Traumatic Brain Injuries (TBI), describe a wide spectrum of pathology and degrees of damage to the brain. A range outcomes can follow TBI, ranging from death to apparent full recovery. Concussion is the most under diagnosed injury on the sportsfield. Mainly because athletes want to stay on the field, it goes unreported. Concussion is defined as “a mild traumatic brain injury caused by biomechanical force.” Perhaps if we all referred to it as a “mild traumatic brain injury” it would be taken more seriously. The after effects of a concussion is enough to encourage anyone to rather have it looked at, than hoping for the best.

Players who sustain concussion injuries are often not the best witnesses of their own condition, and in many cases their perceptions are misleading. It is usually observed best by a mother, teacher or coach. It must not be taken lightly. The consequences of a concussion injury may only appear a week after the actual injury and can get worse from there.

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What does the anatomy look like?

The brain “floats” within cerebrospinal fluid inside your skull.  Almost like a baby “floats” within amniotic fluid within the womb. Your brain is suspended inside a fluid with a hard casing, that’s your skull. So your brain can shift around inside the confines of your skull. Your skull is formed by different bones (frontal, sphenoid, temporal, occipital, parietal) all fused together to form the hard shell of protection.

The large part of the brain, that fills most of the skull cavity, is called the cerebrum. The small part, below the cerebrum at the back, is called the cerebellum. The cerebrum is divided into frontal-, parietal-, occipital- and temporal lobes, situated directly under the part of the skull with the same name.

The brain resembles a walnut in appearance. It is formed by the left and right hemispheres. The different lobes of the brain (frontal, temporal, occipital) have different functions. Your symptoms after a brain injury will depend on which part of the brain is injured.

What does the brain do?

The brain is the control room of your entire nervous system. Different parts of the brain are responsible for different functions. Your ability to breathe when necessary, move and remember are all controlled by your brain. Your brain is HQ for your body.

The brain is a complex soft structure. It contains nerve cells that are grouped into regions. In simple terms there is a layer of grey matter (nerve cell bodies) over the surface of the brain, with white matter (nerve cell fibers) beneath the grey matter, and basal ganglia (nerve cell bodies) that are beneath the white matter.

How does a concussion happen?

A concussion occurs when you get a direct blow to the head. This can be either from a ball / another player / a fall. Off of the sports field a concussion can also be caused by your head slamming onto the dashboard in a car accident, or during a fight. Concussion can also occur indirectly when you receive a blow to your chest / back.

This impact will cause your head to violently move in one direction within a split second. Your brain  (suspended in fluid) will follow the same route, but with a slight delay. The shell of your skull absorbs most of the impact but the brain, hits the inside surface of the skull. The brain rebounds and hit the opposite side as it moves back into position. This follows Newton’s 3rd Law, that every action has a reaction. So we often find signs of brain injury in the two opposing hemispheres, depending on the force and direction of impact.

The brain will swell after impact. Because the skull does not give way, the swelling will increase the pressure within the skull (intracranial pressure), with devastating consequences. In broad terms concussion is described according to the time of onset of injury, and in terms of the distribution of injury within the brain. Both of these should be taken into account in classifying any traumatic brain injury.

Time of onset of injury

Area affected within the brain

Primary brain injury: occurs at the moment of impact

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Secondary brain injury: occurs after the moment of impact

Secondary brain injury happens after impact (hours or days ), due to increase in intracranial pressure because of the primary brain injury.

Diffuse brain injury:
affecting the whole of the brain.

Focal injury:
affecting a single (unifocal) or number  (multifocal) of specific regions in the brain.

What is injured with a concussion?

This impact to the brain may cause a shearing force that can rip or tear the membranes of your brain called the Duramater, Archnoid mater and Subarachnoid mater. These membranes are embedded on the inside surface of the skull, and if suddenly ripped into a direction it may tear lose from its anchors. These membranes supply oxygen and nutrients to your brain tissues, therefore any interruption of circulation of these membranes will cause the cells to suffocate and lead to permanent damage to the brain.

In most cases there is no bleeding with a concussion and therefore no neurological symptoms. Neurological symptoms is the umbrella term used to describe any symptoms that are caused by an injury to the nerves. This can include pins and needles, numbness, weakness or the inability to move.

It is rare to find that the blood vessels or arteries rupture with an concussion. The most damage is due to the injury to the actual grey matter nerves  in the brain where most of the information gets interpreted and processed.

Swelling sets in

Like with any bruise, your body sends cells to the tissue to repair it. This causes a rush of cells to the injured site, almost like all the traffic after an accident, the ambulance, tow trucks and police. This is localized swelling, but you can imagine the effect when a lot of cells rush into the confined space of your skull.  The skull does not “give way”, and therefore swelling leads to an increase the normal pressure within the skull, resulting on pressure on the brain tissue (increased intracranial pressure).

Types of brain injury

Primary brain injury

These injuries occur at the moment of impact, as a result of acceleration-deceleration forces that are transmitted to the head (skull and brain). The forces may be linear- and/or rotational. These forces injure the entire brain. The brain is literally displaced, shaken and rotated within the skull. These injuries may occur without any direct impact to the head.

Because the physical characteristics of grey and white matter differ (density ect.)  the forces that are applied to the head cause regions of grey matter and white matter to accelerate at different rates. This typically results in shear injuries (tearing of tissue).

Loss of Consciousness (Blackout)

Depending on the magnitude and direction of forces, injuries may include a variety of symptoms. This may include permanent destruction of nerve cells (diffuse axonal injury). These injuries are usually characterized by immediate loss of consciousness, followed by variable forms and durations of neurological impairment. In certain cases neurological impairment may occur despite no loss of consciousness.

Secondary brain injury

These injuries typically occur hours or days after the primary injury. The injured brain is more vulnerable than the healthy brain to deprivation of blood supply. Extracranial risk factors such as hypoxia, fat embolism often occur as a result of co-existing orthopaedic-, chest-, abdominal- and/or vascular injuries. These extracranial risk factors often aggravate the effects of the primary brain injury, by hampering recovery of damaged nerve cells and/or by causing further damage to nerve cells.

These injuries are often not detected in the acute phase. They typically make themselves known at a later stage, at the time of resumption of normal daily activities, study and/or work. These injuries are best visualised on CT brain scans taken 2 to 5 days after the injury.

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Physiological Changes in the brain on a cellular level

Concussion initially results in what has been described as a ‘metabolic mismatch,’ during which cerebral blood flow significantly decreases, while the demand for glucose increases. Our brains use glucose as fuel. A concussion will disrupt the circulation to your brain cells, reducing the delivery of glucose, in turn this will decrease the normal behavior of  the nerves in your brain. The most common signs is the inability to concentrate, focus, or execute a task.

Although glucose metabolism initially increases post injury, a period of hypometabolism soon follows, which has been shown to persist for up to 10 days in animal studies and for up to one month in PET (positron emission tomography) studies of TBI. Mild traumatic brain injury has been linked to decreased magnesium levels, diffuse axonal injury, persistent calcium accumulation and alterations in neurotransmitter activity. Research has established that, in some instances of mTBI, both cellular and ultrastructural damage may occur.

Nerve impulses are transferred to your processing centers in your brain, these connections between nerves are called neurotransmitters. Neurotransmission is altered when the circulation is compromised. Neurotransmitters are released in higher amounts than usual. This will cause the nerve cells to go into overdrive. This leads to imbalances in chemicals in the brain.

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Symptoms of Concussion

Following a blow to the head, you may lose consciousness. You may “pass out” for a few seconds or longer. Your brain suffers a temporary overload of firing nerves in your brain, that may cause it to shutdown and reboot.

Your short term memory will be altered, like what the score of the game is. You may suffer from retrograde amnesia (what happened just before your injury) or post traumatic amnesia (what happened after your injury). The duration of the amnesia does not indicate how severe the concussion is.

Your ability to think clearly and focus on tasks may be decreased. Something simple, like unlocking a door, may take you longer than usual. Simple and complex task may take longer to execute. Problem solving will be affected, like  finding the solution to a puzzle.

Serious injury has to be excluded immediately. Rather be safe than sorry. Players who have received a blow to the head will be taken off the field on a spinal board, then evaluated to exclude a brain or spinal cord injury. Our first step is to determine the extent of the brain injury by doing a battery of test.

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Physical symptoms of concussion include:

These are signs that you can pick up by observing how a person reacts and behaves in a certain way that may be out of the ordinary.

  • Amnesia (memory loss)
  • Disorientation (looking confused and ‘lost)’
  • Blurred / double vision – Seeing double or difficulty to make out the shape of objects, miss judging how far away an object.
  • Sensitivity to light / sound – Covering eyes, squinting, wearing sunglasses inside.
  • Incomprehensive speech – Unable to follow a conversation, delayed response to a question
  • Nausea / vomiting – Also loss of appetite due to nausea is much more common.
  • Headache – Aching pressure around their head, not limited to a specific area
  • Imbalance / dizziness – Missing a step, leaning while walking, unable to walk a relative straight line.
  • Decreased concentration – Longer time to reply to a question / difficulty to focus in classroom situations
  • Changes in mood (sad, anxious, depressed)
  • Lethargy / fatigue – Slow motion movements, to do a simple task like picking up a cup, as if in a ‘drunken state’
  • Slowed reaction time to catch a ball or object.
  • Sleep disturbances – Sleepiness, suddenly sleep for 12 hours a day, returning to sleep after only a few hour of being awake.
  • Seizures – Sort sercuting of the nerves in the brain.

Cognitive symptoms of concussion include

Difficulty with short-term or long-term memory

Short term: What day is it today? What’s the score? What you had for breakfast

Long term memory:  What’s your address? When is your birthday?

  • Confusion: Difficulty following a train of thought, or following a conversation.
  • Slowed “processing” (eg, a decreased ability to think through problems)
  • “Fogginess”- Where’s my keys? Where did you put the file/ document.
  • Difficulty concentrating
  • Worsening grades in school – Especially Maths and Science where a process of scientific thinking must be applied with regards to background knowledge.

Emotional symptoms of  concussion include

These are emotional cues that may be observed when interacting with a person that sustained a concussion. It is usually observed as out of the ordinary by someone that knows you well, like a parent, close friend or teacher.

  • Irritability
  • Restlessness – fidgeting,
  • Anxiety – unreasonable reaction in a situation that would not normally be fearful
  • Depression – Overbearing feeling of sadness, regret, negativity
  • Mood swings – Changes from manic to depressive behaviour
  • Aggression – Abnormal response of overly defensive
  • Decreased tolerance of stress – Inability to cope under a reasonable stressful situation.
  • Change in personality or behavior – Seems like a totally different person, or a response like: That doesn’t sound like something that he/she will normally do.

The different areas (lobes) of the brain have different functions. An injury to the specific area will lead to problems with that specific task. Thefrontal lobe (forehead) is responsible for decision making (taking consequence of decisions into account), memory, regulating behaviour. An injury to the frontal lobe may cause difficulty in planning, sequencing tasks, self correction. School work in subjects like maths and science will be impaired.

The occipital lobe (back of the skull) is responsible for the interpretation of your visual field. Injury will lead to visual disturbances, like difficulty to focus on a object or double vision.

The temporal lobe (just above your ear) is responsible for sensory interpretation. That is connecting an image to a memory, understanding language and emotional association. An injury to the temporal lobe may lead to personality changes in the sense that a person does not connect the same meaning to something than before the injury.

How bad is it?

Unfortunately there is no standardized grading of concussion. If you lost consciousness you would probably be taken to the hospital for a physical examination.

Diagnosis

CT scan

CT (computerized tomographic) scans, which are computerized reconstructions of images obtained by conventional tomographic x-rays, are very good at identifying bone, air, water and collections of blood. In the acute phase of head injury, CT scans are therefore useful for detecting skull fractures, intracranial bleeding, localised swelling and/or shift of the brain.

X-ray

X-rays might be taken to rule out any bony damage to the skull or cervical vertebrae. The X-ray will not show any injury to the brain.

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MRI

MRI (magnetic resonance imaging) scans are very good at identifying soft tissues and the planes between different types of soft tissue. MRI scans are therefore best at detecting the gross structure of the brain, cerebral cortex, deep white matter, basal ganglia, ventricles, cerebellum, brain stem and cranial nerves, as well as distortions thereof.

Important to note

Focal contusional (coup-contracoup bruising) brain injuries, which by their nature evolve over time, are often not evident on CT or MRI scans taken on the day of the injury. These injuries are more readily detectable on scans taken 2 to 5 days after the head injury.

 

Prognosis of traumatic brain injury

Whereas the major portion of natural improvement following brain injuries occurs during the first 6 to 12 months, minimal further improvement can occur up to 2 years after the accident, while no further neurological improvement can be expected after 2 years.

In cases of childhood head injury it is common to find increasingly apparent mental disability as the child ages. In other words, despite being neurologically stable, the learning impairment becomes more apparent and more disabling in high school than in primary school.

Reasons for this phenomenon include :

The head injured child’s mental development proceeds at a slower rate than that of his or her uninjured peers, and at a slower rate than would have been the case in the absence of the head injury.

The role of the child’s frontal lobes becomes more heavily taxed in higher grades at school and in adult life, particularly in relation to the escalating needs for abstraction and independent execution of tasks.

Concussion

What makes Concussion worse

Participation in “high risk” sports (rugby, judo, boxing) may lead to repeated episodes of concussion. It is very important to recover completely from each injury before returning to your sport.

Healing/Recovery Time

Each concussion injury is unique. The recovery time will differ from person to person.

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What else could the pain be?

Traumatic brain injury (TBI)

TBI occur with blunt force trauma to the head or even skull fracture. This is a more severe, as dangerous swelling of the brain will occur. Loss of consciousness, inability to speak or move a limb. This needs immediate medical management.

Vertigo (BPPV)

A concussion may lead to the octonia (crystals in the inner ear) to dislodge and move in the semicircular canals. This will cause severe vertigo (spinning of yourself or the room) with head movements.

Whiplash

The delicate structures in the neck may also be injured with a concussion. Neck pain, decreased movements and headaches will be present.

Cervical ligament injury

With excessive force through the neck a ligament may be injured. Extreme spasm, nausea and headache may be present.

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