Concussion pearls

1.  See prior posts on sideline assessment and Vienna return to work
2.  Younger athletes (high school) take longer to recover from concussions than college or NFL players on neuropsychologic testing and should be kept out longer accordingly.
3.  the role of multiple concussions in a single season or time between concussions is unclear but under investigation
4.  Clinical head injury in football is strongly related to translational forces.  Rotational forces follow translational forces.  These forces are highest with helmet to helmet hits and backward falls onto ground
5.  Head down strike increases the mass of the striking player 67 % due to alignment of the torso, and thereby increases the severity of concussion accordingly.
6.  Thicker larger and lighter helmets improve the function of prevention and decrease concussion severity
7.  Clinically differentiate early (temporal) injury involving dizziness and later (>40 msec) injuyr involving fornix and midbrain that is more likely associated with memory loss.
8.  The notion of grading concussion the day of the injury may be in error as late cognitive changes are far more important in predicting delayed recovery

Concussion: University of Pittsburgh sideline mental status examination card

Orientation questions
        What stadium is this?
         What city is this?
         Who is opposing team ?
          What month is it?
           What day is it?

Post-traumatic amnesia
            Remember three words:  girl , dog and green (ask player to repeat them)

Retrograde amnesia
           Ask "What happened in prior half"
           "What happened before you were hit"
          "What was the score before the hit"
          "Do you remember the hit"

Concentration
          ask the player to say the days of the week backwards, starting from today
          ask the player to say the following numbers backwards:  63, 419

Memory
          ask the player to recall the three words given earlier


Vienna conference return to play recommendations1.   Remove from game if any signs of concussion- any items missed on sideline exam
2.   No return to play in current game
3.   Medical evaluation after injury   a. rule out serious focal injury     b. neuropsychologic evaluation
4.   Stepwise return to play    a.  rest till asymptomatic      b.   light aerobic      c.  sport specific training     d.  noncontact practice      e. full contact practice     f. return to play

Concussion- player complaint and observer notation

from Mark Lovell  University of Pittsburgh signs and symptoms of concussion

Signs observed by staff                          player complaint

Appears dazed or stunned                     headache

Is confused about assignment                 nausea

Forgets plays                                         balance problem or dizziness

Unsure of game/score opponent             double or fuzzy/blurry vision

Moves clumsily                                      sensitive to light or noise

answers questions slowly                       sluggish/slowed down

loses consciousness                                "foggy" or "groggy"

behavior/personality change                    concentration or memory problem

retrograde amnesia                                  later sleep problem

anterograde amnesia                                fatigue

orbital pseudotumor due to thyroid opthalmopathy v, myositis

Differential points:  left image, from internet, shows medial rectus hypertrophy which (along with inferior rectus) is characteristic of thyroidopthalmopathy.  This condition is also tendon sparing.  Right image is orbital pseudotumor which in this case affects lateral rectus and tendon.  The condition on right can be secondary to a number of different conditions including RA, orbital tumor, Crohn's disease, and others. 

AAN quick hits 2010 novel uses of medication

pseudoatrophy MRI in MS helped with lamotrigine


cerebellar ataxia benefitted with varenicycline


frataxin level in FA helped with single dose erythropoetin




cell death in SCA type 3 (Machado-Joseph disease) helped by Lithium


improved ataxia and tremulousness with levodopa treatment for Angelman's disease

improved hypoxic damage with SSRI's in medically refractory partial epilepsy

CIS conversion to CDMS reduced by atorvastatin 80 mg

SUNCT/SUNA response to occipital nerve stimulator

CLIPPERS syndrome

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids.  Clippers.  (Mayo Clinic) AAN 2010 P02:182.  Eight patients had a distinctive clinical and radiological CNS disease with treatment.  Presentation was episodic diplopia or facial paresthesias with subsequent progressive ataxia, diplopia, dysarthria and paresis responsive to high dose steroids.  MRi showed gado enhanced peppering of pons extending into the medulla.  Weaning steroids always led to worsening.  Neuropath showed perivascular T lymphocytic infiltration without evidence of granulomas, lymphoma or vasculitis. 

2 type disproportionate anterocollis in Parkinson syndromes

Neurology 2020 AAN PO1.274  Clinical subtypes of disproportionate anterocollis in parkinsonian syndromes Revuelta G, Factor S. 


Myopathic subtype-- neck extensor weakness and limited range of motion, neck extensor myopathy on EMG,


dystonic subtype-- no weakness, full range of motion, laterocollis/torticollis and hypertrophy.