When the Brain Bleeds - Return to Play after Intracranial, Subarachnoid, and Subdural Bleeds: what we know and what we do not Ross Zafonte,DO Earl P and Ida S. Charlton Professor and Chair Harvard Medical School Senior Vice President Spaulding Rehabilitation Network Chief Physical Medicine and Rehabilitation Massachusetts General Hospital Brigham and Women s Hospital REDSOX foundation/mgh Home Base Program
Objectives History Discuss available data Review controversies Employ case example Caveats!!!! evidence level a challenge Disclosure- Funding NIH, NIDRR, USARMY(DOD),
History:Brain Injury related fatalities
History:Football
Severe Injury 94 incidents of severe football head injuries reported to National Center for Catastrophic Sports injury from Sept 1989 June 2002 (13 academic years). Subdural Hematoma (SDH) 75 SDH w/ diffuse brain edema 10 Diffuse brain edema 5 AVM or aneurysm 4 No skull fractures 59 contacts/medical records revealed: 35 (59%) had previous head injury 25 (71%) of those had it during the same season as catastrophic injury 39% (21 of 54) were playing w/ residual neurologic symptoms Injuries >3.5x more common during game-play
Severe Injury 53 of 70 (75.5%) contacts/medical records reported surgery performed (mostly hematoma removal, decompression, ICP monitoring) Outcome from catastrophic injury: 8 (9%) deaths 46 (51%) non-fatal, permanent neurologic injuries i.e. memory loss, slurred speech, paralysis, blindness, seizures, personality changes, hearing loss, spasticity, medical complications NONE returned to play 36 (40%) serious injuries w/ full recovery 2 returned to play without any known recurrences
2012 5 brain injuries with incomplete neurological recovery (4 high school, 1 college) Reduction from 16 in 2011 5 brain injuries with recovery (4 high school, 1 college) (Survey researchers do not have full confidence in full recovery data due to difficulty receiving non-disability injury information)
Case report 17y/o college football had what appears to be a mild concussion that was not reported for 12 days With continued sx of headaches, nausea (post-concussive syndrome) physical activity was restricted He returned to full football regimen 25 days after original trauma and over the next 10 days reported his headaches were less frequent and less severe At that point sustained a 2 nd head injury during a game, in ER had decerebrate posturing, fixed and dilated left pupil, R-side paralysis, shallow breating CT Head w/ acute left subdural hematoma with massive midline shift to the right Tx: burr hole relieved acute subdural, temporoparietal craniotomy evacuated additional clotted subdural Outcome: d/c to home w/o evidence of neurological deficits 19-days later Not engage in future football activities Repeated minor head trauma may make individual more susceptible to an acute subdural hematoma
Acute ICH No athlete should return to play while symptomatic When making RTP or retirement decisions, important to consider how many prior concussions and subconcussive impacts based on sport, position, and style of play Of note, persons w/ subdural hematoma may take longer than those with epidural or subarachnoid hemorrhage to present w/ deteriorating symptoms RTP discussions should include second impact syndrome and it s associated morbidity/mortalitiy
Acute ICH After any intracranial hemorrhage (Subdural, epidural, intracerebral, or subarachnoid) return to collision sport is discouraged, but return to noncollision sport can be considered if recovery is complete If RTP is considered: At should be far removed from time of injury (> 1 yr) All imaging, neurocognitive, balance, and other clinical measures should be at baseline for the individual
Acute Some conditions are contraindications to RTP or any type of participation, especially in collision sports. SAH Multiple Microbleeds** Contraindications on CT or MRI to RTP include persistent edema, hemorrhage, associated cavum septum pellucidum***, or arachnoid cyst
Return to Play No level 1 evidence to guide decisions after subdural or extradural, only expert opinion- level of evidence- POOR No level 1 evidence after craniotomy, only expert opinion Return to neurophysiological/cognitive baseline is a must. w/ an intracranial hemorrhage, must assume underlying neurological injury and through neurological and neuropsychological assessment is required after recovery from hematoma Before considering RTP Controversies : No evidence that prior subdural/extradural predisposes to recurrence in the future Extradural hematoma must be fully resolved and fractures fully healed Subdural hematoma must be resolved, brain reexpanded to fill the subdural space, and no residual hygroma Through workup for risk factors must be negative, including coagulopathy and brain lesions (e.g. vascular malformations) A minimum timeframe of over 1 year (estimated due to healing times for fracture of bone and reabsorption times of the hematoma)
Return to play: controversies Before considering RTP after craniotomy level of evidence- POOR: Complete bony union is documented with radiology, including CT scan with bone window (usually takes 12 months to occur) Normal MRI w/ no underlying brain or meningeal injury Complete neurological recovery is confirmed Varied expert opinion after craniotomy: Allow a boxer to return Not allow a boxer to return Allow a soccer player, or some other sports, to return with a helmet to protect the craniotomy site However, all would allow RTP if only burr hole was performed*** Note: Though not studied, expert opinion suggests rigid bone flap fixation methods are perhaps more stable and may allow athletes to return more quickly but in the long term there may be no difference
Return to play: controversies 3 primary apprehensions about RTP post-craniotomy: Strength of the flap to withstand direct pressure from blows to the head Potential fragility of tissue at operative site and neovascularity from the healing process Alteration of normal CSF pathways, potentially altering the normal buoyancy of the brain Issues regarding any damage and additional exposure Subconcussive issues RTP after bony healing (generally 1 year in non-smokers) and all other neurological and radiological testing normal There have been documented return to contact/collision sports post-craniotomy: professional ice hockey, professional boxing, amateur soccer, professional football Opinion states, discouraging return to contact sports in athletes with direct parenchymal injury requiring craniotomy
Return to Play controversies No surveillance imaging after RTP**- no data RTP guidance for a repeat concussion after previous hemorrhage is usual guidelines with addition of repeat imaging (MRI) if: Loss of consciousness Worsening postconcussive symptoms Focal neurological deficits Persistent mental status changes Additional issues (a case example): Subarachnoid hemorrhage, damage to underlying brain parenchyma (not clear ie single slice imaging changes- that are dislinked), persistent active post-concussive symptoms, permanent neurologic sequelae from head injury, hydrocephalus, foramen magnum abnormalities
Other intracranial imaging abnormalities Arachnoid cyst May present increase risk, though not absolute contraindication for contact sports Should be counseled on risk of traumatically induced hemorrhage Chiari Malformation Type I Relative contraindication for contact sports in asymptomatic patients Though if discovered during evaluation for a concussion, conservative treatment would be to recommend against return to contact sport Absolute contraindication for contact sport if associated syringomyelia, obliteration of subarachnoid space, indentation of anterior medulla, or symptomatic CM-I
Other intracranial imaging abnormalities: and a paucity of evidence Cavum septum pellucidum Presence is common and usually incidental finding and isolated finding should not preclude participation from contact or collision sports However, new development or serial enlargement could be evidence of early signs of chronic brain damage! Ventriculoperitoneal shunts No evidence for contact sport restrictions Survery of neurosurgeons: 89% do not restrict participation in non-contact sports 1/3 do not restrict participation in all contact sports 1/3 prohibit or strongly advise against participation in all contact sports
Chronic concerns and evidence Network links Non aligned data Phenotype expressions
Controversies Risk discussion Decision to retire an athlete after an injury