Patient Presentation
An 11-year-old male came to clinic approximately 20 hours after falling off some school playground equipment. The fall was witnessed by adults but not the parent. The parent was told the child fell approximately 4 feet onto a wood-chip covered surface but hit his head more than once. The adults got to him quickly and did not report loss of consciousness. He says he remembers playing and being picked up by the adults, but not actually hitting his head. His mother took him home and said that during the evening he seemed quieter, tired and ate less. He complained of a headache and she gave him some acetaminophen. In the morning, his mother had to awaken him but he woke up easily. He complained of continued top of his head and frontal headache without radiation. He held his left eye closed because “otherwise I see 2 of things and I don’t like it.” He also complained of light and noise sensitivity. He also had some problems walking but his mother wasn’t sure if it was his balance or because of his eyes. She reported that he seemed to have his normal personality but was tired and wanted to rest throughout the day. The review of systems was negative for any memory loss, or emesis/nausea.

The pertinent physical exam showed a healthy appearing male who answered questions easily and without delay. His vital signs were normal including a blood pressure of 98/56. Visual acuity was 20/30 with each eye and was 20/20 with both eyes. He had a small contusion along his forehead hairline and he reported that his headache was centered around this spot without much radiation. He consistently would close his left eye throughout the examination. His pupils were 3 mm, symmetric and responded appropriately to light and accommodation. He complained of light sensitivity but when visual fields were checked with decreased ambient lighting they were normal for individual eyes and when tested together. He complained of seeing 2 of everything. His retina exam was brief, but discs appeared sharp on partial exam. Neurologically his cranial nerves were intact with normal DTRs bilaterally. He was slower with rapid alternative movements of his hands, and had some past pointing with finger to nose test. Romberg was positive when he closed his eyes and he was not able to do a tandem gait. His gait was normal but slower with his eyes open. He had no balance issues when sitting.

The diagnosis of a concussion was made, but because of the onset after the event of the visual symptoms and the consistent closing of one eye, the pediatrician contacted the neurologist. The neurologist felt that this was consistent with concussion symptoms but felt that he should be seen by ophthalmology and themselves the following day. He was sent home with head injury and strict brain rest instructions.

The patient’s clinical course showed that he still had some double vision and light sensitivity the next day but it was improving and ophthalmology did not see any structural problems. The family reported to neurology that his headache was improving and he was less fatigued but still was sleeping more. On examination they found similar balance problems but his mother said they were improved from the previous day.

After one week of brain rest, followup with the pediatrician showed resolution of all symptoms but he still was fatigued and sleeping more. His mother said that he seemed to take longer to do some activities. The pediatrician recommended slow reintroduction to activities and school and followup in another week which he did not come for. At his well child appointment 3 months later, his mother said that he got better so she didn’t bring him to that appointment.

Discussion
Concussion as defined by the International Conference on Concussion in Sport in 2012 is “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.” It results in quick onset of signs and symptoms of physical and cognitive impairment. Concussion is sometimes referred to as mild traumatic brain injury (TBI) as mild TBI refers to “…concussions that are generally not life threatening despite the potential for short-term disability and serious ongoing sequelae.” Concussion symptoms are usually categorized as:

• Cognitive – confusion, difficulty remembering, difficulty thinking or concentrating, mentally foggy, delayed motor or verbal responses or “feeling slow”
• Emotional – irritability, volatility, nervous, depression or sadness
• Physical/somatic – headache, dizziness, balance problems, nausea/emesis, blurry vision, light sensitivity, sound sensitivity
• Sleep disturbance – increased sleep duration, prolonged sleep latency, drowsiness

Headache is the most commonly reported initial symptom (93%) followed by dizziness and confusion.

Concussion is a clinical diagnosis based on reported symptoms, mental status examination and physical examination.

Learning Point
The duration of concussive symptoms are very individual. A 2015 systemic review and meta-analysis of high school and collegiate athletes found that in general high school athletes report more physical symptoms and cognitive problems than collegiate athletes. High school athletes compared to college athletes report slower recovery for physical symptoms (15 days vs 6 days) and for cognitive recovery (7 days vs 5 days). Especially as the cognitive recovery seems to be about the same for both groups, collegiate athletes may be underreporting their physical symptoms deliberately (because wanting to return to play or pressure to return to play) or are not attributing the symptoms to the concussion.

A 2014 study of the post-concussion symptom duration of 280 teenagers and young adults ages 11-22 years (median 14 years), who came to the emergency room within 72 hours of the concussion, found that initially patients presented with headache, dizziness, fatigue and taking longer to think, but in the followup period new symptoms developed especially cognitive and emotional symptoms including sleep problems, fatigue, forgetfulness and frustration. Visual symptoms were initially reported and occurred after initial assessment included blurry vision (32% and 5.4%), double vision (13.2% and 2.1%) and light sensitivity (42.5% and 10.7%). For all symptoms, 77% had some symptoms on day 7, 32% on day 28 and 15% on day 90. The median days for all symptom duration was 13 days. For all symptoms evaluated the median days of symptoms duration was 14 or less with the exception of sleep disturbance and irritability which was 16 days.

So, many patients have resolution of all symptoms by 2 weeks, but there will be some patients who continue to have some symptoms even several weeks later. Cognitive symptoms were often present initially, developed later in other patients and were more likely to last longer.

Some risk factors for prolonged concussion recovery time include age < 18 years, prior history of concussions, duration of symptoms with those concussions, timing of the concussions relative to each other and the current incident, having migraine headache, depression, attention deficit disorder, learning disabilities and sleep disorders.

Questions for Further Discussion
1. How is acute concussion managed? When can an athlete return to play? When can a child return to learning? For a review click here.
3. How are prolonged concussive symptoms managed?
4. What screening tools can be used to help screen for concussion?

Related Cases

Disease: Concussion

Symptom/Presentation: Ataxia, Dizziness, and Vertigo | Blurred Vision | Headaches | Head Trauma

Specialty: Emergency Medicine | Neurology / Neurosurgery | School

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Concussion

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Consensus statement, SCAT3. Br J Sports Med 2013;47:5 259.

Consensus statement, Child SCAT3, Br J Sports Med 2013;47:5 263.

Eisenberg MA, Meehan WP 3rd, Mannix R. Duration and course of post-concussive symptoms. Pediatrics. 2014 Jun;133(6):999-1006.

Williams RM, Puetz TW, Giza CC, Broglio SP. Concussion recovery time among high school and collegiate athletes: a systematic review and meta-analysis. Sports Med. 2015 Jun;45(6):893-903.

McGinley AD, Master CL, Zonfrillo MR. Sports-Related Head Injuries in Adolescents: A Comprehensive Update. Adolesc Med State Art Rev. 2015 Dec;26(3):491-506.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital