AANS Neurosurgeon : Features

Volume 24, Number 2, 2015

Screening and Management of Pediatric Concussion

Sudhakar Vadivelu, DO

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A growing number of children are visiting the ER for mild traumatic brain injuries resulting from sports-related events. With this, more attention has been placed on the recognition of the severity of second impact syndrome, the management of pediatric concussions, and the overall evolving definition of “concussion.”

Identifying “Concussions”
Today, “mild traumatic brain injury” is used almost synonymously with the term “concussion” in the medical literature. The 4th International Conference on Concussion in Sport, held in Zurich in 2012, stressed the notion of an evolving definition of “concutere” (Latin for concussion), often referred to as commotio cerebri, to represent the most common subset of mild traumatic brain injury and defined as “a complex pathophysiological process affecting the brain, induced by biomechanical forces and including common features, such as 1. direct blow with impulsive force to the head, rapid onset of neurological impairment that may resolve or in some cases have delayed onset; 2. symptoms as a result of functional change rather than structural abnormality on imaging studies, and 3. graded symptoms that may not involve loss of consciousness and may be prolonged.” (1)

An example of a direct blow is seen in common contact sports, such as American football, rugby and ice hockey, though it may also occur in non-helmeted sports, such as soccer, and vehicle-related sports, such as two-wheeled motored biking. Dompier et al. (2) recently reported that approximately 4 to 9 percent of concussions occur in youth, high school and collegiate levels. These concussions usually take place during game time, but also occur during practice time. This raises the potential of employing modified practice and competitive play strategies in order to reduce injury.

In addition, not all “concussions” result in a loss of consciousness. Duhaime et al. (3) explains that the spectrum of presenting symptoms in college-level football and hockey may include subtle findings, such as clouded mentation, headache or dizziness. In fact, other observations report less than 10 percent of concussions have a presenting loss of consciousness. Motorcross is another sport growing in popularity among the pediatric population, and 50 percent of those affected riders also report headache, mental fog and dizziness, but no loss of consciousness. Further, both of these sports (American football and motorcross) encourage the importance of wearing helmets, though it may not be enough in preventing concussions. Instruction on proper fit and use of helmet may aid in this endeavor. (4)

Managing Pediatric Concussions
Concussion identification relies heavily on self-reporting. In fact, imaging studies rarely demonstrate evidence towards structural injury, despite functional discordance. Despite negative findings on CT imaging, there is growing evidence that MRI can detect abnormalities, such as focal white matter injury (see Fig. 1). For these reasons, suspicion remains critical in organized sports and should incorporate the use of athletic trainers with certification in concussion diagnosis concordant. Trainers or team physicians should follow a strict battery of tests and screening measures (ImPACT (5) and ChildSCAT3 (1)) on the field/site addressing mental focus and physical balance. Importantly, if concussion suspicion is raised at any time, or if any of the tests are failed — even if it seems transient — the young athlete must not return to play that same day. This is even truer in children in whom physical and mental recovery takes longer. In general legislation, most states are quite similar regarding no-return-to-same-day-play guidelines, and further encouraging both physical and mental rest for a minimum of 24 to 48 hours with a graduated reinvolvement of sports play over the next 14 days, as long as no symptoms return.

Figure 1: A 5-year-old, presenting with concussion, without LOC, after sports-related collision. MR imageswith abnormal signal within the left superior frontal gyrus (yellow arrow) on both T2 and FLAIR sequences.

Zachary Lystedt, a middle school athlete who returned too soon after suffering a concussion, subsequently developed brain hemorrhage requiring surgery. This sparked the first strict legislation in any state to mandate guidelines on return to play, which was initiated by Lystedt’s neurosurgeon, Richard Ellenbogen, MD, FAANS. (6) To date, 50 states have passed legislation regarding medical involvement in return to play in youth athletics.

Though baseline neuropsychological tests are not standard in concussion care, they are highly encouraged to aid in recovery. This may be especially helpful in determining how much time off from school is recommended following the injury. For example, is one-to-two days recovery enough, or is one-to-two weeks off more beneficial along with increasing allotted times for cognitive activities? Also, multidisciplinary assessments are useful in identifying factors that may require the need for longer observation and period of time before return to play, such as depression and anxiety disorders. (1)

Further discussion and exploration is necessary regarding the prevalence of concussions among young athletes. Do sporting rules and/or regulations need to change in order to be safer for youth? For example, should there be a “no heading” rule in youth soccer? Should pre-play physical assessments include neuropsychological testing of the player, and perhaps even psychological assessment of their families and/or coaches? Consider who or what the pugilist really is when it comes to concussion among youth.

Sudhakar Vadivelu, DO, is assistant professor of neurological surgery at the University of Cincinnati College of Medicine in Cincinnati, and is co-director of the Cerebrovascular Center at Cincinnati Children’s Hospital Medical Center. The author reported no conflicts for disclosure.


1. McCrory P, Meeuwisse WH, Aubry M et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47:250-258.

2. Dompier TP, Kerr ZY, Marshall SW et al. Incidence of Concussion During Practice and Games in Youth, High School, and Collegiate American Football Players. JAMA Pediatr. 2015; May 4. doi: 10.1001/jamapediatrics.2015.0210.

3. Duhaime AC, Beckwith JG, Maerlender AC et al. Spectrum of acute clinical characteristics of diagnosed concussions in college athletes wearing instrumented helmets: clinical article. J Neurosurg 2012; 117(6):1092-1099.

4. Luo TD, Clarke MJ, Zimmerman AK et al. Concussion symptoms in youth motocross riders: a prospective, observational study. J. Neurosurg Pediatr 2015; 15:255-260.

5. Maerlender A, Flashman L, Kessler A et al. Examination of the construct validity of ImPACT™ computerized test, traditional, and experimental neuropsychological measures. Clin Neuropsychol. 2010 Nov;24(8):1309-25.

6. “The Lystedt Law: A Concussion Survivor’s Journey.” Centers for Disease Control and Prevention.

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