Post-concussive symptoms in children with mild traumatic brain injury.

Taylor, H. Gerry; Dietrich, Ann; Nuss, Kathryn E.; Wright, Martha; Rusin, Jerome; Bangert, Barbara; Minich, Nori; Yeates, Keith Owen

doi:10.1037/a0018112

Cited by 225 publications

(205 citation statements)

References 68 publications

(123 reference statements)

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“…[6][7][8][9][10] The identification of concussion is critical to deliver appropriate care and support to patients and their families. [11][12][13] Persistent symptoms following concussion can have a devastating impact. 14,15 Consequences of concussion can include school absenteeism, depression, loss of social activities, and lower quality of life.…”

Section: Introductionmentioning

confidence: 99%

Canadian pediatric emergency physician knowledge of concussion diagnosis and initial management

Zemek

Eady

Farion

et al. 2015

CJEM

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Introduction: The diagnosis of concussion is a critical step in the appropriate management of patients following minor head trauma. The authors hypothesized that wide practice variation exists among pediatric emergency medicine physicians in the application of physical and cognitive rest recommendations following an acute concussion. Methods: The authors developed a 35-item questionnaire incorporating case vignettes to examine pediatric emergency physician knowledge of concussion diagnosis, understanding of initial management using return-to-play/school/work guidelines, use of existing concussion protocols, and perceived barriers to protocol use. Using a modified Dillman technique, the authors distributed an online survey to members of Pediatric Emergency Research Canada, a national association of pediatric emergency physicians. Results: Of 176 potential participants, 115 (65%) responded to the questionnaire, 89% (95% confidence interval [CI]: 0.81, 0.93) of whom reported having diagnosed 20 or more concussions annually. Although 90% (95% CI: 0.83, 0.94) of respondents adequately diagnosed concussion, only 64% (95% CI: 0.54, 0.72) correctly applied graduated return-to-play guidelines. Cognitive rest recommendations were also frequently limited: 40% (95% CI: 0.31, 0.49) did not recommend school absence, 30% (95% CI: 0.22, 0.39) did not recommend schoolwork reduction, and 35% (95% CI: 0.27, 0.45) did not recommend limiting screen time. Eighty percent (95% CI: 0.72, 0.87) of respondents reported having used guidelines frequently or always to guide clinical decisions regarding concussion. Conclusion: Despite a proficiency in the diagnosis of concussion, pediatric emergency physicians exhibit wide variation in recommending the graduated return to play and cognitive rest following concussion.

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Section: Introductionmentioning

confidence: 99%

Canadian pediatric emergency physician knowledge of concussion diagnosis and initial management

Zemek

Eady

Farion

et al. 2015

CJEM

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“…This clinical definition of concussion has been used elsewhere. 28,29 Children who had open head injuries, intoxication with alcohol or controlled substances, receipt of narcotics for pain control, injuries resulting from child abuse, multisystem injuries, or underlying central nervous system abnormalities were excluded.…”

Section: Subjectsmentioning

confidence: 99%

Acute Concussion Symptom Severity and Delayed Symptom Resolution

et al. 2014

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WHAT'S KNOWN ON THIS SUBJECT: Children are often evaluated in the emergency department after a concussion. Although prolonged symptoms are associated with higher initial symptom severity when measured 2 to 3 weeks after injury, a similar association with acute symptom severity has not been demonstrated. WHAT THIS STUDY ADDS:Higher acute symptom severity is not associated with development of persistent post-concussion symptoms 1 month after injury, but persistent post-concussive symptoms affect a significant number of children after concussion. Outpatient follow-up is essential to identify children who develop persistent symptoms. abstract BACKGROUND AND OBJECTIVES: Up to 30% of children who have concussion initially evaluated in the emergency department (ED) display delayed symptom resolution (DSR). Greater initial symptom severity may be an easily quantifiable predictor of DSR. We hypothesized that greater symptom severity immediately after injury increases the risk for DSR. METHODS:We conducted a prospective longitudinal cohort study of children 8 to 18 years old presenting to the ED with concussion. Acute symptom severity was assessed using a graded symptom inventory. Presence of DSR was assessed 1 month later. Graded symptom inventory scores were tested for association with DSR by sensitivity analysis. We conducted a similar analysis for post-concussion syndrome (PCS) as defined by the International Statistical Classification of Diseases and Related Health Problems, 10th revision. Potential symptoms characteristic of DSR were explored by using hierarchical cluster analysis. RESULTS:We enrolled 234 subjects; 179 (76%) completed follow-up. Thirtyeight subjects (21%) experienced DSR. Initial symptom severity was not significantly associated with DSR 1 month after concussion. A total of 22 subjects (12%) had PCS. Scores .10 (possible range, 0-28) were associated with an increased risk for PCS (RR, 3.1; 95% confidence interval 1.2-8.0). Three of 6 of the most characteristic symptoms of DSR were also most characteristic of early symptom resolution. However, cognitive symptoms were more characteristic of subjects reporting DSR.CONCLUSIONS: Greater symptom severity measured at ED presentation does not predict DSR but is associated with PCS. Risk stratification therefore depends on how the persistent symptoms are defined. Cognitive symptoms may warrant particular attention in future study. Follow-up is recommended for all patients after ED evaluation of concussion to monitor for DSR. Dr Grubenhoff conceptualized and designed the study, designed the database, oversaw data collection and analysis, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Deakyne performed the primary statistical analysis, assisted with study design and database design, managed study personnel in recruitment and data acquisition, and co-authored, reviewed, and revised the manuscript; Ms Brou assisted with the cluster analysis and drafting and reviewed and revised the manuscript; Dr Bajaj assisted with study design and ...

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“…8,10,12,14,[48][49][50] Our concussed children responded similar to many previous reports in the literature, with significant symptom reduction in the first 2 weeks after concussion. 2,14,15,19,47,[51][52][53][54][55][56] As predicted, we did not demonstrate findings of gross structural injury by anatomic MRI, DTI, or SWI. [20][21][22][23][24][25] Although others have demonstrated such injury patterns in adults after SRC, 20,22,23,25 it is possible that the mechanisms of injury (head to head, body to head, or head to ground) and the different energy and forces (related to body mass and velocity) involved in pediatric SRC would make it less likely that major structural injury would occur.…”

Section: Discussionmentioning

confidence: 71%

“…[1][2][3][4][5][6][7] Despite its high incidence, the pathophysiology of SRC is not well understood. Symptoms and neuropsychological alterations of SRC have been well characterized [8][9][10][11][12][13][14][15][16][17][18][19] ; however, the biological substrate has been studied limitedly, largely in adults and focusing on structural injury patterns. [20][21][22][23][24][25] Physiologic perturbations detected in the concussed rodent brain 26 include altered neurotransmitters and ions, production of lactic acid (LA), and reduction in cerebral blood flow (CBF).…”

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confidence: 99%

Pediatric Sports-Related Concussion Produces Cerebral Blood Flow Alterations

2011

PEDIATRICS

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WHAT'S KNOWN ON THIS SUBJECT:The pathophysiology of pediatric sports-related concussion (SRC) is largely unknown. Studies of concussed adults have identified neuronal and axonal injury and time-limited metabolic disruptions. An experimental animal model has also demonstrated physiologic perturbations, including reduced cerebral blood flow (CBF). WHAT THIS STUDY ADDS:Using MRI techniques, we found no evidence of neuronal, axonal, or metabolic disruptions in 12 children with SRC. However, when compared with controls, statistically significant alterations in CBF were defined and frequently persisted beyond 30 days after injury.abstract OBJECTIVE: The pathophysiology of sports-related concussion (SRC) is incompletely understood. Human adult and experimental animal investigations have revealed structural axonal injuries, decreases in the neuronal metabolite N-acetyl aspartate, and reduced cerebral blood flow (CBF) after SRC and minor traumatic brain injury. The authors of this investigation explore these possibilities after pediatric SRC. PATIENTS AND METHODS:Twelve children, ages 11 to 15 years, who experienced SRC were evaluated by ImPACT neurocognitive testing, T1 and susceptibility weighted MRI, diffusion tensor imaging, proton magnetic resonance spectroscopy, and phase contrast angiography at ,72 hours, 14 days, and 30 days or greater after concussion. A similar number of age-and gender-matched controls were evaluated at a single time point. RESULTS:ImPACT results confirmed statistically significant differences in initial total symptom score and reaction time between the SRC and control groups, resolving by 14 days for total symptom score and 30 days for reaction time. No evidence of structural injury was found on qualitative review of MRI. No decreases in neuronal metabolite N-acetyl aspartate or elevation of lactic acid were detected by proton magnetic resonance spectroscopy. Statistically significant alterations in CBF were documented in the SRC group, with reduction in CBF predominating (38 vs 48 mL/100 g per minute; P = .027). Improvement toward control values occurred in only 27% of the participants at 14 days and 64% at .30 days after SRC.CONCLUSIONS: Pediatric SRC is primarily a physiologic injury, affecting CBF significantly without evidence of measurable structural, metabolic neuronal or axonal injury. Further study of CBF mechanisms is needed to explain patterns of recovery.

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Post-concussive symptoms in children with mild traumatic brain injury.

Cited by 225 publications

References 68 publications

Canadian pediatric emergency physician knowledge of concussion diagnosis and initial management

Canadian pediatric emergency physician knowledge of concussion diagnosis and initial management

Acute Concussion Symptom Severity and Delayed Symptom Resolution

Pediatric Sports-Related Concussion Produces Cerebral Blood Flow Alterations

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