Head Injuries
mvpboxing  |   May 04, 2017, 12:05PM

Concussion
  1. Definition
    1. A concussion, the most common type of Traumatic Brain Injury (TBI), is a disturbance of brain function without measurable change in brain anatomy, which may be caused by sudden trauma and marked by a change in mental status. Concussions may or may not be accompanied by loss of consciousness (LOC), and may cause a variety of physical, cognitive, and emotional symptoms.
  2. Description
    1. A concussion is a minor traumatic brain injury (MTBI) that may occur when the head hits an object, or a moving object strikes the head, which causes the brain to bounce against the rigid bone of the skull. This force may cause a tearing or twisting of the structures and blood vessels of the brain, subsequently results in a breakdown of the normal flow of messages within the brain. The damage to the brain is generally found deep within the brain tissue. Due to this damage, the normal functions of the brain signals are interrupted.
  3. Causes, incidence, and risk factors
    1. A concussion can result from sports activities (Boxing, MMA and Football), car accidents, and falls. Acceleration (g-forces, jarring) can exert rotational forces in the brain in any direction (especially the midbrain and diencephalon), may cause loss of alertness and unconsciousness. The duration of being unconscious may be a sign of the severity of the concussion. However, concussions don't always involve a loss of consciousness. Most people who have a concussion never pass out, but they may describe seeing all white, black, or stars. You can have a concussion and not realize it.
  4. Symptoms
    1. Physical Symptoms of a concussion can range from mild to severe. They can include:
      1. Acting confused, feeling spacey, or not thinking straight
      2. Headache
      3. Loss of consciousness
      4. Nausea and vomiting
      5. See flashing lights
      6. Balance problems
      7. Tinnitus (ringing in ears)
      8. Post traumatic seizures
      9. Post traumatic epilepsy
      10. Double vision
      11. Dizziness
      12. Fatigue
      13. Trouble falling asleep
      14. Sleep more than usual
      15. Drowsiness
      16. Sensitivity to light
      17. Sensitivity to noise
      18. Numbness or tingling
      19. Difficulty communicating
      20. Difficulty concentrating
    2. Cognitive and Emotional Symptoms
      1. Memory loss (post traumatic amnesia) of events before the injury or right after
      2. Disorientation
    3. The following are emergency symptoms of a concussion. Seek immediate medical care if there are:
      1. Changes in alertness and consciousness
      2. Convulsions (seizures)
      3. Muscle weakness on one or both sides
      4. Persistent confusion
      5. Remaining unconsciousness (coma)
      6. Repeated vomiting
      7. Unequal pupils
      8. Walking problems

        Head injuries that cause a concussion often occur with injury to the neck and spine. Take special care when moving people who have had a head injury.
    4. While recovering from a concussion, you may:
      1. Have a hard time with tasks that require remembering or concentrating
      2. Withdrawn, easily upset, or confused
      3. Have mild headaches
  5. Diagnosis
    1. The doctor will perform a physical exam and check your nervous system. There may be changes in your pupil size, thinking ability, coordination, and reflexes. If the doctor thinks that you have a concussion, he or she will ask questions about the injury and may test your ability to pay attention, your learning and memory. Your doctor may also try to find out how quickly you can solve problems. Then the doctor will check your strength, balance, coordination, reflexes, and sensation. Sometimes the doctor will order imaging tests such as a CT scan or a MRI to make sure your brain is not bruised or bleeding.
    2. Tests that may be performed include:
      1. EEG (brain wave test) may be needed if seizures continue
      2. Head CT scan
      3. MRI of the head
    3. Grade 1: The mild concussion occurs when the person does not lose consciousness (pass out) but may seem dazed.
    4. Grade 2: The slightly more severe form occurs when the person does not lose consciousness, but has a period of confusion, and does not recall the event. People at higher risk are those who are active in high impact sports and those who are taking blood thinners, such as Coumadin.
    5. Grade 3: The classic concussion, which is the most severe form, occurs when the person loses consciousness for a brief period of time and has no memory of the event. Evaluation from a health –care provider should be performed as soon as possible after the injury.
  6. Expectations (prognosis)
    1. Healing or recovering from a concussion takes time. It may take days, weeks, or even months. You may be irritable, have trouble concentrating, unable to remember things, have headaches, dizziness, and blurry vision. These problems will probably go away slowly. You may want to get help from family or friends before making important decisions.
  7. Prevention
    1. A concussion is unexpected, but there are several commonsense precautions you can take to lessen the possibility of traumatic brain injury. In order to prevent head injuries in adults, always wear protective equipment during activities or sports related activities that could cause a head injury .They can help safeguard against traumatic head injuries. Participation in high-contact, high-risk sports such as football, hockey, boxing, MMA and soccer can increase the possibility of a concussion. Skateboarding, snowboarding, horseback riding, and rollerblading are also a threat to your brain's health. Wearing a bike helmet can lower the risk of traumatic head injury by 85%. Ensure that the equipment is properly fitted, well maintained, and worn consistently. Drive and ride smartly. Always wear a seatbelt, obey posted speed limits, and don't use drugs or alcohol because they may impair reaction time. Concussions may be sustained during an assault (fighting), and more males than females report traumatic head injuries.
    2. Wear a helmet and safety equipment when you:
      1. Play sports, such as baseball, hockey, and football. Drive or ride on a motorcycle and scooter.
      2. Wear headgear and/or helmet when training in boxing and MMA, skiing, skateboarding and horse riding
      3. Make your home safer to prevent falls.
    3. Reduce your child's chances of getting a concussion:
      1. Use child car seats and booster seats correctly.
      2. Each your child bicycle safety.
      3. Teach your child how to be safe around streets and cars.
      4. Keep your child safe from falls.
      5. Teach your child playground safety.
    4. Order and display the concussion poster: CDC and the NFL encourage parents, coaches, and school professionals to display this poster in team locker rooms, competition and tournament sites, gymnasiums, ice rinks, and schools nationwide.
  8. Treatment
    1. A more serious brain injury that involves bleeding or brain damage must be treated in a hospital. Any person who may have had a concussion needs to see a doctor. Some people have to stay in the hospital to be watched. Others can go home safely. People who go home still need to be watched closely for warning signs or changes in behavior. Call a doctor or seek emergency care immediately if you are watching a person after a concussion and have these symptoms:
      1. Headache that gets worse or does not go away.
      2. Weakness, numbness or decreased coordination.
      3. Repeated vomiting or nausea.
      4. Slurred speech.
      5. Extreme drowsiness or you cannot wake them.
      6. One pupil that is larger than the other.
      7. Convulsions or seizures.
      8. Problem recognizing people or places.
      9. Increasing confusion, restlessness, or agitation.
      10. Loss of consciousness.
    2. Warning signs in children are the same as those listed above for adults. Take your child to the emergency department if he or she has any of the warnings signs listed above or:
      1. Will not stop crying.
      2. Will not nurse or eat.
    3. A person who might have a concussion needs to immediately stop any kind of activity or sport. Being active again too soon increases the person's risk of having a more serious brain injury. Be sure to see a doctor before returning to play. Rest is the best way to recover from a concussion. Here are some tips to help you get better:
      1. Get plenty of sleep at night, and take it easy during the day.
      2. Avoid alcohol and illegal drugs.
      3. Do not take any other medicines unless your doctor says it is okay.
    4. Avoid activities that are physically or mentally demanding (including housework, exercise, schoolwork, video games, or using the computer). Ask your doctor when it's okay for you to resume normal every day activities.
    5. Use ice or a cold pack on any swelling for 10 to 20 minutes at a time. Put a thin cloth between the ice and your skin in order to prevent frostbite.
    6. Use pain medicine as directed. Your doctor may give you a prescription for pain medicine or recommend you use a pain medicine that you can buy without a prescription, such as acetaminophen (for example, Tylenol) or ibuprofen (for example, Advil or Motrin).
    7. Some people feel normal again in a few hours while others have symptoms for weeks or months. It is very important to allow yourself time to get better and to slowly return to your regular activities. If your symptoms come back when you are doing an activity, stop and rest for a day. This is a sign that you are pushing yourself too hard. It is also important to call your doctor if you are not improving as expected or if you think that you are getting worse instead of better.
    8. After checking for signs of neck injury, the patient should be watched for several hours. Taking the patient to the emergency room is warranted for any of the following: repeated vomiting, worsening headache, dizziness, seizure activity, excessive drowsiness, double vision, slurred speech, unsteady walk, or weakness or numbness in arms or legs, or signs of basilar skull fracture. After this initial danger period has passed, there is debate whether it is necessary to awaken the patient several times during the first night as has traditionally been done, or whether the patient would benefit more from uninterrupted sleep.
    9. The 2008 Zurich Consensus Statement on Concussion in Sport states, "The cornerstone of concussion management is physical and cognitive rest until symptoms resolve." Most (80–90%) concussions resolve within seven to ten days, although the recovery time may be longer in children and adolescents.
    10. Concussion sufferers are generally prescribed rest, including plenty of sleep at night plus rest during the day. Rest includes both physical and cognitive rest until symptoms clear. Health care providers recommend a gradual return to normal activities at a pace that does not cause symptoms to worsen. Education about symptoms, how to manage them, and their normal time course can lead to an improved outcome.
    11. For persons participating in athletics, the 2008 Zurich Consensus Statement on Concussion in Sport recommends persons be symptom free before restarting and then, not all at once, but rather through a series of graded steps. These steps include: complete physical and cognitive rest, light aerobic activity (less than 70% of maximum heart rate), sport-specific activities such as running drills and skating drills, non-contact training drills (exercise, coordination, and cognitive load), full-contact practice, and full-contact games. Only if a person is symptom free for 24 hours, should he or she proceed to the next step. If symptoms occur, the person should drop back to the previous asymptomatic level for at least another 24 hours. This is not a race. The person should go easy and take his or her time. The emphasis is on remaining symptom free and taking it in medium steps, not on the steps themselves.
  9. Concussion Self-Care at Home
    1. Bleeding under the scalp, but outside the skull, creates a "goose egg" or large bruise (hematoma) at the site of the head injury. A hematoma is common and will go away on its own with time. The use of ice immediately after the trauma may help decrease its size.
    2. Do not apply ice directly to the skin which can cause frostbite–instead insert ice and cold water into a plastic zip lock bag. You may also use a bag of frozen vegetables wrapped in cloth, as this conforms nicely to the shape of the head. Apply ice for 20-30 minutes at a time and repeat about every two to four hours. There is little benefit after 48 hours. Rest is important to allow the brain to heal. In 2010, the American Academy of Neurology called for any athlete suspected of having a concussion to be removed from play until the athlete is evaluated by a physician. If a concussion is suspected due to a sports injury, the Centers for Disease Control recommend implementing a 4-step plan:
      1. Remove the athlete from play. Ensure that the athlete is evaluated by a health care professional experienced in evaluating for concussion. Do not try to judge the severity of the injury yourself.
      2. Inform athlete's parents or guardians about the possible concussion and give them the fact sheet on concussion.
      3. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says they are symptom-free and it's OK to return to play.
      4. A repeat concussion that occurs before the brain recovers from the first - usually within a short period of time (hours, days, or weeks) - can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death.
    3. Concussion Medical Treatment
      1. Bed rest, fluids, and a mild pain reliever such as acetaminophen (Tylenol) may be prescribed.
      2. Ice may be applied to bumps to relieve pain and decrease swelling.
      3. Cuts are numbed with medication such as lidocaine, by injection or topical application. The cut is then cleansed thoroughly with a saline solution and possibly an iodine solution. The doctor will explore the injury to look for foreign matter and hidden injuries. The wound usually is closed with skin staples, stitches (sutures), and occasionally a skin glue named cyanoacrylate (Dermabond).
  10. Concussion Follow-up
    1. After initial treatment, the patient will be referred for follow-up care to their primary care doctor or a specialist, such as a neurologist. It is important to keep these appointments, particularly because some of the more subtle problems of concussion (memory deficits, personality changes, and changes in cognition) may not be apparent at the time of the initial injury.
  11. Outlook (Prognosis)
    1. People who have had a concussion seem more susceptible to another one, particularly if the new injury occurs before symptoms from the previous concussion have completely gone away. It’s also a negative process if smaller impacts cause the same symptom severity. Repeated concussions may increase a person's risk later life for dementia, Parkison’s disease and depression.
    2. MTBI has a mortality rate of almost zero. The symptoms of most concussions resolve within weeks, but problems may persist. Problems are seldom permanent, and outcome is usually excellent. People over age 55 may take longer to heal from MTBI or may heal incompletely. Similarly, factors such as a previous head injury or a coexisting medical condition have been found to predict longer-lasting post-concussion symptoms. Other factors that may lengthen recovery time after MTBI include psychological problems such as substance abuse or clinical depression, poor health before the injury or additional injuries sustained during it, and life stress. Longer periods of amnesia or loss of consciousness immediately after the injury may indicate longer recovery times from residual symptoms. For unknown reasons, having had one concussion significantly increases a person's risk of having another. Having previously sustained sports concussion has been found to be a strong factor increasing the likelihood of a concussion in the future. Other strong factors include participation in a contact sports coupled with the acceleration of body mass size making impact. The prognosis may differ between concussed adults and children; little research has been done on concussion in the pediatric population, but concern exists that severe concussions could interfere with brain development in children.
    3. A 2009 study published in Brain found that individuals with a history of concussions might demonstrate a decline in both physical and mental performance for longer than 30 years.
    4. Compared to their peers with no history of brain trauma, sufferers of concussion exhibited effects including loss of episodic memory and reduced muscle speed.
  12. Post-concussion syndrome
    1. In post-concussion syndrome, symptoms do not resolve for weeks, months, or years after a concussion, and may occasionally be permanent. Symptoms may include headaches, dizziness, fatigue, anxiety, memory and attention problems, sleep problems, and irritability. There is no scientifically established treatment, and rest, a recommended recovery technique, has limited effectiveness. Symptoms usually go away on their own within months. The question of whether the syndrome is due to structural damage or other factors such as psychological ones, or a combination of these, has long been the subject of debate.
  13. Cumulative effects
    1. Cumulative effects of concussions are poorly understood. The severity of concussions and their symptoms may worsen with successive injuries, even if a subsequent injury occurs months or years after an initial one. Symptoms may be more severe and changes in neurophysiology can occur with the third and subsequent concussions. Studies have had conflicting findings on whether athletes have longer recovery times after repeat concussions and whether cumulative effects such as impairment in cognition and memory occur.
    2. Cumulative effects may include psychiatric disorders and loss of long-term memory. For example, the risk of developing clinical depression has been found to be significantly greater for retired American football players with a history of three or more concussions than for those with no concussion history. Three or more concussions also are associated with a fivefold greater probability of developing Alzheimer's disease earlier and a threefold greater chance of developing memory deficits.
  14. Second-impact syndrome
    1. Second-impact syndrome, in which the brain swells dangerously after a minor blow, may occur in very rare cases. The condition may develop in people who receive a second blow days or weeks after an initial concussion, before its symptoms have gone away. No one is certain of the cause of this often fatal complication, but it is commonly thought that the swelling occurs because the brain's arterioles lose the ability to regulate their diameter, causing a loss of control over cerebral blood flow. As the brain swells, intracranial pressure rapidly rises. The brain may be herniated and the brain stem can fail within five minutes. Except in boxing, all cases have occurred in athletes under age 20. Due to the very small number of documented cases, the diagnosis is controversial, and doubt exists about its validity.
  15. Complications
    1. Long-term problems are rare but may include:
      1. Brain swelling (which can be life threatening), if you have a second concussion while still recovering from the first one.
      2. Long-term changes in the brain (if you have future brain injuries).
      3. Symptoms of the concussion stay for a long period of time (in a small group of patients)
    2. If symptoms do not go away or are not improving after 2 or 3 weeks, call the doctor if the following symptoms occur:
      1. Changes in behavior or unusual behavior
      2. Changes in alertness or produces any other worrisome symptoms
      3. Changes in speech (slurred, difficult to understand, does not make sense)
      4. Confusion
      5. Difficulty waking up or becoming more sleepy
      6. Double vision or blurred vision
      7. Fever
      8. Fluid or blood leaking from the nose or ears
      9. Headache that is getting worse, lasts a long time, or does not get better with the counter pain relievers
      10. Problems walking or talking
      11. Seizures (jerking your arms or legs without control)
      12. Vomit more than three times
    3. Health care providers examine head trauma survivors to ensure that the injury is not a more severe medical emergency such as an intracranial hemorrhage. As with all head and neck injuries, assessment includes the "ABCs" (airway, breathing, circulation) and stabilization of the cervical spine. Cervical spine injury should be assumed in any athlete who is found to be unconscious after head or neck injury. Maintaining adequate cervical stabilization is critical until neurologic function in all four limbs is found to be intact and the athlete has no reported neck pain or cervical tenderness on palpation. If qualified medical personnel are not available on the field, the athlete should be transported to an emergency facility. Indications that screening for more serious injury is needed include worsening of symptoms such as headache, persistent vomiting, increasing disorientation or a deteriorating level of consciousness, seizures, and unequal pupil size. People with such symptoms, or who are at higher risk for a more serious brain injury, are CT scanned to detect brain lesions and are frequently observed for 24 – 48 hours.
    4. Concussions may be under-diagnosed. The lack of the highly noticeable signs and symptoms that are frequently present in other forms of head injury could lead clinicians to miss the injury, and athletes may cover up their injuries to remain in competition. A retrospective survey in 2005 found that more than 88% of concussions go unrecognized. Diagnosis of concussion can be complicated because it shares symptoms with other conditions. For example, post-concussion symptoms such as cognitive problems may be misattributed to brain injury when they are in fact due to post-traumatic stress disorder (PTSD).

Article by Wikipedia
Reference University of Boston

CTE
  1. Definition
    1. Chronic traumatic encephalopathy (CTE) is a progressive degenerative disease, diagnosed post-mortem in individuals with a history of multiple concussions and other forms of head injury. A variant of the condition, Dementia Pugilistica (DP), is primarily associated with prize fighting and American football. CTE has been most commonly found in professional athletes participating in the following sports:
      1. American football,
      2. Prize fighters (Boxing / MMA),
      3. Ice hockey, professional wrestling , rugby
  2. Causes
    1. The latest research findings suggest that there’s a direct correlation between the blast exposure by military service personnel and/or a concussive head injury by individuals who have experienced head trauma resulting in degeneration of brain tissue and the subsequent development of CTE (accumulation of toxic tau protein). Individuals with CTE may show symptoms of dementia, such as memory loss, aggression, confusion and depression, which may appear within months of the trauma or decades later. Repeated concussions and injuries less serious than concussions ("sub-concussions") incurred during the play of contact sports over a long time period may result in the development of CTE. The brain changes in CTE and DP are similar and are delayed effects of repeated concussions and sub-concussions of the brain.
  3. Epidemiology
    1. CTE is a neurological degenerative disease found in individuals who have been subjected to repetitive traumatic head injuries. Amateur and professional level athletes (prize fighters/ footballers) are the largest demographic to suffer from CTE due to frequent concussions sustained during play in contact-sports. Other individuals that have been diagnosed with CTE were involved in military service, had a previous history of chronic seizures and/ or were involved in activities resulting in head-banging. Reports of CTE have steadily increased in younger athletes, most likely due to athletes becoming bigger and stronger thus, producing greater magnitudes of force in collision.
  4. Signs and symptoms
    1. In order to diagnose a person with CTE, brain imaging must be done to the patient and even then it is difficult to determine the severity. A true diagnosis can be attained from brain biopsy, but this test comes at the risk of death for the patient. Due to the difficulty of diagnosing CTE, it is most commonly diagnosed posthumously.
    2. Diagnosis of CTE is frequently ascertained from patients' medical histories, i.e. past traumatic brain injuries, and secondary symptoms, including: disorientation, confusion, vertigo, headache, poor judgment, overt dementia, slowed muscular movements, staggered gait, impeded speech, tremors and deafness.
    3. Individuals suffering from CTE may also progress through three stages of the disease. The first stage is characterized by its disturbances and psychotic symptoms. In the second stage of the disease the patient may exhibit erratic behavior, memory loss, and the initial symptoms of Parkinson's disease. The final stage is dementia as well as symptoms related to Parkinson's disease.
  5. Prevention
    1. Recently, investigators demonstrated that immobilizing the head during a blast exposure prevented the learning and memory deficits associated with CTE that occurred when the head was not immobilized. This research, represent the first case series of postmortem brains from U.S. military personnel who were exposed to a blast and/or a concussive injury.
  6. Diagnosis
    1. The lack of distinct biomarkers for CTE means there is no definitive way of diagnosing CTE, except with a brain biopsy or post-mortem autopsy. Neuroimaging can detect subtle changes in axonal integrity of CTE and structural lesions of advanced CTE.
  7. History
    1. In 2008, the Sports Legacy Institute joined with the Boston University School of Medicine (BUSM) to form the Center for the Study of Traumatic Encephalopathy (CSTE). Brain Injury Research Institute (BIRI) also studies the impact of concussions.
  8. American Football
    1. In 2002, Dr. Bennet Omalu, a forensic pathologist and neuropathologist in Pittsburgh, Pennsylvania found CTE in the brains of Mike Webster, Terry Long, Andre Waters, Justin Strzelczyk and Tom McHale. Omalu, in 2012 a medical examiner and associate adjunct professor in California, was a co-founder of BIRI and reportedly in 2012 participated in the autopsy of Junior Seau.
    2. Several former National Football League (NFL) players have been diagnosed post-mortem with CTE. Since 2008, autopsies of eleven professional American football players by neuropathologist Dr. Ann McKee revealed CTE. Former Detroit Lions lineman and eight-time Pro Bowler Lou Creekmur, former Houston Oilers and Miami Dolphins linebacker John Grimsley, former Tampa Bay Buccaneers guard Tom McHale, former Cincinnati Bengals wide receiver Chris Henry, and former Chicago Bears safety Dave Duerson, have all been diagnosed post-mortem with CTE. Other football players diagnosed with CTE include Cookie Gilchrist and Wally Hilgenberg.
    3. An autopsy conducted in 2010 on the brain of Owen Thomas, a 21-year-old junior lineman at the University of Pennsylvania who committed suicide, showed early stages of CTE, making him the youngest person to be diagnosed with the condition. Thomas was the second amateur football player diagnosed with CTE, after Mike Borich, who died at 42. The doctors who performed the autopsy indicated that they found no causal connection between the nascent CTE and Thomas's suicide. There were no records of Thomas missing any playing time due to concussion, but as a player who played hard and "loved to hit people," he may have played through concussions and received thousands of subconcussive impacts on the brain.
    4. In July, 2011, Colt tight end John Mackey died after several years of deepening symptoms of frontotemporal dementia. BUSM was reported to be planning to examine his brain for signs of CTE.
    5. In 2012, retired NFL player Junior Seau committed suicide with a gunshot wound to the chest. There was speculation that he suffered brain damage due to CTE. Seau's family donated his brain tissue to the National Institute of Neurological Disorders and Stroke.
    6. On July 27, 2012, an autopsy report concluded that the former Atlanta Falcons safety Ray Easterling, who committed suicide in April 2012, had CTE.
  9. Ice hockey
    1. Athletes from other sports have also been identified as having CTE, such as hockey player Bob Probert. Neuropathologists at Boston University diagnosed Reg Fleming as the first hockey player known to have the disease. This discovery was announced in December 2009, six months after Fleming's death.
    2. Rick Martin, best known for being part of the Buffalo Sabres' French Connection, was diagnosed with CTE after his brain was posthumously analyzed. Martin was the first documented case of an ice hockey player not known as an enforcer to have developed CTE; Martin was believed to have developed the disease primarily as a result of a severe concussion he suffered in 1977 while not wearing a helmet. The disease was low-grade and asymptomatic in his case, not affecting Martin's cognitive abilities; Martin died of unrelated causes in March 2011 at the age of 59.
    3. Also within a few months in 2011, the deaths of three hockey "enforcers"—Derek Boogaard from a combination of too many painkillers and alcohol, Rick Rypien, an apparent suicide, and Wade Belak, who, as Rypien, had reportedly suffered from depression; and all with a record of fighting, blows to the head and concussions—led to more concerns about CTE. Boogaard's brain was examined by BUSM, which in October 2011 determined the presence of CTE. One National Hockey League player known in part for leading "the thump parade", Shawn Thornton of the Boston Bruins, mulled the "tragic coincidence" of the three recent league deaths and said their concurrence was just that, while defending the role of fighting on the rink.
  10. Wrestling
    1. In 2007, neuropathologists from the Sports Legacy Institute (an organization co-founded by Christopher Nowinski) examined the brain of Chris Benoit, a professional wrestler with the WWE. Chris Benoit had apparently killed his wife and son before committing suicide. Originally the suicide and the double murder of his wife and son were thought to be due to the abuse of anabolic steroids. However, a brain biopsy identified pathognomonic brain tissue changes of CTE: large aggregation of tau protein as manifested by neurofibrillary tangles and neuropil threads, which cause neurodegeneration.
    2. In 2009, Bennet Omalu discovered CTE in recently retired wrestler Andrew "Test" Martin, who died at age 33 from a drug overdose.
  11. NHL
    1. Derek Boogaard, one of the National Hockey League's most aggressive players, suffered from Chronic Traumatic Encephalopathy, or CTE, a degenerative brain disease that results from repetitive trauma to the head, an autopsy of his brain has revealed.
    2. Boogaard's death in May was ruled accidental after he consumed alcohol and the powerful painkiller oxycodone.
    3. Dr. Ann McKee, co-director of the VA CSTE Brain Bank, collaboration between Boston University, the Department of Veterans Administration, and the Sports Legacy Institute - made the discovery. She has diagnosed more than 50 athlete brains with CTE.
    4. Individuals affected by CTE can exhibit Alzheimer’s like symptoms, but CTE can only be diagnosed postmortem. It’s most commonly found in athletes who suffered repeated head trauma, such as football players, prize fighters and hockey players.
    5. Boogaard was one of the NHL’s most feared players. He played left wing for the Minnesota Wild from 2005 to 2010 and then joined the New York Rangers for the 2010-2011, season. He was best known as the enforcer - the player who physically, and often violently, checked a player with an offensive play.
    6. Boogaard was considered to be one of the toughest fighters in the NHL. In his NHL history of 277 games, he scored just three goals, had 589 penalty minutes and reportedly participated in 174 career fights.
    7. Boogaard had been unable to play since December 2010 because of injuries from a hockey fight, including a concussion. His family said Boogaard had reportedly had his “bell rung” at least 20 times, but did not always report the hits. He was diagnosed with post-concussion syndrome twice.
    8. Boogaard also struggled with drug addiction for the two years before his death. Since then, he had reportedly begun to act abnormally, was emotionally unstable and had problems with short-term memory and orientation. When Boogaard died, his family agreed to send his brain to the Brain Bank in hopes of finding some answers.
    9. While there is evidence of CTE in Boogaard’s brain, Dr. Bob Stern, one of the bank’s co-directors, is quick to point out the difficulties in determining how CTE contributed to Boogaard’s addiction and behavior.
    10. “Boogaard’s clinical history was complex, so it is unclear as to if or how much CTE contributed to his behavior, addiction or death. However, CTE appears to be a progressive disease in some individuals, so even if it was not directly affecting Boogaard’s quality of life and overall functioning before he died, it is possible it could have in the future.”
    11. Stern couldn't say with certainty that Boogaard's position as an enforcer was a factor in the development of CTE.
    12. “Is it fighting? The regular play of the game? The big hits? We just don’t know what would lead to the disease, " Stern said. “We know that exposure to repetitive brain trauma is necessary to the development of the disease, but not sufficient.”
    13. On average, according to Stern, half of all professional hockey games have some sort of fight. Stern said there is discussion within the NHL and amateur leagues to either diminish or get rid of fighting. Fighting and enforcing is unique to Canadian and American hockey; it is not allowed in the Olympics.
    14. Chris Nowinski, another of the Bank’s co-directors, added, “Unfortunately, this finding does not contribute to our knowledge of the risks of normal hockey play for most participants, as very few hockey players engage in as many fights as Boogaard.” “Athletes and parents should know that anyone who experiences repetitive brain trauma may be at risk to develop CTE, but we are hopeful that risk is small in hockey.” Nowinski added that two other young non-NHL professional hockey players studied did not show signs of CTE at postmortem examination. However, the risks in hockey can’t be ignored. There is constant, fast-moving contact and fights. As Stern said, “It’s boxing on ice.”

Article by Wikipedia
Reference: Nadia Kounang - CNN Medical Producer

Epidural hematoma
  1. Definition
    1. Epidural or extradural hematoma (Extradural hemorrhage, Epidural hemorrhage) is a type of traumatic brain injury (TBI) in which a buildup of blood occurs between the Dura Mater (the tough outer membrane of the central nervous system) and the skull. The Dura Mater also covers the spine, so epidural bleeds may also occur in the spinal column. Often due to trauma, the condition is potentially deadly because the buildup of blood may increase pressure in the intracranial space, compress delicate brain tissue, and cause brain shift. The condition is present in one to three percent of head injuries. Between 15 and 20% of epidural hematomas are fatal.
  2. CAUSES
    1. The most common cause of intracranial epidural hematoma is traumatic, although spontaneous hemorrhage is known to occur. Hemorrhages commonly result from acceleration-deceleration trauma and transverse forces. The majority of bleeds originate from meningeal arteries, particularly in the temporal region. Ten percent of epidural bleeds may be venous, due to shearing injury from rotational forces. Epidural hematoma commonly results from a blow to the side of the head. The pterion region which overlies the middle meningeal artery is relatively weak and prone to injury. Thus only 20 to 30% of epidural hematomas occur outside the region of the temporal bone. The brain may be injured by prominences on the inside of the skull as it scrapes past them. Epidural hematoma is usually found on the same side of the brain that was impacted by the blow, but on very rare occasions it can be due to contrecoup injury. Epidural hematomas may occur in combination with subdural hematomas, or either may occur alone. CT scans reveal subdural or epidural hematomas in 20% of unconscious patient.
  3. Symptoms
    1. A health care provider should be consulted for any head injury that results in even a brief loss of consciousness or if there are any other symptoms after a head injury (even without loss of consciousness).
    2. The typical pattern of symptoms that indicate an epidural hemorrhage is loss of consciousness, followed by alertness, then loss of consciousness again. But this pattern may NOT appear in all people. The neurological examination may indicate that a specific part of the brain is malfunctioning (for instance, arm weakness on one side) or may indicate increased intracranial pressure. If there is increased intracranial pressure, emergency surgery may be needed in order to relieve the pressure and prevent further brain injury. A head CT scan will confirm the diagnosis of an epidural hemorrhage and will pinpoint the exact location of the hematoma and any associated skull fracture.
    3. The symptoms usually occur within minutes to hours after a head injury and indicate an emergency situation.
    4. The most important symptoms of epidural hemorrhage are:
      1. Confusion
      2. Dizziness
      3. Drowsiness or altered level of alertness
      4. Enlarged pupil in one eye
      5. Headache (severe)
    5. Head injury or trauma followed by loss of consciousness, a period of alertness, then rapid deterioration back to unconsciousness
    6. Nausea and/or vomiting are symptoms of epidural hemorrhage and often caused by a skull fracture during childhood or adolescence. This type of bleeding is more common in young people because the membrane covering the brain is not as firmly attached to the skull as it is in older people.
    7. An epidural hemorrhage occurs when there is a rupture of a blood vessel, usually an artery, which then bleeds into the space between the "Dura mater" and the skull. The affected vessels are often torn by skull fractures.
    8. This is most often the result of a severe head injury, such as those caused by motorcycle or automobile accidents. Epidural hemorrhages can be caused by venous (from a vein) bleeding in young children.
    9. Rapid bleeding causes a collection of blood (hematoma) that presses on the brain, causing a rapid increase of the pressure inside the head (intracranial pressure). This pressure may result in additional brain injury.
    10. An epidural hemorrhage is an emergency because it may lead to permanent brain damage and death if left untreated. There may be a rapid worsening within minutes to hours, from drowsiness to coma and death.
  4. DIAGNOSIS
    1. On images produced by CT scans and MRIs, epidural hematomas usually appear convex in shape because their expansion stops at the skull's sutures, where the Dura mater is tightly attached to the skull. Thus, they expand inward toward the brain rather than along the inside of the skull, as occurs in subdural hematoma. The lens-like shape of the hematoma causes the appearance of these bleeds to be "lentiform." Epidural hematomas may occur in combination with subdural hematomas or may occur alone. CT scans reveal subdural or epidural hematomas in 20% of unconscious patients. In the hallmark of epidural hematoma, patients may regain consciousness and appear completely normal during what is called a lucid interval, only to descend suddenly and rapidly into unconsciousness later. The lucid interval, which depends on the extent of the injury, is a key to diagnosing epidural hemorrhage. If the patient is not treated with prompt surgical intervention, death is likely to follow.
  5. TREATMENT
    1. As with other types of intracranial hematomas, the blood may be removed surgically to remove the mass and reduce the pressure it puts on the brain. The hematoma is evacuated through a burr hole or craniotomy. If transfer to a facility with neurosurgery is prolonged, trephination may be performed in the emergency department.
  6. Expectations (prognosis)
    1. In TBI patients with epidural hematomas, prognosis is better if there was a lucid interval (a period of consciousness before coma returns), than if the patient was comatose from the time of injury. Unlike most forms of TBI, people with epidural hematoma and a Glasgow Coma Score of 3 (the lowest score) are expected to make a good outcome if they can receive surgery quickly. An extradural hemorrhage has a high risk of death without prompt surgical intervention. Even with prompt medical attention, a significant risk of death and disability remains.
  7. Possible Complications
    1. There is a risk of permanent brain injury whether the disorder is treated or untreated. Symptoms (such as seizures) may persist for several months, even after treatment, but in time they usually become less frequent or disappear completely. Seizures may begin as many as two years after the injury.
    2. In adults, most recovery occurs in the first six months, with some improvement over approximately two years. Children usually recover more quickly and completely than adults.
    3. Incomplete recovery is the result of brain damage. Other complications include permanent symptoms (such as paralysis or loss of sensation, which began at the time of the injury), herniation of the brain (which may result in permanent coma), and normal pressure hydrocephalus (excess fluid in the cavities of the brain).
  8. Of the spine
    1. Bleeding into the epidural space in the spine may also cause epidural hematoma. These may arise spontaneously (e.g. during childbirth), or as a rare complication of anaesthesia (such as epidural anaesthesia) or surgery (such as laminectomy).
    2. The anatomy of the epidural space means that spinal epidural hematoma has a different profile from cranial epidural hematoma. In the spine, the epidural space contains loose fatty tissue, and the epidural venous plexus, a network of large, thin-walled veins. This means that bleeding is likely to be venous. Anatomical abnormalities and bleeding disorders make these lesions more likely. They may cause pressure on the spinal cord or cauda equine, which may present as pain, muscle weakness, or bladder and bowel dysfunction. The diagnosis may be made on clinical appearance and time course of symptoms. It usually requires MRI scanning to confirm. The treatment is surgical decompression. The incidence of epidural hematoma following epidural anaesthesia is extremely difficult to quantify; estimates vary from 1 per 10,000 to 1 per 100,000 epidural anaesthetics.
  9. When to Contact a Medical Professional
    1. Go to the emergency room or call 911 if symptoms of epidural hemorrhage occur and if emergency symptoms develop after treatment, including:
      1. breathing difficulties
      2. seizures
      3. decreased responsiveness
      4. loss of consciousness
      5. enlarged pupils
      6. uneven pupil size
      7. memory loss
      8. difficulty maintaining attention
      9. dizziness
      10. headache
      11. anxiety
      12. Speech difficulties and complete or partial loss of movement in part of the body
    2. Spinal injuries often occur with head injuries, so if you must move the person before help arrives, try to keep his or her neck still.
  10. Prevention
    1. An epidural hemorrhage may not be preventable once a head injury has occurred.
    2. To minimize the risk of head injury, use appropriate safety equipment (such as hard hats, bicycle or motorcycle helmets, and seat belts).
    3. Follow general safety rules, for example, do not dive into water if the water depth is unknown or if rocks may be present. Use appropriate safety precautions in sports, recreation, and work. Drive safely.
  11. Notable cases
    1. On April 17, 2003, at age 72, Dr. Robert Atkins, creator of the Atkins diet, slipped on the ice while walking to work, hitting his head and causing bleeding around his brain. He lost consciousness on the way to the hospital, where he spent two weeks in intensive care. His death certificate states that the cause of death was "blunt impact injury of head with epidural hematoma". On March 18, 2009, actress Natasha Richardson died as a result of an epidural hematoma sustained two days earlier while skiing in Mont-Tremblant, Québec, Canada.[16] Like many patients, she had a lucid interval where she did not exhibit any symptoms until approximately an hour after her fall when she complained of a headache. By the time she reached medical care, the hematoma had already caused significant damage.
    2. On September 5, 2012, Major League Baseball Pitcher Brandon McCarthy was hit by a line drive to the head from Erick Aybar. He was immediately rushed to the hospital where he underwent a 2-hour surgery to relieve pressure on his brain. Although he never lost consciousness and walked off the field, McCarthy suffered an epidural hemorrhage, brain contusion and skull fracture in the accident.
    3. On March 18, 2009, actress Natasha Richardson died as a result of an epidural hematoma sustained two days earlier while skiing in Mont-Tremblant, Québec, Canada. Like many patients, she had a lucid interval where she did not exhibit any symptoms until approximately an hour after her fall when she complained of a headache. By the time she reached medical care, the hematoma had already caused significant damage.

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