HEAD INJURY with Delayed
Presentation in Football
Wes Bailey, MD
Moses Cone Sports Medicine Fellow
SEACSM Annual Meeting
February 5, 2011
Case

ID/CC
 17
year-old male Varsity cornerback c/o left-side
headache (HA).

HPI
 HA
began during a football game 5 days prior to
presentation.
 HA
started after he suddenly arose from the ground
following a play.
 The player did not recall the details of the play.
 Player eventually pulled from the game when he could not
remember a play call.
Case




Ensuing 4 Days - Not evaluated by trainer or MD.
Worsening headache severity.
Day # 4 (AM) - One episode of vomiting along with
generalized fatigue.
Day # 4 (PM) - Head strike after return to practice.
Blurred vision for ~5 minutes.
 Feet felt “asleep” for ~10 minutes.


Went to bed early 2/2 headache.

Day # 5



Brought by mother to SM office.
Decreased HA severity.
No mood lability or impaired concentration.
Physical Examination


Entire PE including neurological exam WNL.
Standard Assessment of Concussion (SAC)
 Score:
24/30.
 Deficits:
 Orientation
– Date (1 point)
 Immediate memory (2 points).
 Delayed recall (1 point).
 Recitation of the months of the year backwards (1 point).
 Recitation of a six-number string in reverse order (1 point).
Panel/Audience Questions
Differential Diagnoses




Concussion.
Second Impact Syndrome.
Intracranial Bleed.
Post-Concussive Syndrome.
Panel/Audience Questions
Image Findings

Cervical Spine X-Rays


Normal.
Head CT

Thin extra-axial fluid collection
on the left cerebral
hemisphere without mass
effect, midline shift, or
hydrocephalus.
Final Working Diagnosis


Subdural Hematoma.
Concussion.
Treatment & Outcome

Referred to a local neurosurgeon on the day of
presentation.
 Managed
non-operatively given stable medical
condition and lack of mass effect, midline shift, or
hydrocephalus.
 Held from practice and physical education activities.
 Instructed to f/u with the neurosurgeon for interim reassessment and repeat head CT(s).
Treatment & Outcome


Instructed to avoid non-steroidal anti-inflammatory
drugs.
Mother received emergency precautions and
instructed to limited the player’s physical activities at
home.
Treatment & Outcome
Head CT - 2 Days Later

Slightly decreased
size of the fluid
collection.
Treatment & Outcome
Final Head CT - 3 Weeks Later

Cleared subdural
hematoma.
Treatment & Outcome



Headache resolved.
Resumed full-time academic activities w/o difficulty.
Returned to baseline without mood/behavior changes.
Treatment & Outcome




Held from sports and physical education activities for
the remainder of the 2010 football season; for a
period longer than 1 month.
Gradually resumed non-contact physical education
activities at school.
Restricted from wrestling this season.
Cleared for unrestricted sports participation
beginning in the summer of 2011 as long as he
remains symptom-free.
Key Points





Head injury is the leading cause of death in football,
and in sports in general1.
Early communication is key.
Athletes with intracranial bleeding can have normal
physical findings.
History is essential.
Individualized neurosurgical management with serial
imaging.
1. Gerberich S et al. Concussion incidences and severity in secondary school varsity football players. Am J Pub Health. 1983; 73:1370-1375.
Key Points


No official guidelines wrt NSAID use.
No official guidelines wrt activity restrictions.

No physical activity for at least 1 month.

Professional hockey player s/p craniotomy for parenchymal
hemorrhage.

Soccer & ice hockey players s/p sx for ant/post wall fractures
of the frontal sinus.

16 y.o. female soccer player s/p drainage of large chronic
SDH which communicated with an arachnoid cyst and caused a
mass effect. RTP 1 year later. No interim incidents.
Panel/Audience Questions