Understanding Concussion Repercussions: Brain Drama

By Harry Kerasidis, MD — Excerpt from Concussion-ology, chapter 8 “Brain Drama.” Dr. Kerasidis outlines the critical consequences of the most dangerous question in sports, whether to allow an athlete to “play or sit” after sustaining a possible concussion.

From the moment an athlete sustains a hit that bumps the brain against the inner table of the skull, the clock starts ticking. The next few minutes that follow lead to the most serious decision in sports. Because during this period, a number of neurological, physiological, financial and perhaps philosophical, repercussions occur, perhaps with life or death hanging in the balance.

Onlookers may be gasping or cheering with the sound of collision. Amidst opponent’s trash-talking, teammates and coaches may be eagerly helping the player to their feet. The athlete who sustained the hit immediately begins self-assessing their ability to return to play, tasking the potentially-injured brain and body to cooperate almost instantly and signal its own concussion pass or fail test.

Unfortunately, the athlete is not the best judge in this decision. Nor are the coaches. Conflicts of interest abound. Hopefully, an athletic trainer or team doctor intervenes and carries out a series of assessments to help identify the severity of a concussion risk.

Then, typically the decision is made: Play or sit.

It’s this period of time, from the hit to the return-to-play decision, where I fear sports may be risking too much. Too often, the post-hit evaluation process is rushed. With all eyes on the scoreboard, not enough emphasis is on the future well-being of the athlete.

Complicating matters further, signs of a concussion often take several minutes, hours or even days, to materialize.

While science continues to discover ways of assessing concussions, numerous studies show a connection between brain trauma and problematic futures. Consider these:

Perhaps an even louder wake-up call is that most concussions are not reported, and overt concussions are not required to cause brain damage. A 2012 study by the American Association of Neurological Surgeons looked at 45 high school varsity football players, none of whom experienced a clinical concussion during the season. The researchers concluded a single season of football play can produce measurable brain changes that have been previously associated with mTBI — “adding to the increasing amounts of literature demonstrating that a season of participation in a contact sport can show changes in the brain in the absence of concussion or clinical findings.” (Read More on this Here)

Another grave concern is the condition known as Second Impact Syndrome, or sudden cerebral swelling that may occur when a second concussion occurs while the brain is recovering from injury. Most people don’t realize the 50 percent fatality rate among individuals who suffer this fortunately rare event. Of the survivors, 100 percent will have permanent neurological impairments.

Then there is the more common Post-Concussion Syndrome (PCS). This condition results in various symptoms that may persist for days, weeks, months or even years causing complications with the quality of life. PCS symptoms may include:

  • Physical fatigue
  • Dizziness/vertigo, nausea
  • Headaches: Sensitivity to light, sound
  • Sleep disturbances (difficulty sleeping, staying awake or excessive daytime sleeping)
  • Emotional Impairment (personality changes, irritability, anxiety, depression)
  • Cognitive Impairment (aka “Brain fog” typically involving recent or short-term memory loss, poor attention and concentration)

Another seemingly obvious realization is that the hit that may have caused concussion-like symptoms, was not the first. In fact, if the athlete participated in practice, particularly in American football, the head had sustained numerous, if not thousands of “sub-concussive” hits prior to the one that caused the symptomatic blow.

Then, think of all the other times the individual was hit in the head previously in life during other activities like skiing, cycling, falls at a young age, fist-fighting, or in other sports and you can begin to see a straw was about to break the camel’s back. When the brain suffers a hit, but symptoms do not arise, we call them “asymptomatic sub-concussive” because slight damage may have been caused, but not felt.

These series of repetitive hits cumulatively may lead to Chronic Traumatic Encephalopathy (CTE) which is a progressive degenerative disease of the brain commonly found in athletes with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic sub-concussive hits to the head.

Autopsies reveal CTE is associated with a build-up of Tau protein, and looks like a brain afflicted by Alzheimer’s disease. CTE, the focus of the current NFL lawsuits among active and former players, may also be affected by lifestyle factors that can add stress to the damaged brain, including smoking, alcohol abuse, drug use, poor diet and lack of exercise. Medical science has not yet fully uncovered why some athletes develop CTE, while other don’t.

Another frightful symptom that may result from a concussion is the appearance of seizures. Seizures typically occur immediately upon losing consciousness or within the first week of the injury. Seizures are physical manifestations resulting from abnormal electrical discharges in the brain. These manifestations appear to be convulsions, when the body shakes rapidly, even violently.

Seizures occur in about 5 percent of head injuries, and usually within the first seven days. They typically occur more often when hits create a skull fracture or cerebral contusion, and occur more often in adults. Here are the most typical seizure risk factors after mTBI:

  • Post traumatic amnesia lasting longing than 12 hours
  • Intracranial bleeding
  • Persistent neurologic deficit
  • Skull fracture

Perhaps one of the more devastating potential repercussions of brain injury is the damage to the central nervous system, leading to paralysis. Our nervous system is especially sensitive to damage by injury. Both brain and spinal cord injuries have the potential to cause severe and life-changing disabilities. However, the type of disability sustained depends greatly on the region of trauma. The spinal cord is responsible for information transfer between the brain and the body. It follows that injuries to the spinal cord disrupt information transfer. The position of trauma to the spine largely determines the effect of a spinal cord injury on the body. For instance, injuries to the lower half of the spine can lead to paraplegia (paralysis of the lower half of the body with involvement of both legs), while injuries in the neck or brainstem may lead to quadriplegia (paralysis of both arms and both legs). Injury to one side of the brain may lead to hemiplegia of the opposite side of the body.

Is this nervous system damage avoidable? In theory, yes. Realistically, no. But risk can be mitigated, especially during the following moments after a suspected concussion.

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