The First Reported Case of Second Impact Syndrome: A Reexamination of Dr Fekete's Case Report from 1968

Background In the December 28, 1968 edition of the Canadian Medical Association Journal, Dr John Fekete described a 16-year-old hockey player with fatal cerebral edema following a brain impact while actively symptomatic of a concussion incurred 4 days ago. This case has been described as a “possible” case of second impact syndrome, an entity that was named in 1984 and purportedly first described by Schneider in 1973. Method An audit of material in the public register of Dr Fekete's case was undertaken. Information sources included the newspaper report of the death, transcripts from a coroner's inquest held 12 days later, including the autopsy report, genealogical data available online, and available internet resources. Results There was clear documentation of concussive symptomatology following an initial head injury and evidence of a medical assessment, thus fulfilling the “definite” clinical criteria for second impact syndrome as proposed. After 4 days of ongoing concussive symptomatology, a dramatic, rapid neurological deterioration took place following an apparently unremarkable body contact and fall on the ice while playing hockey. His primary brain pathology included cerebral edema. Conclusion Cerebral edema may follow primary or secondary head injury, the latter comprising second impact syndrome. Dr Fekete's case, as described in the December 28, 1968 edition of the Canadian Medical Association Journal, should be recognized as the first description of this condition.

Latent Class Analysis of Brain Injury Symptomatology among College Students

Background Incidents potentially causing mild brain injury (BI) are common, and most people recover rapidly; however, a subset experiences long-lasting challenges. Objective This study used latent class analysis to identify a subset of college students presenting chronic symptomatology consistent with a mild BI diagnosis and pseudo-class mean equality tests to examine relations between latent classes and BI event and academic outcome variables. Methods Participants were 118/423 undergraduates self-reporting possible mild BIs through a survey about general health, daily habits, academic performance, and potential BI events. Twenty-four cognitive, physiological, or socio-emotional sequelae served to identify symptomatology profiles. Results A three-class model including 11% with high symptomatology, 49% with moderate symptomatology, and 40% with negligible symptomatology provided excellent fit and entropy. Symptoms best separating high and moderate classes were memory, thinking speed, new learning, and attention problems. Mean equality tests revealed no significant difference in number of BI events across classes, but high symptomatology respondents were significantly less likely to lose consciousness and significantly more likely to have lower grade point averages and to have failed courses than moderate symptomatology respondents. Discussion Cognitive problems are paramount in distinguishing college students with chronic high symptomatology following BI from those with moderate and negligible symptomatology. Because high symptomatology class individuals differ academically from their counterparts, a functional consequence of mild BI appears to exist. Conclusion About 1 in 10 undergraduate students self-reporting BI events experiences chronic symptomatology affecting general health and academic achievement. Because they may benefit from supportive services, accurate identification is critical.

The Value of Speech-Language Pathologists in Concussion Management

Objective The goal of this article is to make a case for the value of a speech-language pathologist (SLP) to be considered for inclusion on a concussion management team in a consultant capacity and resource for student-athletes during the return-to-learn process particularly at the high school or collegiate level where they may already be on staff or affiliated. SLPs have the skills and expertise to address difficulties and provide structured strategies to address symptoms of a concussion that affect cognitive processing, attention, and focus which often are impacted during recovery from a concussion. These skills alongside an athletic trainer/school nurse will provide a mechanism for student-athletes to be monitored and have a resource through the return-to-learn and return-to-play process.

Reliability and Validity of a Mobile Device Application for Use in Sports-Related Concussion Balance Assessment

Background Balance assessment is necessary when evaluating athletes after a concussion. We investigated a mobile device application (app) for providing valid, reliable, and objective measures of static balance. Objectives The mobile device app would demonstrate similar test–retest reliability to force platform center of pressure (COP) sway variables and that SWAY scores and force platform COP sway variables would demonstrate good correlation coefficients. Methods Twenty-six healthy adults performed balance stances on a force platform while holding a mobile device equipped with SWAY (Sway Medical LLC) to measure postural sway based on acceleration changes detected by the mobile device's accelerometer. Participants completed four series of three 10-second stances (feet together, tandem, and single leg), twice with eyes open and twice with eyes closed. Test–retest reliability was assessed using intraclass correlation coefficients (ICC). Concurrent validity of SWAY scores and COP sway variables were determined with Pearson correlation coefficients. Results Reliability of SWAY scores was comparable to force platform results for the same test condition (ICC = 0.21–0.57). Validity showed moderate associations between SWAY scores and COP sway variables during tandem stance (r = –0.430 to –0.493). Lower SWAY scores, indicating instability, were associated with greater COP sway. Discussion The SWAY app is a valid and reliable tool when measuring balance of healthy individuals in tandem stance. Further study of clinical populations is needed prior to assessment use. Conclusion The SWAY app has potential for objective clinical and sideline evaluations of concussed athletes, although continued evaluation is needed.

A Multipronged Intervention for Treatment of Psychotic Symptoms from Post-football Traumatic Brain Injury in an Adolescent Male: A Case Report

Introduction Traumatic brain injury (TBI) is common in adolescents. TBI can result in impaired cognitive functioning and mood disturbance. In some cases, TBI results in psychotic symptoms. There is little documentation for treatment of psychotic symptoms resulting from TBI. Case presentation The present case study reviews an adolescent male who was seen in an outpatient behavioral health clinic, following a football-related TBI. The TBI resulted in postconcussive syndrome including psychotic symptoms (i.e., visual and auditory hallucinations) and increased anxiety. Management and Outcome The adolescent underwent 12 individual sessions of Acceptance and Commitment Therapy (ACT) and 7 sessions of family therapy for his anxiety and psychotic symptoms. He also underwent Vestibulo-Ocular Therapy. At the end of treatment, the patient's anxiety symptoms and those related to post-concussive syndrome were in remission with no hallucinations experienced for >6 months. Discussion The results provide encouragement for systematic randomized controlled trials of individual and family behavioral interventions as part of an integrated treatment approach for mild TBI.

The Effects of External Jugular Compression Applied during High Intensity Power, Strength and Postural Control Tasks

Introduction Current strategies focused on mitigating concussion in sport have demonstrated limited effectiveness. There is a paucity of research on the optimization of intracranial brain dynamics to mitigate concussion; in the present study, we investigate a novel device that provides mild jugular vein compression and may provide adjunctive protection to protect the brain internally from concussive and sub-concussive impacts. The purpose of this study was to assess the tolerance and acceptance of this device in a population of normal, healthy adults undergoing exertion similar to that is experienced while participating in sports-related competition, while monitoring changes in their biomechanical, strength, power, and postural stability capabilities. Material and Methods A total 18 participants (8 females, 10 males) were tested and included in the final analysis. Laboratory data collection consisted of two separate testing sessions for all participants. During the first testing session, participants were tested while wearing either the mild jugular vein compression neck device or a sham arm device (Sham) that was worn on the upper arm and did not alter venous return; participants exchanged devices for the second session. Participants underwent a battery of physical and neurological tests that included three-dimensional (3-D) biomechanical analysis, dynamic postural control testing using a stabilometer, isokinetic strength testing using a dynamometer, and a maximum vertical jump test. Results Evaluation of vital biomechanics, postural control and dynamic stabilization, isokinetic strength, and power in this population showed no statistically significant effect of wearing a mild jugular vein compression neck device compared with a Sham armband. Conclusions The data evaluated in the current project indicate that the device is safe during high intensity and dynamic postural stabilization exercise and does not alter normal physical or neuromuscular capabilities during physical activity.

Selective Reduction of Brain Docosahexaenoic Acid after Experimental Brain Injury and Mitigation of Neuroinflammatory Outcomes with Dietary DHA

Background Docosahexaenoic acid (DHA) is an omega-3 fatty acid that is important for brain development and function, but the interactions of dietary DHA with fatty acid profiles, sensory sensitivities, and inflammation that may change after traumatic brain injury (TBI) are poorly understood. It is also unknown whether DHA alters experimental TBI outcomes measured more than 2 weeks after injury. The current study investigated whether dietary DHA, provided before (PreDHA) or after (PostDHA) experimental TBI, would improve outcomes for up to 24 days after injury. Methods Rats consumed predetermined diets for 28 days prior to midline fluid percussion injury (mFPI) or to sham surgery. The effects of PreDHA, TBI, and PostDHA on comprehensive fatty acid profiles, neuroinflammation, sensory sensitivity, and spatial learning were then evaluated. Results The results provided novel evidence that TBI selectively reduced brain DHA content, as injury did not decrease any other fatty acid that was measured. Furthermore, PreDHA and PostDHA attenuated injury-induced increases in sensory sensitivity as well as in tumor necrosis factor-α (TNF-α), interleukin-10, and interleukin-1β in the somatosensory cortex. However, [3H]PK11195 autoradiography showed that PostDHA was more effective than PreDHA in reducing microglial/macrophage activation in the somatosensory cortex, hippocampus, and substantia nigra. Spatial learning outcomes were largely unaffected by diet or injury, but PostDHA was associated with shorter swimming distances in the Morris water maze (MWM) at 15 days post-injury. Conclusion Overall, sufficient DHA intake may be necessary to replace DHA that is lost to TBI and may improve some symptoms of post-concussive syndrome (PCS) over an extended period through inflammation-related mechanisms.