Concussion, a traumatic brain injury

What is a concussion

What is a concussion?

The American Association of Neurological Surgeons defines concussion as a brain injury that leads to temporary loss of the normal brain function.

A concussion can lead to headaches and an inability to concentrate. It can also affect one’s memory, balance, and coordination. In rare cases, it can lead to loss of consciousness.

The United States Centers for Disease Control and Prevention (CDC), categorizes a concussion as a type of traumatic brain injury or TBI—caused by a bump, blow, or jolt to the head.  These sudden movements cause the brain to rebound or slide within the inner walls of the skull. This, in turn, causes chemical changes and damage to the brain cells.

What are the signs and symptoms?

The signs and symptoms of a concussion usually occur immediately after a head injury. Some symptoms may show up hours or days afterwards.

A caregiver or witness may observe one or more of the following signs in a concussed person:

  • Confusion and saying things that don’t make sense
  • Temporary loss of memory following the traumatic event
  • Delayed response to questions
  • Clumsy movements
  • Loss of consciousness
  • Changes in behaviour, mood or personality like becoming more irritable

The common symptoms experienced by the patient may include:

  • Headache
  • Nausea or vomiting
  • Blurred vision
  • Fatigue or drowsiness
  • Dizziness and Imbalance
  • Slurred speech
  • Ringing in the ears

How serious are concussions?

Concussions, in general, are not life-threatening. In most circumstances, people recover quickly and completely.

However, in some cases, the effects of a concussion can be serious. A severe traumatic brain injury (TBI) increases the future risk of  several neurodegenerative diseases (diseases that affect the brain nerves) such as Alzheimer’s disease, Parkinson’s disease, dementia and amyotrophic lateral sclerosis (ALS)

One may not understand the seriousness of the concussion immediately after an injury and must keep a check on the signs and symptoms up to a few days after the event.

A visit to the emergency department is recommended if any of the concussion signs or symptoms get worse, for instance,

  • Prolonged severe headache
  • Repeated vomiting or nausea
  • Loss of consciousness (more than 30 seconds), and
  • Increased confusion

What causes a concussion?

A concussion is caused by trauma to the brain occurring by any of the following events:

  • Falling or getting hit while playing sports or other physical activities
  • A violent blow to the head and neck or upper part of the body during a fight or an accident
  • Sudden acceleration or deceleration of head caused by events such as car crash or accident

What causes a concussion

How common are concussions?

Mild traumatic brain injuries are extremely common affecting about 42 million people annually worldwide. About 100-300 per 100,000 people seek medical attention annually worldwide for the same. Certain populations such as contact sports athletes, military personnel and victims of domestic violence are at higher risk of suffering from concussion as compared to the general population.

Traumatic brain injuries are a leading cause of death and disabilities in India. The incidence of traumatic brain injury and related-deaths is estimated to be about 1.5-2 million and 1 million respectively every year. The major causes are road traffic injuries (60%) followed by falls (20-25%) and violence (10%).

Who are at risk?

The risk of concussion is usually higher in:

  • Falls, especially in young children and elderly populations
  • Persons participating in high-risk sports such as football, hockey
  • Individuals playing without proper sports equipment such as helmet
  • Being involved in a motor vehicle collision, accident
  • Being a victim of physical abuse
  • Those with a previous history of concussion

How is a concussion diagnosed?

A doctor will evaluate the signs and symptoms by asking details on how the injury occurred, what part of the head was affected and what symptoms are experienced.

Tests recommended for diagnosis may include a neurological examination, cognitive testing, and imaging tests.

Neurological examination: Involves examination of vision, hearing, sensation, balance, coordination, and reflexes

Cognitive testing: Involves evaluation of cognitive/thinking abilities like memory, concentration, and ability to recall information

Imaging test: In certain cases, brain imaging may be recommended where symptoms have worsened. This helps to determine if the injury has caused fractures, internal bleeding or swelling in the skull. In such cases, computerized tomography (CT) scan or magnetic resonance imaging (MRI) may be used to diagnose complications that may have occurred after a concussion.

In children, unnecessary exposure to radiation is avoided and hence CT scan is used when there are signs of a skull fracture.

How is a concussion treated?

The treatment of concussion depends upon the seriousness of the associated signs and symptoms. In mild cases, rest and pain killers for headaches are recommended.

Physical and mental rest: Taking adequate rest in the first few days after a concussion is the most appropriate way of recovering faster. Activities that require high mental concentration such as reading, writing, watching TV, video games should be avoided in the first 48 hours. Physical activities such as sports or activities that involve vigorous movements should also be avoided. Daily activities should be resumed gradually and should be stopped in case of worsening symptoms. 

Sometimes, special therapies might be recommended by the treating physician such as rehabilitation for vision, balance problems, or cognitive rehabilitation as part of the treatment plan for complete recovery.

It is always recommended to consult the treating physicians once all symptoms have resolved and before returning to routine activity.

Pain killers: Concussions are sometimes followed by headaches, that can last up to weeks. Pain killers are prescribed for the same. Pain-killers should be taken only if prescribed. Self-medication should be avoided, as some pain-killers may increase the risk of bleeding.

What are the possible complications of a concussion?

The potential complications of concussion include:

  • Post-traumatic headaches: A headache that may last up to 7 days after an injury
  • Post-traumatic vertigo: Feeling dizzy or spinning of head lasting up to a month
  • Thinking difficulties: persisting beyond 3 weeks. Such symptoms accompanied by headaches and dizziness persisting beyond three months is known as post-concussion syndrome
  • Second impact syndrome: experiencing a second concussion before the signs and symptoms of a first concussion have resolved may cause rapid and life-threatening brain swelling.

How to prevent a concussion?

Some general tips on concussion prevention include: 

  • Using the right type of approved headgears/helmets for specific sports like skating, cycling, horseback riding, and riding bikes and scooters
  • Wearing a seat belt every time while driving
  • Not driving while under the influence of alcohol or drugs
  • Taking precautions at home by minimizing the risks of a fall. Secure electric cords, put away toys, use safety locks and gates, and install window guards, appropriate handrails for stairs especially for use by the elderly.

Measures to be taken during sports activities:

  • Young children to be supervised throughout the sport
  • Ensure children play sport appropriate for their age
  • Not diving when the water level is less than nine feet either in swimming pools or ponds, lakes and rivers
  • Avoiding clothes or accessories that can interfere with vision
  • Avoiding sports when sick
  • Damaged sporting equipment should be discarded and replaced appropriately

When to seek medical help?

It is advised to seek medical help within 1-2 days if it isn’t an emergency.

Immediate medical attention is required if any of the following warning signs are noticed:

  • Persisting headache or pain around the head
  • Co-ordination disturbances or motor dysfunction
  • Alterations to senses; hearing, tasting or vision
  • Distracted and unable to focus for an extended time
  • Speech difficulties

How is a patient with a concussion treated in immediate emergency care?

Emergency care is usually required for patients with moderate to severe brain injuries. Treatment in these patients primarily focusses on the person getting adequate oxygen, maintaining blood pressure and preventing further injuries to head and neck.

People with severe injuries may require treatment in intensive care units for controlling inflammation and bleeding in the head. Some patients may require treatment for reduced oxygen supply to the brain.

What precautions can athletes with a previous history of concussion take to prevent a future episode?

Adult and child athletes are recommended by experts not to return to play on the day of the injury. Further play to be avoided until recovery from all concussion symptoms.

Experts recommend athletes to avoid any activities that have a higher risk of another concussion, while still suffering from the concussion symptoms.

What steps should be taken in children to ensure a speedy recovery after a concussion?

To ensure speedy recovery a step-by-step approach should be taken in the child’s routine with short-term changes. This should be based on the child’s ability to do the activities without symptoms worsening. Consider the following flow:

  • AANS. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Concussion.
  • Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/concussion/symptoms-causes/syc-20355594
  • Brain Injury Basics. CDC. https://www.cdc.gov/headsup/basics/index.html
  • Gardner RC, Yaffe K. Epidemiology of mild traumatic brain injury and neurodegenerative disease. Mol Cell Neurosci. 2015;66(Pt B):75-80.
  • GururajEpidemiology of traumatic brain injuries: Indian scenario. Neurol Resear. 2002; 24(1):24-8.
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