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Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017
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Image from Wikimedia Commons | Max Andrews.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
The above image shows the forces at work in concussion and the resulting traumatic brain injury (TBI).
TBI is a significant problem in the pediatric population in the United States. A TBI is caused by an insult to the brain that arises from an external mechanical force and disrupts normal function. The severity of a TBI can range from mild (a brief change in mental status or consciousness) to severe (an extended period of unconsciousness or amnesia after the injury).
Image courtesy of Jamie Lien, MD.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
A 5-year-old girl falls 7 feet from a treehouse and strikes her head on the ground. She presents to the emergency department (ED) with headache. Neurologic examination yields normal results, but the patient has a persistent headache, as well as swelling over the right parietal scalp. Computed tomography (CT) scanning of the head is performed.
What significant findings are visible on the axial images shown?
Subarachnoid hemorrhage
Epidural hematoma
Subdural hematoma
Skull fracture
Obstructive hydrocephalus
Image courtesy of Jamie Lien, MD.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Answer: B and D.
The CT scan shows a nondisplaced left parietal bone fracture (left, arrow) with associated epidural hematoma measured at a thickness of 3.2 mm (right).
What is the most common age group presenting with TBI in the United States?
0-4 years
5-9 years
10-14 years
15-19 years
20-24 years
Image from the CDC.[1]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Answer: A. 0-4 years.
In 2009-2010, the rate of ED visits for TBI by children aged 0-4 years was 2193.8 per 100,000 US population, up from 1374.0 per 100,000 in 2007-2008. Children aged 0-4 years consistently have the highest TBI rates of any age group, followed by older adolescents and young adults aged 15-24 years.[1]
Image adapted from the CDC.[2]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Falls are the leading mechanism of TBI-related hospitalizations in children aged 0-14 years.[2] Motor vehicle accidents are another leading cause.
Table adapted from Medscape.[3,4]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
TBI can result in a wide spectrum of injury. Primary brain injury, induced by mechanical force at the moment of injury, may cause scalp injury, skull fracture, surface contusions, intracranial hemorrhage (see the above table), diffuse vascular injury, and injury to cranial nerves and the pituitary stalk.[3,4] Secondary brain injury develops minutes to weeks after primary brain injury and is potentiated by several physiologic and metabolic alterations, as well as by cellular events leading to neuronal cell death.
Image courtesy of Jamie Lien, MD.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
A 2-month-old girl presents to the ED with a 2-day history of vomiting. She appears well and is well hydrated. She tolerates an oral fluid challenge and is discharged home. After 3 days, the patient is brought back to the ED with persistent vomiting, as well as constant crying. On examination, she is irritable and has a full anterior fontanelle. CT of the head is performed, and axial (left) and coronal (right) images demonstrate bilateral subdural hematomas.
What would be the most appropriate next step in this patient's management?
Toxicology screening
Stool guaiac
Genetics consultation
Magnetic resonance imaging (MRI) of the brain
Skeletal survey
Image courtesy of Jamie Lien, MD.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Answer: E. Skeletal survey.
In a patient of this age and presentation, subdural hematomas are most likely due to shaken baby syndrome. Forceful shaking of an infant creates an acceleration-deceleration force that can result in subdural or subarachnoid hemorrhage. These images from the skeletal survey of a 7-month-old boy with unexplained injuries show an acute right clavicle fracture (1), a healing right radius fracture (2), and a healing right distal tibial metaphyseal corner fracture (3).
Abusive or intentional injury should always be considered in infants and young children. Red flags include an inconsistent provider history, a delay in seeking medical care, an injury that is not consistent with developmental stage, other physical signs of injury or neglect, and an unstable social situation.
Image courtesy of Jamie Lien, MD.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
A 16-year-old boy falls while skateboarding and strikes the back of his head. He presents to the ED with scalp swelling and headache. CT scanning of the head is performed.
Which of the following findings are apparent on the image shown?
Epidural hematoma
Subdural hematoma
Pneumocephalus
Midline shift
Skull fracture
Image courtesy of Jamie Lien, MD.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Answer: A, C, and D.
This patient has a hyperdense lenticular-shaped collection (thick arrow) in the right parietal lobe with associated pneumocephalus (medium arrow) and leftward midline shift (thin arrow). A subdural hematoma classically has more of a crescent-shaped appearance. A skull fracture is not visualized in this image.
Image courtesy of Jamie Lien, MD.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
A 6-year-old girl is playing in a soccer game when she collides with another player, striking her forehead. She reports feeling dizzy for a brief period and has a mild headache afterward. The patient is taken to an ED, where she reports feeling sleepy and nauseated. CT scanning of the head is performed.
What significant findings are visible on the CT scan shown?
Skull fracture
Epidural hematoma
Subdural hematoma
Midline shift
None of the above
Image from the CDC.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Answer: E. None of the above.
The patient has sustained a mild TBI, also called a concussion.[5] Mild TBI is characterized by the following features:
It may be caused either by a direct blow to the head, face, or neck or by a blow elsewhere on the body that results in transmission of an "impulsive" force to the head
It typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously
It may result in neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury
It results in a graded set of clinical symptoms that may or may not involve loss of consciousness
It is associated with no abnormality on standard structural neuroimaging studies
Image adapted from Giza CC, Hovda DA. Neurosurgery. 2014 Oct; 75 Suppl 4:S24-33. PMID: 25232881[6] by Sam Shlomo Spaeth.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Current understanding of the pathophysiology of concussion (mild TBI [mTBI]) is summarized in this figure.[6] Biomechanical injury results in ionic flux, triggering an indiscriminate glutamate release. Adenosine triphosphate (ATP)–driven ion pumps attempt to restore ionic and cellular homeostasis, creating significant energy demands and a period of metabolic crisis. Calcium accumulates intracellularly, impairing oxidative metabolism, worsening the cellular energy crisis, and causing cytoskeletal damage. After the initial increase in metabolic demand, a hypometabolic state develops that can persist for 7-10 days (or even longer) after injury. Axonal dysfunction can also result from biomechanical stretch, particularly in unmyelinated axons, leading to neuronal dysfunction, if not cell death. Neurotransmission may remain altered for weeks after injury.
Table adapted from Halstead ME, Walter KD; Council on Sports Medicine and Fitness. Pediatrics. 2010 Sep;126(3):597-615. PMID: 20805152[5]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Symptoms of concussion fall into four categories: physical, cognitive, emotional, and sleep-related (see the above table).[5] Some of these symptoms may appear right away, whereas others may not be apparent for days or months after the injury. These symptoms may be subtle, and they can be difficult to recognize. The diagnosis of concussion is based solely on these symptoms; neurologic examination and structural imaging yield normal findings.
Image courtesy of Eisenberg MA, Meehan WP, Mannix R. Pediatrics. 2014 Jun;133:999-1006. PMID: 24819569[7]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
The above figure presents data from 280 patients aged 11-22 years who presented to an urban children's hospital with concussion.[7] They were assessed for symptoms of concussion at presentation and in follow-up until resolution of symptoms. Headache was the symptom most commonly reported at the time of injury.
Image courtesy of Kuppermann N, Holmes JF, Dayan PS, et al. Lancet. 2009 Oct 3;374(9696):1160-70. PMID: 19758692[8]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
The algorithm shown was developed from data obtained in a large-scale prospective cohort study that attempted to identify children at very low risk for clinically important brain injuries after head trauma.[8] Determination of the need for neuroimaging in a child with TBI may be guided by several factors, including history, symptoms, physical examination, and serial reassessment.
Table adapted from MMWR Morb Mortal Wkly Rep. 2011 Oct 7; 60(39):1337-42. PMID: 21976115[9]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Sports-related TBI is receiving a growing amount of attention in the media and within the medical field. Compared with adults, children are at increased risk for TBIs with increased severity and prolonged recovery. The current recommendation for athletes who have sustained a concussion is immediate removal from play. An athlete with a history of one or more concussions is at greater risk for being diagnosed with another concussion. The sports in which concussion is most commonly reported are football for boys and soccer for girls.[9]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
On the above susceptibility-weighted MRI scan, the arrow points to a microbleed associated with mild TBI.
Patient assessment tools such as the Acute Concussion Evaluation (ACE) form can help to guide the diagnosis and management of concussion. These tools are available from the Centers for Disease Control and Prevention (CDC) as part of a physician tool kit.[10] Systematic serial evaluation of patients with concussion can help to guide return to school, work, and sports, as well as identify those with persistent symptoms who would benefit from referral to a concussion specialist.
Image courtesy of Sharp DJ, Beckmann CF, Greenwood R, et al. Brain. 2011; 134:2233-47. PMID: 21841202[11]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
The resting-state functional MRI scans above, from a study comparing healthy control subjects with patients who have sustained mild TBIs, show changes thought to be directly reflective of brain injury.[11]
Management of concussion centers on cognitive and physical rest.[5] The concussed brain is energy deprived, and introducing additional stress may worsen symptoms and slow recovery. Although children with concussion may appear normal, they may report increased symptoms with cognitive activities, and they often have difficulty focusing on schoolwork, taking tests, and keeping up with assignments. Other activities requiring concentration and attention (eg, watching television, playing video games, or using a computer) may also exacerbate symptoms. Restriction from physical activity is recommended until symptoms have resolved.
Table adapted from the Marcantuono N and Spohn JL[12] and Bell and Herring.[13]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
A 15-year-old boy sustains a concussion during football practice. He has persistent headache, difficulty concentrating, and fatigue.
After what period of time should his symptoms be expected to resolve?
24 hours
2 days
3 days
2 weeks
1 month
Table adapted from Eisenberg MA, Meehan WP, Mannix R. Pediatrics. 2014 Jun;133:999-1006. PMID: 24819569[7] and Halstead ME, McAvoy K, Devore CD, et al. Pediatrics. 2013 Nov;132(5):948-57. PMID: 24163302[14]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Answer: D. 2 weeks.
Studies indicate that most patients experience resolution of concussive symptoms within 2-3 weeks of the injury. Initially, children and adolescents with concussion should remain out of school, but they may return before their symptoms have completely resolved.[14] The current standard recommendation is that patients have 24-48 hours of rest before beginning a stepwise return to activity; extended rest beyond 48 hours has not been shown to offer additional benefit.[15] Students with concussion may appear physically well but may nonetheless experience physical and cognitive difficulties that can hinder learning and adversely affect academic evaluation. Coordinating their return to school should focus on addressing their specific symptoms. Serial neurocognitive testing may be helpful in tracking improvement. The above table lists some adjustments that may be made in the school setting.[14]
Table adapted from Halstead ME, Walter KD; Council on Sports Medicine and Fitness. Pediatrics. 2010 Sep;126(3):597-615. PMID: 20805152[5]
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
The process of determining when a young athlete returns to play should follow an individualized, graduated course (see the above table).[5] Athletes with concussion should never return to play on the same day as their concussion, nor should they return to play while they are still symptomatic at rest or with exertion. The time to recovery of full cognitive function is longer in younger athletes than in college-aged or professional athletes.[16] An athlete with a history of multiple concussions may need a longer time to return to full play. If an athlete who has sustained an initial head injury sustains a second head injury before the symptoms associated with the first have fully cleared, second-impact syndrome may result, causing cerebral vascular congestion, cerebral swelling, and possibly death.
Image courtesy of Wikimedia Commons | Boston University Center for the Study of Traumatic Encephalopathy.
Pediatric Concussion and Other Traumatic Brain Injuries
Jamie Lien, MD | May 18, 2017 | Contributor Information
Long-term effects of concussion in children and adolescents are not clearly understood. Athletes with multiple concussions have been found to exhibit persistent shortcomings in neuropsychologic testing and school performance. Postconcussion syndrome can be defined as the presence of symptoms of concussion that last longer than expected (up to 1-6 weeks after injury). Factors associated with higher risk of prolonged symptoms include previous concussion, history of headaches, developmental disorders such as attention deficit hyperactivity syndrome (ADHD) and learning disorders, and psychiatric disorders.[12,13]
Chronic traumatic encephalopathy (CTE) is a progressive degenerative disease found in people with a history of repetitive brain trauma, which triggers the buildup of an abnormal protein called tau.[17] The image on the left is from a normal brain, while that on the right is from a brain with CTE, which is associated with memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and progressive dementia. There is concern that the degenerative changes of CTE can begin in childhood; in one case, the condition was found in the brain of a 17 year old, with CTE possibly having first manifested at an even younger age in this person.[18]
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Contributor Information
Author
Jamie Lien, MD
Coast Pediatrics, San Diego
Associate Physician
University of California, San Diego, School of Medicine
Rady Children's Hospital
Disclosure: Jamie Lien, MD, has disclosed no relevant financial relationships.
Centers for Disease Control and Prevention. Percent Distributions of TBI-related Hospitalizations by Age Group and Injury Mechanism — United States, 2006–2010. January 22, 2016. Available at: https://www.cdc.gov/traumaticbraininjury/data/dist_hosp.html. Accessed May 9, 2017.
Dawodu ST. Traumatic brain injury (TBI) – definition and pathophysiology. Medscape Drugs & Diseases from WebMD. September 22, 2015. Available at http://emedicine.medscape.com/article/326510-overview. Accessed May 8, 2017.
Pangilinan PH Jr. Classification and complications of traumatic brain injury. Medscape Drugs & Diseases from WebMD. February 13, 2017. Available at http://emedicine.medscape.com/article/326643-overview. Accessed May 8, 2017.
Halstead ME, Walter KD; Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report – sport-related concussion in children and adolescents. Pediatrics. 2010 Sep;126(3):597-615. PMID: 20805152
Giza CC, Hovda DA. The new neurometabolic cascade of concussion. Neurosurgery. 2014 Oct; 75 Suppl 4:S24-33. PMID: 25232881 [Full text].
Eisenberg MA, Meehan WP, Mannix R. Duration and course of post-concussive symptoms. Pediatrics. 2014 Jun;133:999-1006. PMID: 24819569 [Full text].
Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. PMID: 19758692
Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged ≤19 years – United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2011 Oct 7; 60(39):1337-42. PMID: 21976115 [Full text].
Sharp DJ, Beckmann CF, Greenwood R, et al. Default mode network functional and structural connectivity after traumatic brain injury. Brain. 2011; 134:2233-47. PMID: 21841202 [Full text].
Marcantuono N, Spohn JL. Concussion management and rehabilitation. In: Alexander MA, Matthews DJ, eds. Pediatric Rehabilitation: Principles and Practice. 5th ed. New York, NY: Demos Medical Pub: 2015.
Bell KR, Herring SA, eds. Youth sports concussions. Phys Med Rehabil Clin N Am. 2011 Nov;22(4). PMID: 22050946
Halstead ME, McAvoy K, Devore CD, et al. Returning to learning following a concussion. Pediatrics. 2013 Nov;132(5):948-57. PMID: 24163302 [Full text].
Thomas DG, Apps JA, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135(2):213-23. PMID: 25560444 [Full text].
Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr. 2003;142(5):546-53. PMID: 12756388
McKee AC, Cantu RC, Nowinski CJ, et al. Chronic traumatic encephalopathy in athletes: progressive tauopathy following repetitive head injury. J Neuropathol Exp Neurol. 2009 Jul;68:709-35. PMID: 19535999 [Full text].
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