Closed Traumatic Head Injury In A High School Football Athlete

Journal of Athletic Training. -


Frymyer, J. L., S. D. Felton and S. J. Cox.



Background: Athlete is a 17 year-old Caucasian male high school football linebacker. The athlete’s medical history revealed an episode of acute pancreatitis within the past year. Athlete was on punt return team when he made helmet to helmet contact and fell to the ground creating a second head impact. Athlete walked off the field on his own volition. Athlete reported to Certified Athletic Trainer (ATC) complaining of headache and dizziness. He denied any nausea or other symptoms. ATC began side-line examination which consisted of clearing any neck pathologies through palpations and evaluations of extremity myotomes and dermatomes. In addition, he was assessed for a concussion and vital signs were monitored. Within concussion assessment, ATC noted cranial nerve function WNL, Standardized Assessment of Concussion (SAC) test 21/30, and Balance Error Scoring System (BESS) revealed balance deficits. Athlete was removed from competition with clinical examination leading to diagnosis of concussion. Immediate plan of care was discussed with parent and educational materials describing potential signs and symptoms requiring immediate referral were provided to the parent for further monitoring. ATC continued to monitor the athlete for changes in status throughout the competition. During the half-time, athlete reported to ATC and admitted that he had immediately vomited after initial head trauma. With the updated athlete history of vomiting, the ATC, in consultation with his parent, immediately referred the athlete to the ER. Differential Diagnosis: Cervical Neck Pathology, Transient Brian Injury, Concussion, Subdural Hematoma Treatment: Athlete reported to ER and attending physician ordered a CT scan. CT Scan revealed a left periventricular hemorrhage. The athlete was admitted to the hospital for overnight observations. Athlete had follow-up CT scan the next day which demonstrated no exacerbation of focal bleed; thus, released from hospital. Athlete was scheduled for follow-up appointment two weeks following the release from hospital. Athlete returned to school following the weekend and completed postconcussion assessment including, SAC test, BESS, and Immediate PostConcussion Assessment and Cognitive Test (ImPACT) which revealed a statistically significant deviation from baseline. Athlete reported daily to ATC for monitoring, completion of symptom cards, and updates on his status. The athlete’s symptoms included dizziness, sensitivity to light, and nausea lasting five days in duration. Athlete continued to be withheld from competition. At the subsequent 2 week follow-up with neurologist, repeat CT Scan revealed that the periventricular hemorrhage had reabsorbed and thus cleared to full participation by the neurologist. ATC administered follow-up ImPACT test where athlete was at baseline and per District School policy, athlete was allowed to begin four-day progressive return to play protocol (RTP) as described in the NATA position statement on management of concussions. The athlete proceeded through the 4 day RTP with no complications or reoccurrences of signs or symptoms. Eighteen days after initial injury the athlete was cleared by the neurologist and RTP protocol. Uniqueness: Periventricular hemorrhages are an extremely common type of brain bleeds found in pre-term infants. In adults, acute periventricular hemorrhages have been linked to vicious head injuries such as skull fractures, falling from a height, or accelerated backward falls. However, a search of the literature found no cases of periventricular hemorrhage with an associated athletic concussion. Conclusions: This case highlights the diagnosis of an athlete with a periventricular hemorrhage resulting from a sports-related coup and counter-coup concussion. This case is extremely unique due to no similar documented sport-related cases found through a literature review. This case highlights the need for proper evaluation, recognition of atypical head injuries, referral, and need for individualized plans of care. The athlete made a full return to participation three weeks post injury and has had no further problems or complaints.

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