Headaches - Cheerleader

Abstract

HISTORY: A 15-year-old female cheerleader presented to the primary care sports medicine clinic complaining of recurrent headaches after a series of concussions. She had three previous concussions, the last being four months prior. Her initial concussion symptoms were headache, slowed thinking and problems with loud sounds. Once the concussion symptoms resolved she developed intermittent headaches exacerbated by yelling and tumbling. The headache was frontal in nature and resolved with rest. PHYSICAL EXAMINATION: Neurological exam revealed intact sensation, reflexes, strength and cranial nerve function. Pronator drift and Rhomberg testing were intact. Rapid alternating hand movements, tandem gait and finger to nose movements were also intact. 3/3 objects were recalled at one and five minutes. The patient was also able to recite the months of the year backwards. DIFFERENTIAL DIAGNOSIS: Migraine variant Tension headaches Complex concussion Intracranial hemorrhage Syringomyelia Chiari Malformation TEST AND RESULTS: Neuropsychiatric testing ν memory composite verbal- 90th percentile, memory composite visual-68th percentile, visual motor speed composite-30.55 (average), reaction time composite-0.59 (below average) Cervical spine radiographs ν AP, lateral and oblique views show no fracture or dislocation MRI brain and cervical spine ν 9 mm descent of the cerebellar tonsils below the level of foramen magnum consistent with Chiari Malformation, type I ν 6 mm syrinx involving the cervical spinal cord at the level of C2 FINAL WORKING DIAGNOSIS: Complex concussion with Type 1 Chiari Malformation and simple syrinx TREATMENT AND OUTCOMES: 1. Referral to neurosurgery a. Options included serial MRIs every 6 months or cervical decompression surgery b. Family decided to choose decompression surgery 2. Craniocervical decompression surgery a. Collection of dural bleeding which caused worsening headaches and concussion like symptoms 3 weeks post-op b. Drainage of this CSF accumulation, with resolution of most concussion symptoms. 3. Return to activity a. RTP- 6 months, limited cheerleading, no tumbling. b. Repeat ImPact testing demonstrates persistent memory deficits