Head Collision: When It's More Than A Concussion

CASE HISTORY: 17yo M football player removed from play for nausea and abnormal coordination after a hit to the head. Initially patient reported photophobia, headache, dizziness and nausea on sideline. Locker room evaluation was significant for progressive unremitting nausea/dizziness and left sided paresthesia of UE. PHYSICAL EXAM: GCS 15, although slow responses. PERRL. No TTP and FROM at the cervical spine. Negative Spurling's. VOMS: fatigue and dizziness reproduced with vertical and horizontal saccades, unable to complete VOR. CN II-XII unremarkable. Sensation testing showed decreased sensation at C5 dermatome, otherwise equal BL. Strength 5/5 BL UE. Remainder of exam was normal. DIFFERENTIAL: Concussion, EDH, SDH, SAH, Cervical instability, SIS.WORK UP: Taken to ED: CT head w/o contrast: 4 mm high frontal subdural hematoma; punctate foci of anterior BL frontal lobes subarachnoid hemorrhage w/o midline shift or mass effect. CT cervical w/o contrast: no cervical fracture or malalignment. MRI cervical spine unremarkable. Cervical spine collar removed; patient admitted to SICU for monitoring. Repeat CT head at 7 and 14 hrs: stable SDH and slight interval improvement respectively, resolution of SAH. FINAL DIAGNOSIS: SDH and SAH. DISCUSSION: Few cases describe SRSBI (Sports Related Structural Brain Injury) identified on sideline evaluation after a head collision during gameplay. Fewer reports have described symptom progression of such an injury. The most reported MOI is direct blunt head trauma, though it should also be considered with repetitive head collisions. Given the infrequency of such occurrence of SRSBI, this case underscores the importance of prompt sideline recognition of neurological deficits, transfer to appropriate facility, proper management and safe return to play. CASE OUTCOME: Patient’s symptoms improved over the next 48 hrs with treatment. Repeat CT head outpatient at 3 weeks: resolution of SDH. Outpatient follow up with neurosurgery at 4 weeks demonstrated no neurological deficits. Neurosurgery cleared for progressive return to sports. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: An RTP protocol was implemented for concussion, and he was monitored closely in training room for lingering deficits. Patient cleared to return to sports at 5 weeks post injury.