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Medical: Multiple Concussion Injury; Second Impact Syndrome


Overview: The Brain and Concussion

The brain is composed of semigelatinous material. Microscopically, it is made up of nerve cells, connective tissue cells, and blood vessels. There are areas of gray and white matter. The gray matter is made up of the gray nerve cell bodies that account for most cerebral functions. Also, in the gray matter are blood vessels, nerve axons and dendrites, and neuroglia (a supporting tissue). The white matter consists principally of nerve fibers, which appear white because of their coating of myelin, a fat-like substance. See: 1 Attorneys Medical Advisor §3:9, Brain; Overview; 1 Attorneys Medical Advisor §§3:9 to 3:25 discussing the brain in detail.

 

Head trauma that results in conditions of temporarily altered mental status is classified as “concussion.” The term “concussion” is not a precise term and has been used to describe the mechanism of injury or describe a set of symptoms. Concussion injury has been said to be the direct effect of physical force on the brain nerve cells, paralyzing or inhibiting their function. It has been characterized as a disturbance of consciousness usually lasting for only a few moments, but occasionally for a few hours or longer. See: 5 Attorneys Medical Advisor §36:56, Concussion-Introduction. For additional definitions of “concussion” see: Medic8 - Mild Head Injury (Concussion) and Mayo Clinic - Concussion.

 

Brain injury from concussion, such as from a car accident or sports injury, can be the result not only of linear acceleration (up and down movement) but of rotational acceleration (rotation within the skull) of the brain matter. See: Daniel, Rowson, Duma, “Head Impact Exposure in Youth Football,” Annals of Biomedical Engineering (February 15, 2012).

 

Concussion may produce permanent impairment or disability. See: 5 Attorneys Medical Advisor §36:56, Concussion-Introduction.

 

Multiple concussions are said to result in a cumulative effect and “over months or years may result in cumulative neuropsychological deficits.” See: Traumatic Brain Injuries, 90 Am. Jur. Trials 1. Persons who sustain multiple concussions process information more slowly during neuropsychological testing, and take more time to recover, compared to patients experiencing their first concussion. “[T]his phenomenon can lead to a choice between ending a career and risking a considerable loss of function and quality of life.” See: Attorneys Medical Advisor § 36:60 ConcussionCumulative effects of multiple concussions.

 

Guidance: Counsel may have difficulty proving the existence, severity, or cause of a multiple concussion injury as concussion is not necessarily susceptible to ready and accurate diagnosis. Symptoms of concussion need not necessarily appear immediately after the injury and may set in only after a latent period of many days or weeks. See: Presenting Plaintiff's Medical Proof-Common Injuries and Conditions, 6 Am. Jur. Trials 1 §12; Excessiveness or adequacy of damages awarded for injuries to head or brain, 50 A.L.R.5th 1.

 

See also: Traumatic Brain Injuries, 90 Am. Jur. Trials 1; Traumatic Brain Injuries, 72 Am. Jur. Proof of Facts 3d 363; the Brain Injury Association of America.

 

Grading: Concussion injury generally is graded using three grades of severity, although the precise criteria for each grade vary: Grade 1 - mild concussion, Grade 2 - moderate concussion, Grade 3 - severe concussion.

 

Also, concussion has been graded using a scale that employs the following five detailed grades:

  • Grade I - the person is confused temporarily but does not display any memory changes.
  • Grade II - the person suffers brief disorientation and anterograde amnesia of less than five minutes' duration.
  • Grade III - there is retrograde amnesia and loss of consciousness for less than five minutes in addition to the two criteria for a grade II concussion.
  • Grade IV - similar to a grade III, except that the duration of loss of consciousness is between five to ten minutes.
  • Grade V - similar to a grade III, except that the duration of loss of consciousness is longer than ten minutes.

 

See: 5 Attorneys Medical Advisor §36:57.

 

Loss of Consciousness: There is some conflict among the authorities regarding whether a severe concussion is indicated by a loss of consciousness. Some find that concussion does not always result in a complete loss of consciousness and that even severe brain injuries may not be accompanied by a loss of consciousness. See: Presenting Plaintiff's Medical Proof-Common Injuries and Conditions, 6 Am. Jur. Trials 1 &s; 14. “[A] recent study [questions] the validity of employing loss of consciousness as a marker of severity of concussion for purposes of deciding whether an athlete may return to play.” See: 5 Attorneys Medical Advisor §36:63, Concussion—Decisions governing return to sports.

 

Syndromes

Post-Concussion Syndrome: Post-concussion syndrome (PCS) is a group of symptoms including confusion, dizziness, headaches, behavioral changes, memory loss, cognitive deficits, depression, emotional outbursts, and blurred vision that may occur following a concussion. This is a variety of vague and persistent symptoms. The symptoms of PCS can be extremely debilitating. PCS usually lasts two to four months, with symptoms typically peaking four to six weeks following the concussion.

 

Second Impact Syndrome: Repeat concussions over a short period may lead to the Second Impact Syndrome (SIS). In this syndrome, a concussion sustained while the injured person is still symptomatic from an earlier concussion results in progressive cerebral edema,” or swelling of the brain. See: Traumatic Brain Injuries, 90 Am. Jur. Trials 1. SIS refers to the effect of a rapid rise in intracranial pressure leading to progressive cerebral edema. This is a rare but potentially fatal condition. “It is hypothesized that this phenomenon occurs as a result of dysfunction of the autoregulation mechanism in the cerebrum.” See: Attorneys Medical Advisor §36:61.

 

“The second impact syndrome is serious and can be fatal; a person needs to be completely asymptomatic before returning to any contact activity.” See: Kristina M. Gerardi, Tackles That Rattle The Brain, 18 Sports Law. J. 181 (Spring 2011). “Second-impact syndrome has a mortality rate of nearly 50% and a morbidity rate (disabling impairments) of nearly 100%. Not only is the risk of second-impact syndrome of real concern for athletes, they may also suffer from the long-term effects that result from sustaining multiple concussions…Chronic Traumatic Encephalopathy (CTE) is one such long-term effect. It is described as a progressive degenerative disease of the brain, common in athletes and others who have suffered multiple concussions.” See: Marie-France Wilson, Young Athletes At Risk: Preventing And Managing Consequences Of Sports Concussions In Young Athletes And The Related Legal Issues, 21 Marq. Sports L. Rev. 241 (Fall 2010).

 

Symptoms

Neurological changes to a person who has suffered a concussion include:

  • Disorientation or confusion
  • Amnesia
  • Loss of consciousness, for varying periods of time up to several minutes

 

Other symptoms of concussion may include:

  • Headache
  • Dizziness
  • Nausea or vomiting
  • Slurred or incoherent speech
  • Imbalance or coordination problems

 

See: 5 Attorneys Medical Advisor §36:58, Concussion-Symptoms.

 

A person with mild concussion typically progresses from restlessness and confusion to lengthening periods of rationality. See: 5 Attorneys Medical Advisor §36:58, Concussion-Symptoms.

 

A person with a serious concussion injury may also show signs of:

  • Extended drowsiness or confusion
  • Severe headache
  • Convulsions
  • CSF drainage from the ear or nose
  • Weakness or loss of feeling in the extremities
  • Asymmetrical pupils
  • Double vision

 

See: 5 Attorneys Medical Advisor §§ 36:58, Concussion-Assessment; Hospitalization.

 

Confusion, and often amnesia, are clinical hallmarks of concussion. Other symptoms include headaches, memory problems, anxiety, insomnia, and dizziness. See: Traumatic Brain Injuries, 90 Am. Jur. Trials 1.

 

Diagnosis

The physician should determine whether the head injury is limited to concussion or if it involves a more serious intracranial injury. If the physician determines the patient has suffered a more serious concussion injury, the person should be hospitalized or more thoroughly evaluated. See: 5 Attorneys Medical Advisor §36:58, Concussion-Assessment; Hospitalization.

 

CT Scans or MRIs of the brain may be required to determine whether there is any bleeding over the brain surface or in the brain as the patient's injury may include a skull fracture, cerebral contusion, or hematoma. Diffusion-weighted MRI and functional brain imaging techniques are capable of identifying pathology in many instances of mild concussion. Neuropsychological testing also may be used as this type of testing has been shown to identify deficits in different areas following initial or repeat concussions. See: 5 Attorneys Medical Advisor §36:58, Concussion-Assessment; Hospitalization.

 

If the doctor’s initial diagnosis and assessment is that the patient has no lingering neurological deficits, hospitalization likely is not required. See: 5 Attorneys Medical Advisor §36:58, Concussion-Assessment; Hospitalization.

 

Release by the examining physician is usually accompanied by precautionary instructions to:

  • Remain under observation by a reliable person for a minimum period (typically 12 hours)
  • Abstain from alcohol for several days
  • Use no pain medications stronger than over-the-counter pain relievers.

 

See: 5 Attorneys Medical Advisor §36:58, Concussion-Assessment; Hospitalization.

 

It can be difficult to diagnose and treat a concussion injury as the symptoms of post-concussion syndrome can result in a disturbing interplay of behavioral, cognitive, and emotional complaints. See: Traumatic Brain Injuries, 90 Am. Jur. Trials 1.

 

Treatment

No uniform, generalized treatment exists for Post-Concussion Syndrome and other concussion injury. Treatment is geared toward improving symptoms and obtaining rest to allow the body to heal. There many kinds of treatments for these patients including medications and noninvasive interventions such as psychotherapy.  See: 5 Attorneys Medical Advisor §§36:64 to 36:69.

 

Whether to allow a sports participant to return to play after a repeat concussion is a difficult determination. “[P]rematurely allowing [sports] participants … especially boxing, football, and hockey, in which repeated blows to the participant are guaranteed, places the participant at greater risk for subsequent concussion and the second impact syndrome specifically, or the cumulative effects of brain injury, generally.” See: 5 Attorneys Medical Advisor § 36:63, Concussion—Decisions governing return to sports.

 

The American College of Sports Medicine and the National Collegiate Athletic Association have implemented guidelines for the determination of when it is appropriate to allow an athlete to return to contact sports activity. However, the guidelines are not universally applied and vary. Generally, the guidelines provide recommendations regarding when an injured player can return to play based on the grade of severity of concussion and the number of concussions in a season. Also, the guidelines provide that an athlete who is suspected of having a concussion should be removed from sports participation immediately, and should not return to play while signs or symptoms of concussion are present at rest or with exercise, i.e., the player should be asymptomatic. An athlete who has suffered repeated concussions generally requires a longer period of asymptomatic rest. See: 5 Attorneys Medical Advisor § 36:63, Concussion—Decisions governing return to sports.

 

The risk of complications associated with concussions is increased when an athlete prematurely returns to play. Athletes that suffer prolonged loss of consciousness, post-traumatic amnesia, or signs and symptoms that worsen or persist after a concussion should be evaluated in the emergency department. Athletes should not be allowed to resume sports participation until all symptoms of a concussion have resolved. See: Traumatic Brain Injuries, 72 Am. Jur. Proof of Facts 3d 363.


Prognosis and Ability to Work

The ability to work after multiple concussion injury varies significantly depending on the severity and the characteristics of the affected person.

 

Most patients who suffer concussions achieve full recovery, but headaches, memory problems, anxiety, insomnia, and dizziness can persist following the injury. See: Traumatic Brain Injuries, 90 Am. Jur. Trials 1.

 

Most patients who have Post-Concussion Syndrome recover over time. However, some suffer from persistent difficulties, remaining unable to return to work or other normal activities for weeks to months, or even a year or longer. See: 5 Attorneys Medical Advisor §§36:64 to 36:69.

 

Up to 60% of patients who sustain a mild brain injury continuing to experience a range of symptoms for as long as a year after the injury. See: Traumatic Brain Injuries, 90 Am. Jur. Trials 1.

 

Personality change may be another result of a concussion injury. The “[p]rognosis for personality change due to closed head trauma depends upon the extent of the brain injury. Some concussion victims may be asymptomatic at the end of [six] months, but individuals with fairly severe brain injury may have significant mental, emotional, coping and vocational problems the rest of their lives. It is particularly important to have good diagnostic tests, such as neuropsychological testing and positron emission tomography, along with a careful neurological work-up, in order to determine prognosis. Some individuals with more serious brain injury may be occupationally disabled, requiring the receipt of social security disability income for the rest of their lives…[F]or a patient with continuing brain injury symptoms, it may be necessary to wait until he or she has had [six] to 12 months of rehabilitation, in order to determine prognosis. Generally speaking, the maximum amount of improvement occurs in the first [two] years following brain injury, with minor improvement up to 10 years after the injury.” See: Personality Change Due to Closed Head Trauma, 34 Am. Jur. Proof of Facts 3d 1.

 

 

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