Second impact syndrome: A devastating injury to the young brain

New imaging findings

2013-01-01

(Press-News.org) Charlottesville, VA (January 1, 2013). Physicians at Indiana University School of Medicine and the Northwest Radiology Network (Indianapolis, Indiana) report the case of a 17-year-old high school football player with second impact syndrome (SIS). A rare and devastating traumatic brain injury, SIS occurs when a person, most often a teenager, sustains a second head injury before recovery from an earlier head injury is complete. To the best of the authors' knowledge, this is the first reported case in which imaging studies were performed after both injuries, adding new knowledge of the event. Findings in this case are reported and discussed in "Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Case report," by Elizabeth Weinstein, M.D., and colleagues, published today online, ahead of print, in the Journal of Neurosurgery: Pediatrics.

The patient sustained the first injury when he received a helmet-to-helmet hit from an opposing player during a punt return. Despite immediate symptoms of dizziness and visual disturbance, he continued to play in the game. For the next few days he experienced severe headaches and fatigue. Four days after the game, he consulted a doctor about the headaches. Computerized tomography (CT) scans of the patient's head appeared normal, but he was advised not to return to play until all of his symptoms were gone. The young man chose instead to return to practice immediately.

The following day, despite complaints of headache and difficulty with concentration, the young man participated in hitting drills. After a few hits he was slow standing up, and after several more hits he collapsed, became unresponsive, and suffered a seizure. He was transferred initially to a local emergency department, where a CT examination revealed small, thin subdural hematomas on each side of the brain. The patient received intubation and was treated medically. Shortly thereafter he was airlifted to a tertiary trauma and neurosurgical center at Indiana University Health Methodist Hospital in Indianapolis.

At the tertiary center, the patient was found to be minimally responsive and to have increased intracranial pressure (25-30 mm Hg; normal 5-15 mm Hg). Additional CT scans obtained there confirmed the presence of the subdural hematomas and mild cerebral swelling. Magnetic resonance images of the brain and upper spinal cord showed downward herniation of the brain, subdural hematomas on both sides of the brain, and abnormal diffusion in the medial left thalamus. Structures in the vicinity of the brain's midline, including the thalamus and hypothalamus, had shifted downward. There did not seem to be any blood vessel damage or spinal cord injury. The MR images did not detect cerebral edema.

The patient's injury involved other serious consequences identified during the hospital stay, including prolonged elevated intracranial pressure, areas of brain softening (in both thalami, the medial frontal lobes, and elsewhere), hypotension, renal failure, sepsis, pneumonia, and temporary cardiac arrest. Even with optimal care, the patient remained in the hospital for 98 days and was unable to walk or talk when he was discharged. Three years later, he has regained much of his speech but is very impulsive and is confined to a wheel chair.

In SIS, the brain injury produces a loss of cerebral autoregulation. Cerebral arteries widen, allowing more blood to flow throughout the brain, and massive cerebral swelling can occur. These lead to increased intracranial pressure, causing the brain to enlarge. Because the skull is a limited container, the brain can become herniated as it seeks a space to expand. The authors note that some investigators previously postulated that the loss of cerebral autoregulation is caused by a "space-occupying injury" from the initial injury. Findings in this case do not substantiate that claim because the CT scan was normal. Weinstein and colleagues point out that several types of injury do not necessarily register on an imaging study, and " a normal head CT scan does not obviate the need for close clinical follow-up and for the athlete to be cognitively normal and asymptomatic before return to play."

In this case, the patient experienced severe headaches throughout the interval between injuries. The authors state that evidence of persistent, long-lasting, severe headaches, which have repeatedly been identified in patients with SIS, indicate an ongoing and significant pathological neurophysiological condition in the absence of evidence on the CT scan. The authors suggest that this symptom may be a specific predictor for the possibility of SIS if a second injury occurs before the first has resolved.

The take-away message in this study, according to coauthor Dr. Michael Turner, "is that there must not be a return to play if the athlete is at all symptomatic. A normal CT scan will not identify a patient who can be released to play. The mechanism of SIS is probably hyperemia [increased blood in the brain], not occult hematoma."

SIS rarely occurs, but when it does the effect is usually devastating. Often the patient dies. The authors stress the importance of educating coaches, athletes, family members, and treating physicians about the risks and possible consequences of sports-related head injuries.

### Weinstein E, Turner M, Kuzma BB, Feuer H. Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Case report. Journal of Neurosurgery: Pediatrics, published online, ahead of print, January 1, 2013; DOI: 10.3171/2012.11.PEDS12343.

Disclosure: Dr. Henry Feuer is the neurosurgical consultant for the Indianapolis Colts and is a member of the Return to Play Subcommittee of the National Football League Head, Neck, and Spine Medical Committee. He is also the neurosurgical consultant for the Indiana High School Athletic Association. Dr. Elizabeth Weinstein provides emergency medical support along with Indiana University Health for NFL players at Indianapolis Colts home games.

For additional information, please contact: Ms. Jo Ann M. Eliason, MA, ELS
Communications Manager
Journal of Neurosurgery Publishing Group
One Morton Drive, Suite 200
Charlottesville, VA 22903
Email: jaeliason@thejns.org
Telephone 434-982-1209
Fax 434-924-2702 The Journal of Neurosurgery: Pediatrics is a monthly peer-reviewed journal focused on diseases and disorders of the central nervous system and spine in children. This journal contains a variety of articles, including descriptions of preclinical and clinical research as well as case reports and technical notes. The Journal of Neurosurgery: Pediatrics is one of four monthly journals published by the JNS Publishing Group, the scholarly journal division of the American Association of Neurological Surgeons, an association dedicated to advancing the specialty of neurological surgery in order to promote the highest quality of patient care. The Journal of Neurosurgery: Pediatrics appears in print and on the Internet.

ELSE PRESS RELEASES FROM THIS DATE:

Differences in generic pill characteristics may lead to interruptions in essential medication use

2013-01-01

Boston, MA—Generic medications currently account for over 70 percent of prescriptions dispensed. However, while generic drugs are clinically bioequivalent to the brand-name version, they often differ in their physical characteristics, such as color and shape. Researchers from Brigham and Women's Hospital (BWH) have found that some patients who receive generic drugs that vary in their color are over 50 percent more likely to stop taking the drug, leading to potentially important and potentially adverse clinical effects. The study will be published electronically on December ...

Did Lucy walk, climb, or both?

2013-01-01

Much has been made of our ancestors "coming down out of the trees," and many researchers view terrestrial bipedalism as the hallmark of "humanness." After all, most of our living primate relatives—the great apes, specifically—still spend their time in the trees. Humans are the only member of the family devoted to the ground, living terrestrial rather than arboreal lives, but that wasn't always the case. The fossil record shows that our predecessors were arboreal habitués, that is, until Lucy arrived on the scene. About 3.5 million years ago in Africa, this new creature, ...

Annals of Internal Medicine tip sheet for 1 Jan. 2013

2013-01-01

1. Distributing Naloxone to Heroin Users May be a Cost-effective Way to Reduce Overdose Deaths Distributing naloxone to heroin users to use to reverse overdose may be a cost-effective strategy to reduce overdose-related mortality. Opioid overdose is a leading cause of accidental death in the United States and accounts for half of the mortality among heroin users. Naloxone is a short-acting opioid antagonist that can reverse opioid overdose. Researchers developed computer models to estimate the cost-effectiveness of distributing naloxone to heroin users for use at witnessed ...

Houston, we have another problem

2013-01-01

As if space travel was not already filled with enough dangers, a new study out today in the journal PLOS ONE shows that cosmic radiation – which would bombard astronauts on deep space missions to places like Mars – could accelerate the onset of Alzheimer's disease. "Galactic cosmic radiation poses a significant threat to future astronauts," said M. Kerry O'Banion, M.D., Ph.D., a professor in the University of Rochester Medical Center (URMC) Department of Neurobiology and Anatomy and the senior author of the study. "The possibility that radiation exposure in space may ...

Late-life depression associated with prevalent mild cognitive impairment, increased risk of dementia

2013-01-01

CHICAGO – Depression in a group of Medicare recipients ages 65 years and older appears to be associated with prevalent mild cognitive impairment and an increased risk of dementia, according to a report published Online First by Archives of Neurology, a JAMA Network publication. Depressive symptoms occur in 3 percent to 63 percent of patients with mild cognitive impairment (MCI) and some studies have shown an increased dementia risk in individuals with a history of depression. The mechanisms behind the association between depression and cognitive decline have not been ...

Economic environment during infancy linked with substance use, delinquent behavior in adolescence

2013-01-01

CHICAGO – The larger economic environment during infancy may be associated with subsequent substance use and delinquent behavior during adolescence, according to a report published Online First by Archives of General Psychiatry, a JAMA Network publication. The current economic crisis has received much attention from policy makers, although the focus has been on short-term effects, while the long-term influences of such financial crises, especially on young children, have generally not been examined, according to the study background. Seethalakshmi Ramanathan, M.B.B.S., ...

As climate warms, bark beetles march on high-elevation forests

2013-01-01

MADISON – Trees and the insects that eat them wage constant war. Insects burrow and munch; trees deploy lethal and disruptive defenses in the form of chemicals. But in a warming world, where temperatures and seasonal change are in flux, the tide of battle may be shifting in some insects' favor, according to a new study. In a report published today (Dec. 31, 2012) in the Proceedings of the National Academy of Sciences, a team of scientists from the University of Wisconsin-Madison reports a rising threat to the whitebark pine forests of the northern Rocky Mountains as ...

Jackson Laboratory researchers provide definitive proof for receptor's role in synapse development

2013-01-01

Jackson Laboratory researchers led by Associate Professor Zhong-wei Zhang, Ph.D., have provided direct evidence that a specific neurotransmitter receptor is vital to the process of pruning synapses in the brains of newborn mammals. Faulty pruning at this early developmental stage is implicated in autism-spectrum disorders and schizophrenia. The definitive evidence for N-methyl-D-aspartate receptor (NMDAR) in pruning has eluded researchers until now, but in research published in the Proceedings of the National Academy of Sciences, Zhang's lab had serendipitous help in ...

Jellyfish experts show increased blooms are a consequence of periodic global fluctuations

2013-01-01

Scientists have cast doubt on the widely held perception that there has been a global increase in jellyfish. Blooms, or proliferations, of jellyfish can show a substantial, visible impact on coastal populations – clogged nets for fishermen, stinging waters for tourists, even choked cooling intake pipes for power plants – and recent media reports have created a perception that the world's oceans are experiencing trending increases in jellyfish. Now, a new multinational collaborative study, involving the University of Southampton, suggests these trends may be overstated, ...

How to Decide if Bankruptcy is for You

2013-01-01

How to decide if bankruptcy is for you Tough economic times are causing many people to struggle financially. Unforeseen events such as the loss of a job, a major medical issue or the accumulation of credit-card interest and penalties can cause even the hardest working people to rack up thousands of dollars of debt. Even worse, creditor harassment can make life incredibly stressful. These circumstances understandably cause many people to feel like they are drowning in a sea of debt. Fortunately, many options are available for dealing with debt and creating a path toward ...

Second impact syndrome: A devastating injury to the young brain

ELSE PRESS RELEASES FROM THIS DATE:

LAST 30 PRESS RELEASES: