Concussion is a transient disturbance in brain function caused by head injury, usually a blow. By definition, there are no structural brain abnormalities visible directly or on imaging studies, in contrast to more serious brain injuries (traumatic brain injuries Traumatic Brain Injury (TBI) Traumatic brain injury (TBI) is physical injury to brain tissue that temporarily or permanently impairs brain function. Diagnosis is suspected clinically and confirmed by imaging (primarily... read more [TBIs]).
Pathophysiology is still being clarified, but brain dysfunction is thought to involve excitotoxicity, which is neuronal damage caused by excessive release of excitatory neurotransmitters, particularly glutamate. (For additional information, see Concussions: What a neurosurgeon should know about current scientific evidence and management strategies.)
Estimates of the incidence of sports-related concussion in the United States vary from 200,000 a year up to 3.8 million a year; the highest numbers include rough estimates of injuries that are not evaluated in a hospital or otherwise reported. The awareness and thus reporting of concussions has risen significantly in the past decade—the incidence of serious and fatal sports-related TBI has not increased similarly. Sports that routinely involve high-speed collision (eg, football, rugby, ice hockey, lacrosse) have the highest rates of concussion, but no sport, including cheerleading, is free of risk. An estimated 19% of participants in contact sports have a concussive injury over the course of a season.
Unlike with other causes of concussion (eg, vehicular crashes, falls), which are usually isolated events, sports participants are continually exposed to risk of concussion. Thus, repeat injury is common. Athletes are particularly vulnerable if the repeat injury occurs before they have fully recovered from a previous concussion, but even after recovery, athletes who have suffered one concussion are 2 to 4 times more likely to suffer another concussion at some point. Also, repeat concussions may occur after a less severe impact.
Furthermore, although most athletes eventually recover fully from a single concussion, about 3% of those who had multiple (even apparently minor) concussions develop chronic traumatic encephalopathy Chronic Traumatic Encephalopathy (CTE) Chronic traumatic encephalopathy (CTE) is a progressive degenerative brain disorder that may occur after repetitive head trauma or blast injuries. (See also Overview of Delirium and Dementia... read more (CTE, initially described in boxers and termed dementia pugilistica). In CTE, patients have structural neurodegenerative changes, including cortical atrophy, somewhat similar to changes present in patients with Alzheimer disease Alzheimer Disease Alzheimer disease causes progressive cognitive deterioration and is characterized by beta-amyloid deposits and neurofibrillary tangles in the cerebral cortex and subcortical gray matter. Diagnosis... read more . Symptoms can include
Dementia-like symptoms (eg, disturbances in memory, cognition, mood, or behavior)
Impaired judgment and decision making
Personality changes (eg, irascibility, volatility)
Several prominent retired athletes who had sustained recurrent TBI have committed suicide.
The Centers for Disease Control and Prevention (CDC) reports an average of 1.5 deaths a year from sports-related concussions. In most cases, a concussion, usually undiagnosed, had occurred before the fatal one.
Second-impact syndrome is a rare but serious complication of concussion. In this syndrome, acute, often fatal brain swelling occurs when a second concussion is sustained before complete recovery from a previous concussion. Vascular congestion is thought to lead to rapidly increased intracranial pressure (ICP) that is difficult or impossible to control.
The mortality rate approaches 50%.
Symptoms and Signs of Sports-Related Concussion
The most obvious disturbance of brain function with a concussion is
Loss of consciousness
However, many patients do not lose consciousness but instead manifest symptoms and signs such as
Confusion: Appears dazed or stunned, is unsure of opponent or score, answers slowly
Memory loss: Does not know plays or assignment, does not recall events before the injury (retrograde amnesia) or afterward (anterograde amnesia)
Vision disturbance: Has double vision or light sensitivity
Dizziness, clumsy movements, impaired balance
Nausea and vomiting
Loss of smell or taste
Postconcussive symptoms are symptoms that may be present for a few days to weeks after concussion; they include
Short-term memory difficulties
Personality changes (eg, irritability, mood swings)
Sensitivity to light and noise
Postconcussive symptoms typically resolve in a few weeks to several months.
Pearls & Pitfalls
Diagnosis of Sports-Related Concussion
Sometimes neuroimaging to exclude more serious injuries
Athletes with possible concussion should be evaluated by a clinician with experience in evaluation and management of concussions. Sometimes such clinicians are on site at high-level athletic events; otherwise, sideline staff should have training in recognizing concussive symptoms and protocols for referring patients for evaluation.
Diagnostic tools, such as the Standardized Assessment of Concussion (SAC), or its subsequent versions (Sports Concussion Assessment Tool 2 [ SCAT2 ], SCAT3 , or the current version [ SCAT5 ], which are available free online and can be downloaded to handheld devices), can help coaching staff, trainers, and inexperienced clinicians screen athletes on site. The CDC has tools and training information for anyone who needs to recognize, respond to, and try to prevent concussion and other serious brain injuries (CDC "Heads Up" programs ).
Neuroimaging Neuroimaging Traumatic brain injury (TBI) is physical injury to brain tissue that temporarily or permanently impairs brain function. Diagnosis is suspected clinically and confirmed by imaging (primarily... read more is not helpful to diagnose concussion itself but is done if more serious brain injury (eg, hematoma, contusion) is suspected. Typically, CT should be done if patients have any of the following:
Loss of consciousness
Glasgow Coma Score (GCS) < 15 (see table Glasgow Coma Scale Glasgow Coma Scale* )
A focal neurologic deficit
Persistently altered mental status
Other signs of deterioration
Formal neurocognitive testing can likely show abnormalities in symptomatic patients but is not typically done unless postconcussive symptoms last longer than expected or the patient has severe cognitive problems. However, some athletic programs do baseline neurocognitive tests on all participants and repeat them after concussion so that more subtle abnormalities can be identified and further participation deferred until the person returns to baseline. One of the more commonly used tests is a commercial computer-based tool called ImPACT.
Treatment of Sports-Related Concussion
Removal from contest or activity
Acetaminophen for headache
Graduated increase to full athletic activity
Patients who had any concussive symptoms or signs should not return to play that day and are advised to rest. School and work activities, driving, alcohol, excessive brain stimulation (eg, using computers, television, video games), and physical exertion should be avoided during early recovery to prevent prolongation or exacerbation of the symptoms (1 Treatment reference Sports activities are a common cause of concussion, a form of mild traumatic brain injury. Symptoms include loss of consciousness, confusion, memory difficulties, and other signs of brain dysfunction... read more ).
No drugs have been shown to improve recovery from concussion, but specific symptoms can be treated with appropriate medications (eg, preferably acetaminophen, or alternatively nonsteroidal anti-inflammatory drugs [NSAIDs] for headache).
Family members are advised to watch for signs of deterioration and take the person to the hospital if they occur. These signs include
Decreased level of consciousness
Focal neurologic deficits (eg, hemiparesis)
Deterioration of mental function (eg, seems confused, cannot recognize people, behaves abnormally)
Return to play
Typically, a graduated approach is recommended. Athletes should refrain from athletic activities until they are completely asymptomatic and require no medication. Then they may begin light aerobic exercise and advance through sport-specific training, noncontact drills, full-contact drills, and finally competitive play. Patients who remain asymptomatic at one level can be advanced to the next.
But however quickly they improve, patients are typically advised not to return to full play until they have been asymptomatic for 1 week. Those who had severe symptoms (eg, unconsciousness for > 5 minutes, > 24 hours of amnesia) should wait at least 1 month.
Athletes who have had multiple concussions in one season need to be fully advised of the risks versus benefits of continued participation. Parents of school-aged children should be involved in these discussions as well.
1. Brown NJ, Mannix RC, O'Brien MJ, et al: Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics 133(2):e299–304, 2014. doi: 10.1542/peds.2013-2125
Prognosis for Sports-Related Concussion
Patients recover fully, although postconcussive symptoms can persist for up to several months.
Chronic traumatic encephalopathy causes progressive brain dysfunction typically leading to death within 10 to 15 years of initial presentation.
Concussion involves transient, traumatic brain dysfunction; consciousness may be lost, but sometimes patients manifest only confusion, memory loss, and gait or balance difficulties.
Symptoms may resolve quickly or persist for up to several weeks.
Athletes with possible concussion should be removed from play and evaluated; screening tools such as SCAT3 or SCAT5 may be helpful.
Neuroimaging is done if there is loss of consciousness, GCS < 15, focal neurologic deficits, persistently altered mental status, or clinical deterioration.
After concussion, patients are more susceptible to repeat concussion for a period of time and must refrain from sports activities until they have been asymptomatic for 1 week or more (depending on severity of injury).
Athletic activities are resumed gradually.
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