Head Injury - High School Football

HISTORY: A 16-year-old high school football player with a history of headaches and known arachnoid cyst sustained a helmet to helmet hit without loss of consciousness. He had onset of headaches and blurry vision later that day but did not report his symptoms to the athletic trainer until three days later. At that point he was diagnosed with a concussion. The day after his diagnosis, he developed emesis, prompting presentation to the emergency department (ED). In the ED, he had continued headache with photophobia. PHYSICAL EXAM: Examination in the ED included normal vital signs and a tired but nontoxic appearance. The GCS score was 15, there were no cranial nerve deficits. There was no tenderness to the cervical region and there was full pain-free range of motion of the neck. Pupillary exam, strength, sensation, and reflexes were normal. The remainder of his exam was free of abnormalities. DIFFERENTIAL DIAGNOSIS: 1. Cerebral hemorrhage 2. Concussion 3. Meningitis 4. Migraine Syndrome 5. Symptomatic Arachnoid Cyst TEST AND RESULTS: CT head without contrast- Bilateral 3 mm subdural fluid collections- Arachnoid cyst in the left middle cranial fossa Consultations:- Pediatric neurosurgery consulted and recommended follow up with outpatient MRI in 2 weeks and strict return precautions FINAL/WORKING DIAGNOSIS: Concussion with arachnoid cyst rupture TREATMENT AND OUTCOMES: - Three days after discharge, he experienced worsening headache and emesis, prompting return to the ED 11 days after initial injury.- Vitals at that time were concerning for increased ICP, prompting admission to the ICU- Underwent three neurosurgical procedures over a 16 night hospitalization, including cyst drain placement, craniotomy with cyst fenestration, and finally cysto-peritoneal shunt due to lack of improvement.- Activity restriction included no contact activity, planned follow up in 4-6 weeks for clinical evaluation and repeat imaging. - Return to play decision will be individualized based on patient’s exam, imaging, and consideration of the risks of continued participation. Although it is generally considered safe for patients with arachnoid cysts and VP shunts to participate in sports, there are no consensus guidelines for return to play after cyst rupture requiring surgery.