Ryan A. Sprouse, MD, CAQSM George D. Harris, MD, MS, CAQSM Gretchen D. E. Sprouse, MD Madison Humerick, MD Ryan T. Miller, DO West Virginia University School of Medicine – Eastern Division, Harpers Ferry rsprouse@wvumedicine.org
The authors reported no potential conflict of interest relevant to this article.
From The Journal of Family Practice | 2016;65(8):538-544,546.
References
The initial assessment
A child or adolescent who sustains a suspected concussion should be seen by a physician within 24 to 48 hours. Whether the initial assessment occurs in your office or on the sidelines of a game, it is important to confirm the time the incident occurred and the mechanism of injury.
Concussion is diagnosed by a combination of history, physical exam, and objective testing when symptoms or exam findings associated with mild brain trauma—headache, dizziness, light and/or noise sensitivity, among others—closely follow a head injury.8-10 Certain maneuvers—assessing eye movements by asking the athlete to look in various directions, for instance, then to follow a pen or finger as you move it closer to his or her face—may provoke dizziness, headache, or other symptoms of concussion that were not apparent initially.
The differential diagnosis includes cervical musculoskeletal injury, craniofacial injury, epidural and subdural hematoma, heat-related illness, uncomplicated headache and migraine, upper respiratory infection, and vertigo.8-10
Tools aid in diagnosis
Many clinical assessment tools exist to aid in the diagnosis of concussion (TABLE 2).8-10,12-14 Any one of these tools, many of which use combinations of symptom checklists, balance exams, and cognitive assessments, may be included in your evaluation. No single tool has been found to be superior to any other.8-10 A combination of tools may improve diagnostic accuracy, but assessment tools should not be the sole basis used to diagnose or rule out concussion.
Reserve neuroimaging, such as CT and MRI, for patients with more serious clinical findings or symptoms that persist longer than expected.
Any child or adolescent who had a blow to the head and at least one sign or symptom of concussion should be evaluated as soon as possible and assessed again later that day or the next day if any reason for concern remains.
Neuropsychological (NP) testing may involve computerized tests developed specifically for athletes. Patients may be required to react to objects that appear on a screen, for example, in a way that tests memory, performance, and reaction time. Because cognitive recovery often lags behind symptom resolution, NP testing may identify subtle brain deficits even in athletes who are asymptomatic at rest or with exercise. In general, NP testing has a sensitivity of 71% to 88% for athletes with concussion,10 but it is most beneficial when baseline test results are available. Interpretation of NP testing should be done only by qualified clinicians.
While NP testing may provide additional prognostic information, it should not alter the management of athletes who are symptomatic either at rest or with exercise.15 Nor is NP testing vital, as concussion can be accurately diagnosed and adequately managed without it.
Neuroimaging, including computed tomography (CT)and magnetic resonance imaging (MRI), is often used unnecessarily in the initial assessment of a patient who sustained a possible concussion.8-10 In fact, neuroimaging should be reserved for cases in which it is necessary to rule out more serious pathology: intracranial or subdural hematoma or a craniofacial injury, for example, in patients with clinical findings that are red flags. These red flags include focal neurologic deficits, continuing nausea/vomiting, or persistent disorientation (TABLE 3),8-10 or symptoms that worsen or persist beyond a few weeks. In such cases, further evaluation—with MRI of the brain, formal NP testing, and/or referral to a neurologist, physiatrist, or other physician who specializes in concussion care—is indicated.
