Acute Concussion Evaluation Research Articles

Pediatric Assessment and Management of Concussions

Concussions and mild traumatic brain injuries have become more widely recognized and understood during the past 5 to 10 years. Earlier and more active evaluation and management of this brain injury is necessary to reduce risk to the developing child and adolescent. Pediatricians play a central role in the evaluation and management of concussions and should develop a working understanding of the injury and its clinical manifestations. An individualized approach to evaluation and management by the pediatrician requires the development of a skillset to define the characteristics of the injury, conduct a full assessment of post-concussion symptoms, and define any risk history that may modify recovery. This evaluation forms the basis of concussion treatment, which involves the active management of the child’s daily routines at home, school learning and performance, and sports/recreational activities. The Acute Concussion Evaluation (ACE) and ACE Care Plan, published in the CDC’s “Heads Up: Concussion in Your Practice,” are presented as a set of tools that can assist the pediatrician in this endeavor.

Diagnostic confirmation of mild traumatic brain injury by diffusion tensor imaging: a case report

IntroductionTraumatic brain injury is a form of acquired brain injury that results from sudden trauma to the head. Specifically, mild traumatic brain injury is a clinical diagnosis that can have significant effects on an individual's life, yet is difficult to identify through traditional imaging techniques.Case presentationThis is the case of a 68-year-old previously healthy African American woman who was involved in a motor vehicle accident that resulted in significant head trauma. After the accident, she experienced symptoms indicative of mild traumatic brain injury and sought a neurological consultation when her symptoms did not subside. She was initially evaluated with a neurological examination, psychological evaluation, acute concussion evaluation and a third-party memory test using software from CNS Vital Signs for neurocognitive function. A diagnosis of post-concussion syndrome was suggested. Diffusion tensor imaging revealed decreased fractional anisotropy in the region immediately adjacent to both lateral ventricles, which was used to confirm the diagnosis. Fractional anisotropy is a scalar value between zero and one that describes the degree of anisotropy of a diffusion process. These results are indicative of post-traumatic gliosis and are undetectable by magnetic resonance imaging. Our patient was treated with cognitive therapy.ConclusionMinor traumatic brain injury is a common injury with variable clinical presentation. The system of diagnosis used in this case found a significant relationship between the clinical assessment and imaging results. This would not have been possible using traditional imaging techniques and highlights the benefits of using diffusion tensor imaging in the sub-acute assessment of minor traumatic brain injury.

Mild Traumatic Brain Injury

Research indicates that the assessment and discharge teaching practices for persons with traumatic brain injury are more focused on ruling out severe brain injury and informing the person about "red flags" warranting a return visit to the medical provider. Our primary purpose was to determine the extent to which discharge practices were aligned with the Centers for Disease Control and Prevention guidelines contained within the Acute Concussion Evaluation care plan. Responses from 87 nurses (25.0% response rate) to a tailored survey were analyzed to determine emergency department nurses' discharge teaching practices for adults who experienced a mild traumatic brain injury (MTBI). Results indicated that nurses in general were focused on injury-specific information and less often provided information about MTBI, symptom management, or strategies for preventing future brain damage. System improvements are justified to provide injured persons with a clearly defined diagnosis and instructions for follow-up and symptom management.

The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters

Sports-related concussion has received increasing attention as a cause of short- and long-term neurologic symptoms among athletes. The King-Devick (K-D) test is based on measurement of the speed of rapid number naming (reading aloud single-digit numbers from 3 test cards), and captures impairment of eye movements, attention, language, and other correlates of suboptimal brain function. We investigated the K-D test as a potential rapid sideline screening for concussion in a cohort of boxers and mixed martial arts fighters. The K-D test was administered prefight and postfight. The Military Acute Concussion Evaluation (MACE) was administered as a more comprehensive but longer test for concussion. Differences in postfight K-D scores and changes in scores from prefight to postfight were compared for athletes with head trauma during the fight vs those without. Postfight K-D scores (n = 39 participants) were significantly higher (worse) for those with head trauma during the match (59.1 ± 7.4 vs 41.0 ± 6.7 seconds, p < 0.0001, Wilcoxon rank sum test). Those with loss of consciousness showed the greatest worsening from prefight to postfight. Worse postfight K-D scores (r(s) = -0.79, p = 0.0001) and greater worsening of scores (r(s) = 0.90, p < 0.0001) correlated well with postfight MACE scores. Worsening of K-D scores by ≥5 seconds was a distinguishing characteristic noted only among participants with head trauma. High levels of test-retest reliability were observed (intraclass correlation coefficient 0.97 [95% confidence interval 0.90-1.0]). The K-D test is an accurate and reliable method for identifying athletes with head trauma, and is a strong candidate rapid sideline screening test for concussion.

Mild Traumatic Brain Injury

Research reported that mild traumatic brain injury (MTBI), the most common neurological condition in the world, is often undetected in the emergency department. Failure to properly detect and offer treatment therapies has been linked to chronic complications such as, mood disorders and postconcussion syndrome. This descriptive study used a tailored survey (25.0% response rate) to determine emergency department nurses' practices for the assessment and documentation of persons with MTBI. The primary purpose was to determine the extent to which these practices were aligned with the Centers for Disease Control and Prevention guidelines contained within the Acute Concussion Evaluation care plan. Results indicated that physical and cognitive symptoms were assessed and documented more than emotional or sleep symptoms. Still, some cognitive and physical symptoms were rarely assessed or documented. Focus seemed to be on ruling out more severe brain injury versus detection of a mild brain injury. Aligning the systematic assessment and documentation of persons with suspected concussion MTBI with recommendations from the Centers for Disease Control and Prevention is suggested.

A Cognitive–Representational Approach to Patient Education After Mild Traumatic Brain Injury

We propose that before implementing the Centers for Disease Control and Prevention Acute Concussion Evaluation protocol for mild traumatic brain injury, which includes self-monitoring and self-management activities, specific cognitive processes should be evaluated. These include determining the injured person's illness representation of the mild traumatic brain injury diagnosis, his or her capacity for help seeking, and attentional capacity for self-monitoring. Following this thorough assessment, an individualized follow-up action plan using the CDC clinical protocol can be implemented. Such an individualized action plan, at the point-of-care, has the potential to prevent the occurrence of postconcussion syndrome, and restore the injured person to preinjury functioning.

Evaluation of the Military Acute Concussion Evaluation for Use in Combat Operations More Than 12 Hours After Injury

The diagnosis and management of concussion can be difficult in a combat environment, especially in the absence of loss of consciousness or post-traumatic amnesia. As no validated test exists to diagnose or grade neurocognitive impairment from a concussion, the military currently employs the Military Acute Concussion Evaluation (MACE) in Iraq. This is a two-part test, which incorporates the standardized assessment of concussion (SAC) as its objective score, although it has not been shown to be valid unless administered shortly after injury. A research team deployed to Iraq between January and April 2009 to examine the validity of several tests of neurocognitive function following a concussion, including the MACE. When administered more than 12 hours after the concussive injury, the MACE lacked sufficient sensitivity and specificity to be clinically useful.

Sports-related concussions in pediatrics

Mild traumatic brain injury (mTBI) accompanied by concussion is a common presenting complaint among children presenting to emergency departments (EDs). There is wide practice variation regarding diagnosis and management of sports-related concussions in children. Our aim is to review the most recent evidence and expert recommendations regarding initial diagnosis and management of sports-related concussions in children. Previous classifications and return-to-play guidelines for sports-related concussions in children were inadequate and have been abandoned. The most recent recommendations, from the Third International Conference on Concussion in Sport (CIS), reinforce an individualized evaluation of the athlete's neurocognitive functioning, symptoms and balance. They further reinforce a step-wise approach in the return-to-play process once neurocognitive function has returned to baseline and all symptoms have resolved. The need for a standardized and objective tool to aid in the initial evaluation and diagnosis of mTBI in the clinical setting led to the development of the Acute Concussion Evaluation (ACE) protocol, which is currently being modified for specific use in the ED. Computed tomography (CT) in the acute setting is not likely to be useful for children with mTBI. Newer functional imaging techniques may prove relevant in the future. Further research on both the incidence of sports-related concussions in children and management paradigms is needed. The role of novel imaging modalities in clinical assessment also needs to be elucidated. An individualized approach to evaluation and management of sports-related concussions is recommended. It should incorporate standard symptom assessment, neuropsychological testing and postural stability testing.

Creatine Kinase BB Isoenzyme Blood Levels in Trauma Patients With Suspected Mild Traumatic Brain Injury

This pilot study sought to determine if creatine kinase isoenzyme BB (CK-BB) levels might serve as a biological marker of injury severity in mild TBI (mTBI). This was a retrospective study of 64 soldiers with suspected mTBI seen in a combat support hospital in Mosul between March and August of 2007. Four of the 64 total samples were positive for CK-BB. One major trauma patient had a negative CK-BB. This yields a sensitivity of 11% and a specificity of 97%. Military Acute Concussion Evaluation (MACE) scores collected also did not appear to reflect extent of injury. Although the low sensitivity of CK-BB from this study does not support its use as an early marker of suspected mTBI, the result is not conclusive given the small sample and the possibility of isoenzyme degradation during transport. Although limited, the data collected on MACE scores warrant additional evaluation of whether this measure is clinically relevant.

Improving Identification and Diagnosis of Mild Traumatic Brain Injury With Evidence

A dearth of standardized assessment tools exists to properly assess and triage mild traumatic brain injury (mTBI) in primary care and acute care settings. This article presents evidence of appropriate psychometric properties for the Acute Concussion Evaluation (ACE), a new structured clinical interview. Parent informants of 354 patients, aged 3 to 18 years, with suspected mTBI completed the ACE via telephone interview. Acute Concussion Evaluation. Evidence is presented for appropriate item-scale membership, internal consistency reliability as well as content, predictive, convergent/divergent, and construct validity of the ACE symptom checklist. Overall, the ACE symptom checklist exhibits reasonably strong psychometric properties as an initial assessment tool for mTBI.