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Concussion

Concussion

Overview

According to the centers for disease control and prevention (CDC), from 2006 to 2014, the number of TBI-related emergency department visits, hospitalizations, and deaths increased by 53%.

Concussion is extremely challenging to deal with since patients present with symptoms that may appear immediately or a few days after a concussed event.

Those who have sustained a concussion may have to deal with chronic neurological symptoms for longer than expected which is truly a hassle to deal with!

In this article, we wanted to give an overview of concussion, as well as the importance of concussion management inclusive of a neuropsychological evaluation.

How does a concussion happen?

To understand the mechanism that causes a concussion, we need to cover the structure of a neuron.

A neuron is the scientific name of a brain cell. Each neuron has a cell body, dendrites, and an axon. There are billions of neurons inside your brain, which communicate with each other, using those dendrites and axons.


Here’s a schematic illustration that depicts the structure of a neuron. Focus on the three items we mentioned, as it will be important in explaining how a concussion happens.

The brain is the most fragile organ in the body that has the texture and consistency of gelatin. Fortunately, the skull provides anatomical protection against external trauma. However, this protection could be a double-edged sword.

Now imagine your brain moving around the skull with no medium that separates the gelatin-like structure from the bony, hard structure. What do you think would happen?

Well, every time you shake your head, stand up, or run, your brain would come in contact with the skull in a brutal way that may damage it. For this reason, there is a liquid called the cerebrospinal fluid (CSF), which surrounds the brain and acts as a shock-absorbent to reduce the friction between the two structures.

In other words, your brain is floating in the CSF to be able to easily move around when you change positions.

A concussion happens when the brain hits the skull with an intensity that surpasses the CSF-cushioning ability. As a result, this can shear the axons of some neurons; a phenomenon referred to as diffuse axonal injury.

 


 Congratulations! You have made it through your first anatomy lecture!

Signs and symptoms of a concussion

The signs and symptoms of a concussion vary greatly, depending on the location and severity of brain injury.  region affected inside the brain.

Nevertheless, here are some of the most common signs and symptoms you would expect:

As you can see, the clinical presentation of a concussion is highly unspecific and may be confused with other neurological conditions if a history of physical trauma is not reported by the patient.

Diagnosis

The diagnosis of a concussion involves three steps:

Your physician will start by asking you a few questions to establish a history of physical trauma and other risk factors. He/she will then conduct a neurological physical examination to look for any signs that align with the diagnosis of concussion.

If you present with severe symptoms, your doctor may order an MRI or a CT scan to visualize the brain and pinpoint the injured region. However, don’t be surprised if your MRI or CT scan come back normal and you are still experiencing significant symptoms. That’s because the shearing of the axons that we talked about earlier is hard to detect on these sort of imaging techniques. It doesn’t mean your injury isn’t real or it’s “all in your head”, it just means the microscopic shearing that occurred didn’t show up. Sometimes Diffuse Tensor Imaging (DTI) can better detect the impact of a concussion (unfortunately it is not usually covered by insurance).

Once the diagnosis is established, it is time for medical/surgical management.

Treatment option

Depending on the severity of your symptoms, the treatment approach will vary. For instance, if the CT scan shows internal bleeding inside your skull, you may need a surgical procedure by a neurosurgeon to drain that blood and relieve the pressure.

In most cases, symptomatic treatment may be sufficient. So, if you present to the emergency department with a headache after hitting your head, your physician may prescribe acetaminophen to relieve your pain and advise you to get a lot of rest and hydration. It is important that rest for the first 24-48 hours are crucial but after that you may start to do yourself a disservice. You should be trying to slowly resume previous daily activities to complement recovery.

The importance of neuropsychological evaluation in concussion treatment

If you are not familiar with neuropsychological evaluation, it is the collection of information by a certified clinician (psychologist) to determine if the symptoms of one patient can be explained by a brain-based abnormality.

Unfortunately, and as we mentioned earlier, not all patients with concussions fully recover as fast as expected. In fact, a considerable number of people will have to deal with neurological and psychological sequelae for a long period of time, hence the importance of neuropsychological evaluations and psychotherapeutic treatment.

According to the American Psychological Association,  a neuropsychological evaluation might be sufficient for patients to avoid wrongfully attributing normal memory slips or other everyday problems to their concussions. Psychotherapy will also assist with the adjustment of returning to work or school with persistent symptoms.

Additionally, if the patient presents with severe symptoms, the neuropsychologist may recommend rehabilitation therapy that consists of memory practice, and problem-solving interventions to strengthen cognitive skills.

Integrating a neuropsychological evaluation and psychotherapy in the management plan could be a great tool to accelerate recovery and minimize complications.

Multiple studies support this concept and encourage healthcare institutions to implement neuropsychological evaluation in post-concussion medical management.

Conclusion            

Although, concussion is a difficult medical condition to deal with- a neuropsychological evaluation can be a great tool that improves the outcome of patients who undergo a concussion.  Why? Because a neuropsychologist will be able to identify changes in brain functioning, changes in mood that can interfere with efficient cognitive functioning and can refer to the appropriate professionals that can help in concussion recovery (i.e. vision therapy, headache specialists, physical therapy etc.)

If you have any questions about concussions, feel free to share your thoughts in the comment section below or shoot me an e-mail (murray@nyns.info).

Author
Dr. Nicole Murray Dr. Murray assists her clients in resuming their lives that have been disrupted by changes in health status. She received her Doctorate in Clinical Psychology at the Illinois School of Professional Psychology. She completed her internship and two-year fellowship at Mount Sinai-Icahn School of Medicine specializing in rehabilitation and neuropsychology. Her office is located near Grand Central.

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