Optom concussion testing

C O N C U S S I O N SJ O D Y A B R A M S , M D

HERE COMES THE BOOM

CONCUSSIONS

• This is a complex pathophysiological process affecting the brain

• From rotational, acceleration or deceleration injury to the head

CONCUSSIONS

• The forces on the brain causes an alteration in the function of the brain function

CONCUSSIONS

• Most of the media focus on sports• Football and hockey

highest rates

• Multiple lawsuits for this now

• Our field also sees a lot from MVAs

CONCUSSIONS

• CDC had around 3 million reported concussion in 2010

• Underestimated

• Lack of awareness

• 90% without LOC

CONCUSSIONS

• Football has the highest rate

• 1/3 of all concussions occur during practice

• 1 in 5 school athletes will sustain a concussion during the season

CONCUSSIONS

• Concussions at a younger age are more damaging then when older

• Leads to dementia

• Depletes cerebral reserves

CONCUSSIONS

• Regulations for testing on athletes coming out

• No return to play until cleared

• Limit the long term affects

CONCUSSIONS

• During the trauma to the brain the neurons are stretched and strained

• This disruption of the cells alignment and configuration cause dysfunction

• A concussion does not usually cause large structural damage but more a functional problem

CONCUSSIONS

Which one has the concussion?

CONCUSSIONS

Tensor Diffusion Imaging

CONCUSSIONS

• Simple Concussions• Signs and symptoms resolve within 7-10 days,

with no residual deficits

• Complex Concussions • Persistent symptoms without exertion lasting for

more than 10 days• Prolonged loss of consciousness (>1 min)• History of multiple concussions• Neuropsychological testing and referral to a

neuropsychologist or neurologist recommended

CONCUSSIONS

• Individuals with complex concussion are 18 times more likely to have unusually low scores on neuropsychological tests

• Within 72 hours of the concussion, individuals with

complex concussion perform significantly worse than individuals with simple concussion

CONCUSSIONS

• Most fall in mild range

• LOC often not present

• Amnesia brief

CONCUSSIONS

• Previously concussed athletes are 4-6 times more likely to experience a second concussion, even if the second head injury is relatively mild

• Those who experience LOC are 6 times more likely to sustain another concussion than those who have never lost consciousness

CONCUSSIONS

• Secondary Impact Syndrome

• Sustaining another concussion while recovering from another magnifies effect

• Auto regulation is disrupted and increases ICP

• Can cause brain swelling and possible death

CONCUSSIONS

• This is what has happened in the case of Nathan Stiles

• Even after 3 weeks the brain was not healed

• He died at halftime of his return game

CONCUSSIONS

• Signs of a Concussions• Loss of Consciousness (LOC)• Amnesia, retrograde or anterograde• Disorientation• Appearing dazed • Forgetting game rules or play assignments• Inability to recall score or opponent • Inappropriate emotionality • Poor physical coordination• Imbalance• Seizure• Slow verbal responses• Personality changes

CONCUSSIONS

• Post Concussions symptoms• Headache• Dizziness• Nausea and/or vomiting• Difficulty balancing• Visual changes• Photophobia• Phonophobia• Feeling “out of it”• Difficulty with concentration• Tinnitus• Drowsiness• Sadness• Hallucinations

CONCUSSIONS

• At present, there are a number of ways in which concussion is assessed including:• Clinical Examination• Symptom Checklist• Concussion Graded Scale• Standard Assessment of Concussion • Player self-report of current functioning• Neuropsychological testing• Imaging

CONCUSSIONS

• Neuro-psych testing assess neurocognitive and psychological effects

• Need a baseline test to compare any changes

• Helps track recovery

CONCUSSIONS

• Neuropsychological testing assesses the following cognitive domains:• Memory • Speed of information processing• Planning executive functioning • Visual spatial abilities• Visuomotor abilities• Attention • Reaction Time

CONCUSSIONS

• Memory and processing speed appear to be the most susceptible

CONCUSSIONS

• Advantages of computerized testing: • Ease of administration • Short administration time • Easy and widespread access• On-site immediate assessment • Ideal for mass administration • Cost Effectiveness• Automated data collection, storage, analysis and

interpretation

CONCUSSIONS AND VISION

CONCUSSIONS AND VISION

• Can be subtle (CI) or obvious (blindness)

• Is important to ask about any recent head traumas or motor vehicle accidents

• Often injury is downplayed

CONCUSSIONS AND VISION

• Work up should include • VA• Motility measurements (distance and near)• Formal visual fields • Pupillary response• Optic nerve evaluation (oct, vep, ect)• Peripheral retinal exam

CONCUSSIONS AND VISION

• Accommodative-convergence insufficiency

• Very common with concussions

• Often overlooked

• Exact control area unkonwn

CONCUSSIONS AND VISION

• ACI patients complain of problems mostly at near

• Can have double vision

• Causes premature presbyopia

• Nothing on MRI

CONCUSSIONS AND VISION

• Good refraction at near and distance helps

• Could uncover latent refractive error

CONCUSSIONS AND VISION

• Convergence insufficiency

• With or with out accommodative insufficiency

• Problem mostly with near

CONCUSSIONS AND VISION

• Often complain of blurred vision, headaches and even double vision

• Very common injury

• Check deviation distance and near

CONCUSSIONS AND VISION

• Treat with near point exercises (PPU)

• Occasionally base in prism for reading

CONCUSSIONS AND VISION

• 6th nerve palsy

• Most common CN in concussion

• Long intracranial course

CONCUSSIONS AND VISION

CONCUSSIONS AND VISION

• Often recovers in 6 months

• Can use patching, prism, or botox

• Surgical repair if not better in 6 months

CONCUSSIONS AND VISION

• 4th nerve palsy

• Can occur with minor trauma

• Trauma could breakdown old phoria

CONCUSSIONS AND VISION

• Longest intracranial course

• Look at old photos for head tilt

• Measure vertical amplitude

CONCUSSIONS AND VISION

• Treat with patching or prism

• Wait 6 months to surgical fix

• Often do inferior oblique myectomy

• Worry about bilateral 4th nerve

CONCUSSIONS AND VISION

• 3rd nerve palsy

• Mechanism is possible from downward displacment of brainstem or from disruption of blood flow

CONCUSSIONS AND VISION

• Can be complete or partial

• Image to image for space occupying lesion from the trauma

Heme

CONCUSSIONS AND VISION

• Can be hard to treat

• Often do not recover much

• Difficult prism or surgery

• Often must occlude

CONCUSSIONS AND VISION

• Traumatic Optic Neuropathy

• Variable presentation

• Minimal visual field defect to complete loss of vision

CONCUSSIONS AND VISION

• Can see decreased VA, change in VF, or color vision changes

• Acutely nerve looks normal, 3-6 weeks atrophy can appear

CONCUSSIONS AND VISION

• Most traumatic optic neuropathy in males

• Often MVA or bicycle accidents

• Helmets are important

CONCUSSIONS AND VISION

• Traumatic optic neuropathy felt to be from shearing force to the nerve or vascular supply

• The tight fit in the optic canal contributes to damage

CONCUSSIONS AND VISION

• Swelling can occur in acute phase

• Further compromises blood supply

• Retinal ganglion cell loss

CONCUSSIONS AND VISION

• Document damage with VF and OCTs

• VEP can be useful• If no response on flash VEP little chance for recovery

CONCUSSIONS AND VISION

• Get imaging to look for treatable problems

CONCUSSIONS AND VISION

• Treatment is debated

• Steroids make us feel better

• Alphagan- makes us still feel better

• Optic canal decompression

• No good study showing what works

CONCUSSIONS

• Suspected concussions need formal workup

• Outside of the visual complications the treatment is rest

• Warn patient about risk of damage with subsequent injury

• The eyes truly are the window to the problem