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Ann-Christine Duhaime

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Young M. Lee, Mitchell J. Odom, Scott L. Zuckerman, Gary S. Solomon and Allen K. Sills

Object

Sport-related concussions (SRCs) in high school and college athletes represent a significant public health concern. Research suggests that younger athletes fare worse symptomatically than older athletes after an SRC. Using reliable change index (RCI) methodology, the authors conducted a study to determine if there are age-related differences in number, severity, and resolution of postconcussion symptoms.

Methods

Between 2009 and 2011, baseline measures of neurocognitive functions and symptoms in high school and college athletes were entered into a regional database. Seven hundred forty of these athletes later sustained an SRC. Ninety-two athletes in the 13- to 16-year-old group and 92 athletes in the 18- to 22-year-old group were matched for number of prior concussions, sex, biopsychosocial variables, and days to first postconcussion testing and symptom assessment. A nonparametric Mann-Whitney U-test was used to compare the severity of each of 22 symptoms comprising the Total Symptom Scale (TSS) at baseline and first postconcussion test. To obtain a family-wise p value of 0.05 for each test, the significance level for each symptom comparison was set at an alpha of 0.05/22 = 0.0023. The number of days to return to baseline TSS score was compared using the RCI methodology, set at the 80% confidence interval, equal to a change in raw score of 9.18 points on the TSS.

Results

There was no statistically significant difference in symptom presence, symptom severity, and total symptoms between the age groups at baseline or at postconcussion testing. There was no statistically significant difference in return to baseline symptom scores between the age groups.

Conclusions

Using RCI methodology, there was no statistically significant difference between younger and older athletes in return to baseline symptoms postconcussion.

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Ivan Sosa and Alan Bosnar

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Scott L. Zuckerman, Young M. Lee, Mitchell J. Odom, Gary S. Solomon and Allen K. Sills

Object

Up to 16% of children in the US between the ages of 3 and 17 years have either attention deficit–spectrum disorder or a learning disability (LD). Sports-related concussions among youth athletes represent a significant public health concern, and neurocognitive testing is a method to evaluate the severity of cognitive impairment and recovery after a sports-related concussion. The goal of this study was to assess baseline neurocognitive differences between athletes with attention deficit hyperactivity disorder (ADHD) and/or LD versus those with neither disorder and to establish normative data for these special populations.

Methods

Between August 2007 and March 2012, 6636 young athletes underwent baseline neurocognitive testing performed using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery. Of these participants, 90 had self-reported LD only, 262 had self-reported ADHD only, and 55 reported both. Those with ADHD and/or LD were matched with 407 participants with no history of ADHD or LD by age, sex, and number of prior concussions. The mean scores and SDs were calculated for each group to obtain normative values. A pairwise comparison between each diagnostic group was done to assess whether LD and/or ADHD diagnostic status predicted participants' baseline neurocognitive scores.

Results

Participants with ADHD had significantly lower verbal memory, visual memory, and visual motor processing speed scores, along with significantly higher reaction time, impulse control, and symptom scores compared with those without LD or ADHD. Participants with LD had similar results, with significantly lower verbal memory, visual memory, and visual motor processing speed scores, higher reaction time and symptom score, but did not differ in their impulse control score compared with those without LD or ADHD. Participants with both LD and ADHD had a significantly lower visual motor speed score and a significantly higher reaction time and symptom score than those without LD or ADHD, but did not differ with regard to the other composite scores.

Conclusions

Athletes with ADHD and/or LD have lower baseline ImPACT neurocognitive scores compared with athletes without ADHD and LD. Preliminary normative neurocognitive data for these special populations are provided.

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Scott L. Zuckerman, Colin T. Prather, Aaron M. Yengo-Kahn, Gary S. Solomon, Allen K. Sills and Christopher M. Bonfield

OBJECTIVE

Arachnoid cysts (ACs) are congenital lesions bordered by an arachnoid membrane. Researchers have postulated that individuals with an AC demonstrate a higher rate of structural brain injury after trauma. Given the potential neurological consequences of a structural brain injury requiring neurosurgical intervention, the authors sought to perform a systematic review of sport-related structural-brain injury associated with ACs with a corresponding quantitative analysis.

METHODS

Titles and abstracts were searched systematically across the following databases: PubMed, Embase, CINAHL, and PsycINFO. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Peer-reviewed case reports, case series, or observational studies that reported a structural brain injury due to a sport or recreational activity (hereafter referred to as sport-related) with an associated AC were included. Patients were excluded if they did not have an AC, suffered a concussion without structural brain injury, or sustained the injury during a non–sport-related activity (e.g., fall, motor vehicle collision). Descriptive statistical analysis and time to presentation data were summarized. Univariate logistic regression models to assess predictors of neurological deficit, open craniotomy, and cystoperitoneal shunt were completed.

RESULTS

After an initial search of 994 original articles, 52 studies were found that reported 65 cases of sport-related structural brain injury associated with an AC. The median age at presentation was 16 years (range 4–75 years). Headache was the most common presenting symptom (98%), followed by nausea and vomiting in 49%. Thirteen patients (21%) presented with a neurological deficit, most commonly hemiparesis. Open craniotomy was the most common form of treatment (49%). Bur holes and cyst fenestration were performed in 29 (45%) and 31 (48%) patients, respectively. Seven patients (11%) received a cystoperitoneal shunt. Four cases reported medical management only without any surgical intervention. No significant predictors were found for neurological deficit or open craniotomy. In the univariate model predicting the need for a cystoperitoneal shunt, the odds of receiving a shunt decreased as age increased (p = 0.004, OR 0.62 [95% CI 0.45–0.86]) and with male sex (p = 0.036, OR 0.15 [95% CI 0.03–0.88]).

CONCLUSIONS

This systematic review yielded 65 cases of sport-related structural brain injury associated with ACs. The majority of patients presented with chronic symptoms, and recovery was reported generally to be good. Although the review is subject to publication bias, the authors do not find at present that there is contraindication for patients with an AC to participate in sports, although parents and children should be counseled appropriately. Further studies are necessary to better evaluate AC characteristics that could pose a higher risk of adverse events after trauma.

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Scott L. Zuckerman, Aaron M. Yengo-Kahn, Thomas A. Buckley, Gary S. Solomon, Allen K. Sills and Zachary Y. Kerr

OBJECTIVE

Sport-related concussion (SRC) has emerged as a public health problem, especially among student-athletes. Whereas most concussions resolve by 2 weeks, a minority of patients experience postconcussion syndrome (PCS), in which symptoms persist for months. The objective of this study was to elucidate factors predictive of PCS among a sample of National Collegiate Athletic Association (NCAA) student-athletes in the academic years 2009–2010 to 2014–2015.

METHODS

The SRC data originated from the NCAA Injury Surveillance Program (ISP) in the 2009–2010 to 2014–2015 academic seasons. The NCAA ISP is a prospective database made up of a convenience sample of schools across all divisions. All SRCs are reported by certified athletic trainers. The PCS group consisted of concussed student-athletes with concussion-related symptoms that lasted ≥ 4 weeks. The non-PCS group consisted of concussed student-athletes with symptom resolution in ≤ 2 weeks. Those with symptoms that resolved in the intermediate area of 2–4 weeks were excluded. Odds ratios (ORs) were estimated using logistic regression.

RESULTS

During the 2009–2010 to 2014–2015 seasons, 1507 NCAA student-athletes sustained an SRC, 112 (7.4%) of whom developed PCS (i.e., concussion-related symptoms that lasted ≥ 4 weeks). Men's ice hockey contributed the largest proportion of concussions to the PCS group (28.6%), whereas men's football contributed the largest proportion of concussions in the non-PCS group (38.6%). In multivariate analysis, recurrent concussion was associated with increased odds of PCS (OR 2.08, 95% CI 1.28–3.36). Concussion symptoms that were also associated with increased odds of PCS included retrograde amnesia (OR 2.75, 95% CI 1.34–5.64), difficulty concentrating (OR 2.35, 95% CI 1.23–4.50), sensitivity to light (OR 1.97, 95% CI 1.09–3.57), and insomnia (OR 2.19, 95% CI 1.30–3.68). Contact level, sex, and loss of consciousness were not associated with PCS.

CONCLUSIONS

Postconcussion syndrome represents one of the most impactful sequelae of SRC. In this study of exclusively collegiate student-athletes, the authors found that recurrent concussions and various concussion-related symptoms were associated with PCS. The identification of initial risk factors for the development of PCS may assist sports medicine clinicians in providing timely interventions and treatments to prevent morbidity and shorten recovery time after SRC.

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Aaron M. Yengo-Kahn, Andrew T. Hale, Brian H. Zalneraitis, Scott L. Zuckerman, Allen K. Sills and Gary S. Solomon

OBJECTIVE

Over the last 2 decades, sport-related concussion (SRC) has garnered significant attention. Even with increased awareness and athlete education, sideline recognition and real-time diagnosis remain crucial. The need for an objective and standardized assessment of concussion led to the eventual development of the Sport Concussion Assessment Tool (SCAT) during the Second International Conference on Concussion in Sport in 2004, which is now in its third iteration (SCAT3). In an effort to update our understanding of the most well-known sideline concussion assessment, the authors conducted a systematic review of the SCAT and the evidence supporting its use to date.

METHODS

English-language titles and abstracts published between 1995 and October 2015 were searched systematically across 4 electronic databases and a review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines adapted for the review of a heterogeneous collection of study designs. Peer-reviewed journal articles were included if they reported quantitative data on any iteration of the SCAT, Standardized Assessment of Concussion (SAC), or modified Balance Error Scoring System (mBESS) data at baseline or following concussion in an exclusively athlete population with any portion older than 13 years of age. Studies that included nonathletes, only children less than 13 years old, exclusively BESS data, exclusively symptom scale data, or a non–SCAT-related assessment were excluded.

RESULTS

The database search process yielded 549 abstracts, and 105 full-text articles were reviewed with 36 meeting criteria for inclusion. Nineteen studies were associated with the SAC, 1 was associated with the mBESS exclusively, and 16 studies were associated with a full iteration of the SCAT. The majority of these studies (56%) were prospective cohort studies. Male football players were the most common athletes studied. An analysis of the studies focused on baseline differences associated with age, sex, concussion history, and the ability to detect an SRC.

CONCLUSIONS

Looking toward the upcoming Concussion in Sport Group meeting in fall 2016, one may expect further revision to the SCAT3. However, based on this systematic review, the authors propose further, in-depth study of an already comprehensive concussion test, with acute, diagnostic, as well as long-term use.

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Scott L. Zuckerman, Andrew Kuhn, Michael C. Dewan, Peter J. Morone, Jonathan A. Forbes, Gary S. Solomon and Allen K. Sills

Object

Sports-related concussions (SRCs) represent a significant and growing public health concern. The vast majority of SRCs produce mild symptoms that resolve within 1–2 weeks and are not associated with imaging-documented changes. On occasion, however, structural brain injury occurs, and neurosurgical management and intervention is appropriate.

Methods

A literature review was performed to address the epidemiology of SRC with a targeted focus on structural brain injury in the last half decade. MEDLINE and PubMed databases were searched to identify all studies pertaining to structural head injury in sports-related head injuries.

Results

The literature review yielded a variety of case reports, several small series, and no prospective cohort studies.

Conclusions

The authors conclude that reliable incidence and prevalence data related to structural brain injuries in SRC cannot be offered at present. A prospective registry collecting incidence, management, and follow-up data after structural brain injuries in the setting of SRC would be of great benefit to the neurosurgical community.

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Clinton D. Morgan, Scott L. Zuckerman, Young M. Lee, Lauren King, Susan Beaird, Allen K. Sills and Gary S. Solomon

OBJECT

Sport-related concussion (SRC) is a major public health problem. Approximately 90% of SRCs in high school athletes are transient; symptoms recover to baseline within 1 week. However, a small percentage of patients remain symptomatic several months after injury, with a condition known as postconcussion syndrome (PCS). The authors aimed to identify risk factors for PCS development in a cohort of exclusively young athletes (9–18 years of age) who sustained SRCs while playing a sport.

METHODS

The authors conducted a retrospective case-control study by using the Vanderbilt Sports Concussion Clinic database. They identified 40 patients with PCS and matched them by age at injury and sex to SRC control patients (1 PCS to 2 control). PCS patients were those experiencing persistent symptoms at 3 months after an SRC. Control patients were those with documented resolution of symptoms within 3 weeks of an SRC. Data were collected in 4 categories: 1) demographic variables; 2) key medical, psychiatric, and family history; 3) acute-phase postinjury symptoms (at 0–24 hours); and 4) subacute-phase postinjury features (at 0–3 weeks). The chi-square Fisher exact test was used to assess categorical variables, and the Mann-Whitney U-test was used to evaluate continuous variables. Forward stepwise regression models (Pin = 0.05, Pout = 0.10) were used to identify variables associated with PCS.

RESULTS

PCS patients were more likely than control patients to have a concussion history (p = 0.010), premorbid mood disorders (p = 0.002), other psychiatric illness (p = 0.039), or significant life stressors (p = 0.036). Other factors that increased the likelihood of PCS development were a family history of mood disorders, other psychiatric illness, and migraine. Development of PCS was not predicted by race, insurance status, body mass index, sport, helmet use, medication use, and type of symptom endorsement. A final logistic regression analysis of candidate variables showed PCS to be predicted by a history of concussion (OR 1.8, 95% CI 1.1–2.8, p = 0.016), preinjury mood disorders (OR 17.9, 95% CI 2.9–113.0, p = 0.002), family history of mood disorders (OR 3.1, 95% CI 1.1–8.5, p = 0.026), and delayed symptom onset (OR 20.7, 95% CI 3.2–132.0, p < 0.001).

CONCLUSIONS

In this age- and sex-matched case-control study of risk factors for PCS among youth with SRC, risk for development of PCS was higher in those with a personal and/or family history of mood disorders, other psychiatric illness, and migraine. These findings highlight the unique nature of SRC in youth. For this population, providers must recognize the value of establishing the baseline health and psychiatric status of children and their primary caregivers with regard to symptom reporting and recovery expectations.

In addition, delayed symptom onset was an unexpected but strong risk factor for PCS in this cohort. Delayed symptoms could potentially result in late removal from play, rest, and care by qualified health care professionals. Taken together, these results may help practitioners identify young athletes with concussion who are at a greater danger for PCS and inform larger prospective studies for validation of risk factors from this cohort.

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Scott L. Zuckerman, Rachel P. Apple, Mitchell J. Odom, Young M. Lee, Gary S. Solomon and Allen K. Sills

Object

Sport-related concussions (SRCs) among youth athletes represent a significant public health concern. Prior research suggests that females fare worse symptomatically after an SRC. The authors aimed to assess sex differences in number, severity, and resolution of postconcussive symptoms using reliable change index (RCI) methodology applied to days to return to symptom baseline.

Methods

Between 2009 and 2011, 740 youth athletes completed valid neurocognitive and symptom testing before and after an SRC using Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). A total of 122 female and 122 male athletes were matched on number of prior concussions, age, and number of days to first postconcussion test. At baseline and postconcussion, the authors compared each of the individual 22 symptoms on ImPACT to calculate individual symptom severity and aggregate symptom severity, or the Total Symptom Score (TSS). When comparing individual symptoms, the significance level for the comparison of each symptom was set at 0.05/22 = 0.0023. When comparing aggregate symptom severity, or TSS, a single value was compared, requiring an alpha set to 0.05. The number of days to return to baseline TSS was compared using RCI methods set at the 80% confidence interval, equal to a raw score point value of 9.18 on the TSS.

Results

At baseline, females reported a greater severity for the symptom, “sleeping less than usual,” compared with males (0.88 ± 1.49 vs 0.31 ± 0.86, p < 0.001). However, no other individual symptom severity differences were noted before or after SRC. At baseline, females exhibited a statistically significant greater aggregate symptom severity than males (7.24 ± 10.22 vs 4.10 ± 6.52, p = 0.005). Greater aggregate symptom severity for females was also found postconcussion (21.38 ± 19.02 vs 16.80 ± 17.07, p = 0.049). Females took longer to return to baseline TSS (9.1 ± 7.1 days vs 7.0 ± 5.1 days, p = 0.013).

Conclusions

The results of this retrospective study indicate that females endorse a greater severity of symptoms at baseline and postconcussion than males without significantly different symptom profiles. Furthermore, after suffering an SRC, females take longer to return to their baseline symptom level.