Differences in How Teens Experience Concussion

At the University of Kentucky neuropsychologist Dan Han, an expert on concussions, and psychologist Lisa Koehl, joined forces to study how concussions cause and are complicated by emotional effects in a group of 37 student athletes age 12-17. What they found is that 22 of the 37 students showed chronic post-concussive symptoms. Of those, 23 percent were sensitive to light while 14 percent were sensitive to noise. In comparison, of the 15 teens without emotional symptoms, 13 percent were sensitive to light and no teens were sensitive to noise. Teens in the study who reported anxiety were 55 percent more likely to experience attention difficulties than those without anxiety, while teens with irritability/aggression were 35 percent more likely to self-report problems with attention than teens without irritability.

There were no differences between the two groups in factors such as what percentage experienced loss of consciousness, amnesia, nausea and/or headaches, indicating that the groups were likely comparable in the level of severity of concussion.

According to the researchers their findings demonstrate a bidirectional relationship between both emotional symptoms developing in conjunction with physical symptoms, and also emotional symptoms developing because of the physical symptoms. They hope the data can be used to plan more effective treatment for people with concussions.

What is Post-Concussion Syndrome?

Here is a good definition of post-concussion syndrome (PCS) from the National Institute of Neurological Disorders and Stroke:

Within days to weeks of the head injury approximately 40 percent of TBI patients develop a host of troubling symptoms collectively called postconcussion syndrome (PCS). A patient need not have suffered a concussion or loss of consciousness to develop the syndrome and many patients with mild TBI suffer from PCS. Symptoms include headache, dizziness, vertigo (a sensation of spinning around or of objects spinning around the patient), memory problems, trouble concentrating, sleeping problems, restlessness, irritability, apathy, depression, and anxiety. These symptoms may last for a few weeks after the head injury. The syndrome is more prevalent in patients who had psychiatric symptoms, such as depression or anxiety, before the injury. Treatment for PCS may include medicines for pain and psychiatric conditions, and psychotherapy and occupational therapy todevelop coping skills.

Doctor examining a brain CT scan

New MRI Technique Shows Holes in Brain Membranes After Concussion

Up until now it has not been possible to visualize the effects of mild TBI on an MRI scan because standard MRI only picks up significant damage to brain tissue. However a new technique using MRI following injection of dye can demonstrate tiny holes in the meninges caused by a concussion, because the dye leaks through the holes. The meninges are the three thin membranes which snugly wrap the outside of the brain. Their job is to hold the brain in place, cushion the brain from minor shock, and keep out harmful molecules. The meninges contain an intricate set of blood vessels and nerves. It was established long ago that concussion can cause severe, post-traumatic headache by dilating blood vessels in the meninges and stretching the nerves that wrap around those vessels.

The new technique was developed by an ingenuous senior at Stanford University named Theo Roth who is majoring in biology. His work with humans (which was published online in the Journal Nature on December 8, 2013) derived from years of experimentation with mice in which Roth used a surgically implanted micro-camera to record the effects of concussion on mice brains in real time. Roth’s work was sponsored and made possible by Dorian McGavern’s lab at the National Institute of Neurological Disorders and Stroke (NINDS). Roth explains that when a concussion causes holes in the meninges it has damaged meningeal cells which leak internal substances (in particular something called reactive oxygen species) that are toxic to cells in the underlying brain tissue.

In the article in Nature Roth worked with co-scientist Lawrence Latour to examine 142 patients who have recently suffered a concussion but whose initial MRI scans had not revealed any physical damage to the brain tissue. Many of these patients were sent home from the hospital with the negative scans, but had since suffered headaches, memory loss or other hallmark symptoms of a mild brain injury. Latour injected the patients with a dye and conducted a follow-up MRI scan; in 49 percent of these patients, Latour saw the dye leaking through the meninges. This new technique is a true breakthrough for people suffering from mild TBI who are not believed by family, treating physicians or – in the case of litigation – by liability insurance companies and their defense lawyers.

Beta-Amyloid is Deposited within Hours of Moderate to Severe TBI

Neuropathologists such as Bennet Omalu, M.D. and Ann McKee, M.D. have already established that NFL football players who had many concussions and who suffered from the cognitive, memory, personality, and behavioral changes consistent with CTE (chronic traumatic encephalopathy) had significant deposits of the beta-amyloid protein seen in Alzheimer’s disease when they died. What about people who have just one significant concussion? We now have a startling answer. On November 11, 2013 neuroscientist Hong Young published a study titled Amyloid Imaging With Carbon 11–Labeled Pittsburgh Compound B for Traumatic Brain Injury in JAMA Neurology online (doi:10.1001/jamaneurol.2013.4847). Dr. Young had PET scans performed on 15 persons (aged 21-50) with moderate to severe TBI and 11 healthy age-matched controls who had no signs, symptoms or history of neurologic disease. The results of the PET scans showed significant deposits of beta-amyloid protein in the cortical gray matter and striatrum (the brain’s motivation center) beginning within hours of the TBI in the TBI group, and an absence of such deposits in the brains of the healthy controls.

Although the size of the study was small and this is only study, it is important not just because it refutes the NFL position that even dozens of concussions do not cause brain changes associated with dementia, but because it alerts victims of even one significant concussion to their need for proper diagnosis and initiation of anti-amyloid therapy if significant amyloid deposits are found.

Why is Grandpa or Grandma Acting That Way?

Older people often have poor balance. If they fall forward they can strike their head on the ground and sustain a concussion, but may not remember the event. Afterwards they can exhibit cognitive slowing, poor memory, difficulties with word retrieval and other problems that family may wrongly attribute to Alzheimer’s. How frequent are falls among the elderly causing TBI? Very. According to a research paper published in October 2013 in the Journal of the Canadian Medical Association by Stephen Robinovitch of Simon Fraser University in Canada, some 60% of the hospital admissions of long-term care elderly patients were due to traumatic brain injury. Fraser found that sideways falls into the wall or furniture were the least common and that falling forward to the ground was the most common. He also said, “We were actually surprised that falling forwards is much more risky. You’re three times more likely to impact your head if you fall forward.”

There is No Concussion Proof Helmet

In cases where a bike rider suffered a TBI from a fall or crash caused by someone else’s negligence but the rider was not wearing a helmet, the defense will always claim that but for the rider’s failure to wear a helmet the TBI would not have occurred. Sometimes this is blatantly false, as where the impact occurs to the rider’s face, a place that no helmet covers. But what about cases where the impact occurs to a place on the rider’s head that would have been covered? Can any helmet prevent a concussion? One of American’s leading experts on the neurological effects of head trauma in sports, Dr. Barry D. Jordan of the Burke Rehabilitation Hospital in NY, says no.

In an interview with The Guardian here is what Dr. Jordan said when asked whether improved helmet design for NFL players had helped reduce concussions, “Probably not, because there is no concussion proof helmets. The mechanism of a concussion is really rapid acceleration deceleration of the head and the head will accelerate or decelerate regardless if you have a helmet on or not. The helmet is helpful in protecting against more serious brain injuries such as intracranial hemorrhages and skull fractures. There is no concussion proof helmet.” While I am in favor of bicycle riders ALWAYS wearing a helmet, even on a two minute trip to the corner grocery store, it’s important to remember that no helmet can completely protect the brain from trauma.

Doctor examining a brain CT scan

A New Concussion Test That Uses Objective Factors

In March 2013 two neurologists at Mayo Clinic presented their research into finding an objective, biological marker for concussion that does not rely on subjective reporting of symptoms. Dr. David Dodick and Dr. Bert Vargas presented their findings at the American Academy of Neurology annual meeting in San Diego.

These doctors found significant abnormalities in heart rate and blood pressure in 21 patients who had just sustained a concussion. The timeliness and low cost of testing for such autonomic nervous system changes makes this kind of testing very useful. Brain scans are typically done so long as a patient has had a concussion that his or her brain has already healed by the time the scan is done, and these scans are very expensive.

The autonomic nervous system is a control system for automatic body functions like heart rate, blood pressure, digestion, breathing rate, and perspiration. Previously it was thought that disturbances in autonomic function were associated with moderate to severe TBI not mild TBI (which is equivalent to a concussion).

Sub-Concussive Brain Trauma Causes Auto-Immune Brain Response

Until now it was thought the brain could only be damaged by trauma sufficient to cause a concussion – an event marked by loss of consciousness or by detectable alteration of consciousness (such as dazing, confusion or memory loss). A new study of 67 college football players shows that sub-concussive trauma (trauma below the level required to cause a concussion) can damage the brain by leaking a protein called S100B into the bloodsteam that causes antibodies to form.These antibodies attack the protein and set off an auto-immune response in the brain of the same type that researchers have seen cause dementia. Prior to this study S100B had only been seen in head-injured athletes who had sustained concussions.

The study concluded that the more sub-concussive head trauma an athelete endures the greater the amount of protein S100B circulating in the brain’s bloodstream, and the greater the auto-immune response. The study was conducted by Damir Janigro, Ph.D., the director of cerebrovascular research in Cleveland Clinic’s Lerner Research Institute, and his collaborators Nicola Marchi, Ph.D., of Cleveland Clinic and Jeffrey Bazarian, M.D., M.P.H., of the Clinical and Translational Science Institute at the University of Rochester Medical Center. A sideline bloodtest costing $40 can be done to detect S100B after a football player suffers a hard hit even if he isn’t knocked out or put into an obviously confused state. Any player with elevated S100B should be evaluated by a neurologist and kept from play as the doctor directs. The study can be found at in the March 6, 2013 online issue of PloS One.

CTE (Chronic Traumatic Encephalopathy) Killed Junior Seau

Medical investigators from the National Institutes of Health have concluded that when NFL linebacker Junior Seau committed suicide in May 2012 he was suffering from CTE (chronic traumatic encephalopathy). CTE is a degenerative brain disease accompanied by personality change, mood swings, and violence. CTE results from cumulative blows to the head and has affected boxers and football players in their 30s and 40s. The distinct pathological changes evident in Seau’s brain match up with all the concussions he suffered during twenty years of football and with testimony from family members that Seau became moody, depressed, irritable, angry, and socially isolated close in time to his suicide.

Surgical Cure For Post-Concussive Headache

Ivica Ducic, MD, Associate Professor of Plastic Surgery and the Director of Peripheral Nerve Surgery at Georgetown is a pioneer in surgery to eliminate or reduce headaches following concussion. Dr. Ducic says that two different kinds of pain-producing nerves may be affected by a concussion: intracranial nerves that traverse the membranes covering the brain (which she does not touch) and peripheral nerves that lie outside the skull in the muscles of the forehead, temple, and base of the head. With regard to the peripheral nerves of of the face and head, Dr. Ducic says they may be damaged by stretch injury occuring during the event that causes the concussion by means of whiplash, head rotation or even contact between the face or head with a hard surface.

When medication fails to stop post-concussive headaches after three months, she will evaluate the patient to see if one or more peripheral nerves are tender to the touch and if the headache can be stopped temporarily by a pain block injection to the involved nerve(s). The areas of interest lie just above the eyebrows; on the sides of the head by the ear and jaw; and along the sides of the base of the head at the junction with the neck. If the nerve is tender and if the pain can be relieved by a nerve block injection, she will discuss surgery with the patient.

According to Dr. Ducic: “What we do with surgical intervention depends on the mechanism of the injury. If the mechanism of the injury has caused direct trauma with cuts and open skin requiring sutures in that anatomical region, I might need to remove that nerve although it is a sensory nerve. The only deficit after that would be numbness in that respective area because these nerves have nothing to do with any motion of the face, arms, or legs and besides that they’re not in the brain.

We don’t go into either the brain or the spine; incisions made over the front part of the head, side, and back part of the head are rather superficial and scars are mainly hidden by hair. If the trauma has not directly damaged the nerves and scarred them, but rather just disturbed them to the degree that they can cause some swelling and different three-dimensional spacing that can cause malfunction of the nerve, what they would do then is decompress those nerves. It’s the equivalent of unbuttoning shirt and tie because it’s too tight and you can’t breathe or speak normal. So that phenomenon in the example has been done for carpal tunnel for centuries and it can now be applied very easily in the treatment of the post-traumatic headaches and migraines.”

Dr. Ducic has done the decompression surgery more than 1,200 times. He says this surgery relieves headaches in many patients. The way He describes it is as follows: “What we do is make an incision after the opening which is accessing just plain sub-cutaneous, and then you are approaching the areas were nerves actually live; in her case in the back of the head. Then you would go ahead and free the fascial layer which is just a coat over the muscles but due to trauma it gets to be stiffer. So instead of just being a nice envelope around the nerve, it starts pinching the nerve and pressing it, and obviously the nerve protests and gives you the headache or migraine. If intra-operatively atomically variations or pressure by any other structure of vessels or a portion of the muscle, are identified, we would free up that as well.”