Theodore Hannah, Nickolas Dreher, Adam Y. Li, Dhruv S. Shankar, Ryan Adams, Alex Gometz, Mark R. Lovell, and Tanvir F. Choudhri
Concussions are a major public health concern, especially for high school and college student athletes. However, there are few prognostic metrics that can accurately quantify concussion severity in order to anticipate recovery time and symptom regression. The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) is a widely used neurocognitive assessment that can diagnose and track recovery from concussions. This study assesses whether initial ImPACT scores, collected within 48 hours of the injury, can predict persistence of concussion at follow-up.
Results from 6912 ImPACT tests were compiled in 2161 unique student athletes, ages 12–22 years. The authors defined a novel metric, the Severity Index (SI), which is a summation of the number of standard deviations from baseline at the 80% CI for each of the 5 composite scores reported by ImPACT. Patients were binned into groups based on SI (0–3.99, 4–7.99, 8–11.99, 12+) and the relationships between SI groups, composite scores, symptom profiles, and recovery time were characterized using 1-way and 2-way ANOVAs and Kaplan-Meier plots. A logistic regression assessed the value of SI for predicting concussion at follow-up.
Patients with a higher SI at diagnosis were more likely to still be concussed at their first follow-up (F3,2300 = 93.06; p < 0.0001). Groups with a higher SI also displayed consistently slower recovery over a 42-day period and were more likely to report symptoms in all 4 symptom clusters (Migraine, Cognition, Sleep, and Neuropsychiatric). When controlling for sex, age, number of previous concussions, days between assessments, and location, SI significantly increased the odds of being concussed at follow-up (OR 1.122, 95% CI 1.088–1.142; p < 0.001). This model showed good discrimination with an area under the curve of 0.74.
SI is a useful prognostic tool for assessing head injury severity. Concussions with higher initial SI tend to last longer and have broader symptomatic profiles. These findings can help patients and providers estimate recovery based on similar ImPACT score profiles.
Muhammad Ali, Nek Asghar, Adam Li, Theodore Hannah, Zachary Spiera, Naoum Fares Marayati, Nickolas Dreher, John Durbin, Alex Gometz, Mark Lovell, and Tanvir Choudhri
Concussions in youth sports comprise an estimated 1.6–3.8 million annual injuries in the US. Sex, age, and attention-deficit hyperactivity disorder (ADHD) have been identified as salient risk factors for concussion. This study seeks to evaluate the role of premorbid depression or anxiety (DA), with or without antidepressant use, on the incidence of concussion and the recovery of symptoms and neurocognitive dysfunction after concussion.
Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) was administered to 7453 youth athletes at baseline. Throughout the season, concussions were examined by physicians and athletic trainers, followed by readministration of ImPACT postinjury (PI) and again at follow-up, a median of 7 days PI. Individuals were divided into three categories: 1) unmedicated athletes with DA (DA-only, n = 315), athletes taking antidepressants (DA-meds, n = 81), and those without DA or antidepressant use (non-DA, n = 7039). Concussion incidence was calculated as the total number of concussions per total number of patient-years. The recovery of neurocognitive measures PI was calculated as standardized deviations from baseline to PI and then follow-up in the 5 composite ImPACT scores: symptom score, verbal memory, visual memory, visual motor skills, and reaction time. Univariate results were confirmed with multivariate analysis.
There was no difference in concussion incidence between the DA-only cohort and the non-DA group. However, the DA-meds group had a significantly greater incidence of concussion than both the DA-only group (OR 2.67, 95% CI 1.88–7.18, p = 0.0001) and the non-DA group (OR 2.19, 95% CI 1.16–4.12, p = 0.02). Deviation from baseline in PI symptom scores was greater among the DA-meds group as compared to the non-DA group (OR 1.14, 95% CI 1.01–1.28, p = 0.03). At follow-up, the deviation from baseline in symptom scores remained elevated among the DA-meds group as compared to the non-DA group (OR 1.62, 95% CI 1.20–2.20, p = 0.002) and the DA-only group (OR 1.87, 95% CI 1.12–3.10, p = 0.02). Deviation from baseline in follow-up verbal memory was also greater among the DA-meds group as compared to both the non-DA group (OR 1.57, 95% CI 1.08–2.27, p = 0.02) and the DA-only group (OR 1.66, 95% CI 1.03–2.69, p = 0.04).
Premorbid DA itself does not seem to affect the incidence of concussion or the recovery of symptoms and neurocognitive dysfunction PI. However, antidepressant use for DA is associated with 1) increased concussion incidence and 2) elevated symptom scores and verbal memory scores up to 7 days after concussion, suggesting impaired symptomatic and neurocognitive recovery on ImPACT.