Sports Related Concussion - Diagnosis and Evaluation
There is not one agreed upon definition of a concussion, however it is generally accepted that a concussion is an alteration in mental status secondary to a traumatic injury to the head or the body. The alteration to mental status can be obvious, such as loss of consciousness (being knocked out), confusion or disorientation. Other symptoms may not be easily identified at first and can include findings such as changes in vision, sensitivity to light or irritability. The list of symptoms that an athlete can develop in association with a concussion can be quite extensive and are listed below. A common misconception is that the injury must occur from a direct blow to the head. However, a concussion can certainly occur from an injury to the body causing the brain to be jarred within the skull, without direct impact to the head.
If the injury occurs on the field of play the initial assessment includes an evaluation of the consciousness of the athlete along with confirmation that the athlete is breathing and the heart is beating by checking the pulse. It is important to not be preoccupied by other injuries such as a broken bone that may distract one's attention away from any life threatening concerns. Typically, the next step would be to evaluate for any signs of spinal cord injury, such as lack of sensation, paralysis or weakness. If the athlete is unable to respond or communicate one must assume they have a neurological injury until proven otherwise. Lastly, the athlete should be checked for tenderness along the bony aspect of the neck. Pain over the central aspect of the neck may indicate a possible fracture and the patient should be stabilized for transport for further evaluation.
If the patient is clinically stable and able to communicate they should be assessed for the presence of the associated symptoms listed below. If any of those symptoms are present then the diagnosis can be made and the athlete would be placed on a concussion protocol. Keep in mind symptoms may present several days after the initial injury. A more detailed assessment can also be done looking at cognitive function, however this may not be appropriate at the time of injury as it is unlikely to change the overall management. Cognitive function testing may include examples such as SCAT 3, ImPact Testing or Cogstate assessment to name a few. In my opinion, they tend to be more helpful with return to play rather than confirming the diagnosis of concussion.
Do I need a CT scan or MRI?
Another misconception is that an MRI or CT scan is needed to make the diagnosis of concussion. In actuality, concussion is a clinical diagnosis determined by evaluating the circumstances and constellation of symptoms. In a coherent patient with mild symptoms there usually is no need for any advanced imaging with a CT or MRI. If a patient has had loss of consciousness and is unable to communicate, a head and neck CT may be appropriate to further assess for any type of bleeding within the brain, skull or neck fracture. Imaging may also be appropriate for an athlete that has had a dramatic worsening in their symptoms after initially appearing stable.
List of Symptoms
Adapted from Sports Concussion Assessment Tool 3 - British Journal of Sports Medicine