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CME/CE: Neurology
which may increase the risk of neurologic
disorders such as Alzheimer and
Parkinson diseases. 17
Diagnosis of Concussion
Until an objective measure is available,
the only way to diagnose a concussion
is through a history of the event. It is
best to use an open-ended format to
interview the patient and/or others who
witnessed the injury. Let them tell their
story and describe what they were doing
just before, during and afterward. Ask
the patient to include what he or she saw,
heard, smelled, tasted and felt. In some
cases, it may not be possible to establish
whether loss of consciousness (LOC) or
post-traumatic amnesia (PTA) occurred.
Establish the timeline of the event
as soon as possible, when memories
are fresher. In addition to helping with
questions about the case later on, recording
early memories helps confirm the
length and degree of cognitive impairment.
Understanding the particulars of the
injury is helpful: type of vehicle, belted or
not, protective gear, position, speed, what
body part hit what, and so on. Ask whether
any damage to protective gear occurred
(crack in helmet or safety glasses, etc).
What symptoms did the patient experience
right after the event, and what are the
current symptoms Common symptoms
immediately after a concussive event can
include headache, tinnitus, dizziness,
nausea, vomiting and increased irritability.
The initial interview should also
include a thorough patient history to
evaluate concurrent conditions, current
or prior use of alcohol or drugs, current
medications, caffeine use, dietary
habits and prior history of concussions.
These answers are helpful in determining
treatment options and in identifying
issues that may exacerbate symptoms or
complicate recovery. 11
The physical examination portion of
the visit should consist of three parts:
• a focused neurologic exam including
a mental status assessment, cranial
nerve testing, extremity tone and deep
tendon reflex testing, strength, sensation,
gait and postural stability (Romberg test)
• a focused vision exam including
gross acuity, eye movement, binocular
function and visual fields/attention
Table 2
Sports Concussion Grading System 8
Grade 1: Transient confusion with resolution of symptoms in less than 15 minutes
Grade 2: Transient confusion and symptoms lasting more than 15 minutes
Grade 3: Any loss of consciousness
Developed by the American Academy of Neurology, http://www.aan.com/professionals/practice/guidelines/
pda/Concussion_sports.pdf
Table 3
Indications for Computed Tomography After
Minor Head Injury 18
(The New Orleans Criteria)
Consider computed tomography within 7 days of minor traumatic brain injury for
patients who exhibit one or more of the following:
◗ Physical evidence of trauma above the clavicles
◗ Seizure
◗ Vomiting
◗ Headache
◗ Short-term memory deficits (persistent antrograde amnesia)
◗ Age older than 60
◗ Drug or alcohol intoxication at the time of injury
◗ Coagulopathy
http://www.nejm.org/doi/pdf/10.1056/NEJM200007133430204
• a focused musculoskeletal examination
of the head and neck, to include
range of motion of the neck and jaw, focal
tenderness and referred pain.
Normal neurologic exam findings suggest
that no major structural injuries to
the brain have occurred. Findings that
require urgent consultation with the
neurology or neurosurgery departments
include altered consciousness, progressive
decline in neurologic findings, pupillary
asymmetry, seizures, repeated vomiting,
double vision, worsening headache,
inability to recognize people, disorientation
to place, unusual behavior, confusion,
slurred speech, unsteadiness, and
weakness or numbness of arms or legs. 11
Understanding the mechanism of injury
helps determine whether radiologic
studies are needed. The New Orleans
criteria for computed tomography after
minor head injury are shown in Table 3
and are intended for use within the first
7 days after injury. 18 If imaging is desired
after the first 7 days, it may be more effective
to use MRI or other imaging studies
that can provide more detail about the
brain anatomy.
Often, an affected patient exhibits
no outward signs of a concussion. The
symptoms of concussion are wide ranging.
Physical symptoms of concussion
include headache, dizziness, balance
problems, nausea or vomiting, fatigue,
visual disturbances, light sensitivity, tinnitus,
and sleep disturbances. Cognitive
symptoms include slowed thinking, poor
concentration, trouble with word choice,
and short-term memory loss. Emotional
issues include anxiety, depression, irritability
and mood swings.
The physical examination findings and
the symptom complaints should direct
care. Start with the symptom that is most
disabling for the patient. An interplay may
exist among some of the most common
symptoms. When one of the symptoms
is treated effectively, others may improve.
For example, the symptoms of headache,
sleep disturbance, memory loss and mood
change tend to improve when one of them
is improved. 19
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