal spray (DHE)

• If >2-4 per month and missing school/work, also use prophylactic “PREVENT” therapy Anticonvulsants: Topiramate (Topamax) or Valproic acid (Depakote) qHS/bid,

Antidepressants: Amitriptyline qHS; SSRIs less effective

Propranolol (Inderal): avoid in asthma, DM, depression

Outpatient: Spells, cognitive, behavioral

Syncope/spells• If cardiac symptoms – ECG, Holter, echo; cardiology

consultation• If concern for seizure - EEG first, then CT/MRI second

unless focal neuro finding, neurology consultation • Other general tests – lytes, serum glucose, check for

orthostatic BP

Cognitive/behavioral symptoms• Inform school/work, short-term accommodations• Consider neuropsychological testing • Psychiatry/psychology consultation, cognitive

behavioral tx• Treat comorbid conditions – ADHD (stimulants-

amphetamine, dexedrine). Depression (TCAs, SSRIs), Anxiety (benzos, SNRIs)

Outpatient : Dizziness, PCS, Sleep

Post-concussion syndrome

Headache medicationControlled exercise

• Amantadine: Open trial• Fish oil, omega 3s: no clinical data

Sleep disturbance, insomnia

Sleep hygieneSleep study

• Melatonin • TCAs (amitriptyline, doxepin)

• Trazodone

Limited evidence for meds but these are used!

Dizziness / vertigo / vestibular• Treat confounders – good hydration, avoid hypoglycemia• Desensitization exercises• Vestibular therapy, physical therapy• Rarely medications – diphenhydramine, meclizine

Objectives1. To assess acute concussion / mild traumatic brain injury2. To determine the appropriate role of acute neuroimaging for

concussion / mild TBI3. To provide evidence-based initial management & education

for concussion / mild TBI4. To make sports safer

How can we improve youth sports safety?

Avoid unnecessary contact!

Use protective equipment properly!

Enforce rules consistently!

Identify and manage concussions properly!

Practice good technique!

Safety: CA Assembly Bill 25

L NUMBER: AB 25 CHAPTEREDBILL TEXT

CHAPTER 456FILED WITH SECRETARY OF STATE OCTOBER 4, 2011APPROVED BY GOVERNOR OCTOBER 4, 2011PASSED THE SENATE AUGUST 31, 2011PASSED THE ASSEMBLY SEPTEMBER 6, 2011AMENDED IN SENATE AUGUST 30, 2011AMENDED IN SENATE JULY 6, 2011AMENDED IN ASSEMBLY MAY 27, 2011AMENDED IN ASSEMBLY MARCH 25, 2011AMENDED IN ASSEMBLY JANUARY 31, 2011

INTRODUCED BY Assembly Member Hayashi(Coauthors: Assembly Members Buchanan, Conway, Fong, Hill,

Huffman, Ma, Nestande, John A. Pérez, and Smyth)(Coauthors: Senators Alquist, Padilla, Steinberg, and Strickland)

DECEMBER 6, 2010

THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

SECTION 1. Section 49475 is added to the Education Code, to read: 49475. (a) If a school district elects to offer an athletic program, the school district shall comply with both of the following:

(1) An athlete who is suspected of sustaining a concussion or head injury in an athletic activity shall be immediately removed from the activity for the remainder of the day, and shall not be permitted to return to the activity until he or she is evaluated by a licensed health care provider, trained in the management of concussions, acting within the scope of his or her practice. The athlete shall not be permitted to return to the activity until he or she receives written clearance to return to the activity from that licensed health care provider.

(2) On a yearly basis, a concussion and head injury information sheet shall be signed and returned by the athlete and the athlete's parent or guardian before the athlete's initiating practice or competition.

(b) This section does not apply to an athlete engaging in an athletic activity during the regular schoolday or as part of a physical education course required pursuant to subdivision (d) of Section 51220.

Signed into lawby Governor BrownOctober 4, 2011

(1) An athlete who is suspected of sustaining a concussion or head injury in an athletic activity shall be immediately removed from the activity for the remainder of the day, and shall not be permitted to return to the activity until he or she is evaluated by a licensed health care provider, trained in the management of concussions, acting within the scope of his or her practice.

Safety: CA Assembly Bill 2127

• No more than 2 full-contact practices/week• No more than 90 min per full-contact practice• No full-contact practice in off-season

Signed into lawby Governor BrownJuly 21, 2014

Sum Up1. Concussion is a biomechanically induced syndrome with a range of

neurological signs & symptoms that include amnesia, headache, confusion, incoordination and disorientation.

2. Recognize: Concussion is a clinical diagnosis, there is no single test!

3. Remove: If in doubt, sit ‘em out! Protect from repeat injury.

4. CT imaging is generally not indicated for concussion. Obtain CT if you suspect something other than concussion.

5. Recover: Provide education, reassurance & activity/symptom management to facilitate recovery. Avoid prolonged inactivity.

6. Return: First return to school, then non-contact physical activity, then gradually return to contact risk.

7. There are many ways to decrease sports concussion risk, including practicing good technique, reducing contact, proper equipment, rule enforcement and managing concussions appropriately.