Making sports safer- concussion evaluation, management and return to play decision making for the non-neurologist

Nitin K Sethi, MD, MBBS, FAAN


American football, soccer, rugby, ice hockey, boxing, mixed martial arts, and wrestling are popular contact and combat sports both in the United States and in countries around the world. In these sports head impact exposures resulting in concussions are common. In American football, rugby and soccer, concussive injuries to the brain occur accidently when there is contact of the player’s head with the opposing player(s) head, torso, turf or as occurs in soccer with the ball while heading. In boxing every punch thrown at the head is thrown with the intention of winning by causing a knockout. As a result, concussions, and acute traumatic brain injuries such as subdural and epidural hematoma are common. Subdural hematoma is the most common cause of boxing related mortality. In recent years, the risk of chronic traumatic encephalopathy (CTE), a chronic neurodegenerative disorder associated with contact and combat sports has garnered the attention of physicians, players, and fans.

Concussion definition and evaluation

Concussion is defined as a clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma. It is important to remember that loss of consciousness is not required for a concussion. Concussions are informally and non-scientifically graded into mild, moderate, and severe based on the duration of loss of consciousness and post traumatic amnestic period. Concussive properties of any head impact exposure depend upon the force, velocity, and angle of the hit to the cranium and how the mechanical forces are transferred and absorbed through the intracranial cavity. Both linear and rotational (angular) acceleration forces play a role as does impact deceleration occurring when the athlete falls and strikes the head against the ground.

Image Credit: Patrick J. Lynch, medical illustrator – Modified version of Image: Skull and brain normal human.svg by Patrick J. Lynch, medical illustrator (Source Wikipedia). The image is solely for educational purposes only.

The nature of many contact and combat sports is such that head impact exposures cannot be altogether avoided. Abundant medical literature highlights the long-term health significance of multiple head impact exposures. Minor concussions (sub concussive injuries) contribute to the development of CTE, a neurodegenerative disorder presenting with a constellation of cognitive, mood, and behavioral changes along with motor system dysfunction (Parkinsonism) usually after the athlete has retired. The symptoms of concussion are predominantly subjective such as headache, dizziness, nausea, light sensitivity, sound sensitivity, and cognitive dysfunction. Frequently, when athletes sustain head impact exposures, they themselves are unaware that they are concussed and continue to play. As a result, it is important that when an athlete sustains a head impact exposure, a standardized concussion evaluation be conducted. While this can be conducted on the sidelines, evaluation in the locker room where the athlete is less likely to be distracted is more ideal. Since some athletes exhibit motor signs such as impaired coordination, balance, and stance after a concussion while others exhibit only cognitive dysfunction, it is important that multimodal concussion evaluation be conducted. This includes use of Maddocks questions to gauge awareness, standardized concussion assessment tools such as SCAT5, King Devick test and Balance Error Scoring System (BESS).

Concussions are common in soccer especially during heading the ball.

Management of concussive injury

The athlete’s mentality is to never quit. Hence many athletes will deny symptoms of a concussive injury to the brain. Physicians should be aware of this. An athlete who has suffered a concussion should be pulled out of play and “benched.” This is done for two main reasons. A concussed athlete with impaired attention, concentration, balance, and coordination is more prone to a second head impact exposure. The other reason is that if the concussed athlete continues to play, it is likely that he or she will exhibit more profound and prolonged post-concussion symptoms. The benched athlete is advised a period of cognitive and physical rest. The rationale for this is that a concussed brain is in a state of energy crises and fares better when the cognitive and physical demands on it are less. Cognitive rest entails pulling back from cognitive activities such as team meetings, college work, screen time (amount of time spent using devices with screens such as a smartphone, computer, television, or video game console). Physical rest entails pulling back from normal physical activities such as running and jogging. Here it is important to emphasize that complete cocooning is ill-advised with recent research work showing that it may in fact be detrimental and lead to prolongation of symptoms. The concussed athlete should be evaluated by a physician skilled in concussion management. In most cases neuroimaging with computed tomography or magnetic resonance imaging is not warranted and if conducted comes back negative. There is currently no validated imaging or biofluid (blood or cerebrospinal fluid) biomarkers for concussion. In the absence of biomarkers, the diagnosis of concussion is made clinically based on history of head impact exposure followed by characteristic symptoms (post-concussion symptoms). The concussed athlete is advised to drink adequate water and to avoid alcohol intake and sudden inversions till symptomatic. The role of supplements such as magnesium, vitamin B2 (riboflavin), vitamin B12, fish oil among other remains unclear but these are frequently prescribed. There is no treatment for the head injury itself. Treatments for symptoms of concussion such as headache, dizziness, cognitive impairment, poor sleep, mood, and behavioral disorder involves a multi-disciplinary team consisting of neurologists, neuropsychologists, neurosurgeons, neuroradiologists, neuro-ophthalmologists, physical therapists, occupational therapists, and vestibular therapists with expertise in concussion management.

After a few days of cognitive and physical rest when the acute concussion symptoms have abated, the athlete begins a graded and gradual return to play (RTP) program preferably under the guidance of an athlete trainer with expertise in concussion management. Nowadays most contact and combat sports have sport specific return to play (RTP) protocols. Despite individual variations, the basis tenant remains the same and involves the athlete progressing from light aerobic activity (walking or stationary bike for 10 minutes, no resistance training) to sport-specific activity/drills to non-contact training drills to contact practice and if asymptomatic return to play after a release has been signed by the treating physician.


Concussion is a common head injury in contact and combat sports. Timely identification of the concussed athlete, removal from play and medical management usually results in a good outcome. Closer medical supervision of sports and education of all concerned parties on concussion recognition and management remains the need of the hour.

The stunned brain: neuroanatomical correlates of an acute concussion in boxing


                                                              The stunned brain: neuroanatomical correlates of an acute concussion in boxing

Nitin K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)










A concussion can be defined as a transient alteration of mental status due to biomechanical forces affecting the brain. Concussions are common in contact sports like boxing and mixed martial arts (MMA). In boxing frequently the goal is to win by causing a knockout (KO)/concussion though a fight may also be won by a body shot if the boxer is unable to continue. This is then ruled a technical knockout (TKO). In the case report that follows, the clinical semiology of an acute concussion in boxing is described and a speculative hypothesis about the neuroanatomical correlate of the syndrome is postulated.





Case Report


A-32-year old right handed professional male boxer with a record of 20 wins, no losses with 10 of the wins coming by way of knockout suffered a brutal KO during a high profile televised bout. The boxer went down with the head striking and then bouncing off the ring canvas. Immediately on impact with the ring canvas the boxer exhibited decerebrate posturing followed by a 20 second convulsion characterized by stiffening of the arms and low amplitude clonic jerks of the legs. The referee immediately signaled an end to the fight and motioned the ringside physician to enter the ring to tend to the downed fighter. Examination inside the ring revealed a conscious boxer (eyes open) with unresponsiveness (no response to commands). This conscious unresponsiveness state lasted for about one minute. Pupils were midsize, equal in size with sluggish response to light. The emergency medical service (EMS) personnel stationed ringside were summoned into the ring by the ringside physician. While maintaining spinal fixation, the boxer was placed in a hard cervical collar and lifted on to and strapped on a hard backboard. As this was been accomplished, the boxer suddenly became responsive and started punching the air with his gloved hands as if he was back in the midst of the bout. He was combative and attempting to get up from the board. He was restrained by the medical staff. After about 1 minute, he calmed down and became fully alert and oriented. He realized that the fight had been stopped because of a KO and requested the medical staff to allow him to get up. At the post-fight medical evaluation he was determined to have suffered an acute concussion and administered a 90 day medical suspension. A neurology clearance was also requested prior to return to competitive boxing.






The 5th international conference on concussion in sport held in Berlin, October 2016 defined a sport related concussion (SRC) as a traumatic brain injury induced by biomechanical forces resulting in the rapid onset of short-lived impairment of neurological function that resolves spontaneously 1. However, in some cases, signs and symptoms may evolve over a number of minutes to hours. While SRC may result in neuropathological changes, the acute clinical signs and symptoms largely reflect a functional brain disturbance rather than a structural injury with no abnormality seen on standard structural neuroimaging studies such as CT or MRI.


The centripetal theory of cerebral concussion postulates that in a concussion there is a centripetal progression of strains from the outer surfaces to the core (midbrain and basal diencephalon) of the brain 2, 3, 4. The anatomical localization of memory is in the temporal lobes or orbitotemporal regions. As per the centripetal theory, less degree of force does not penetrate deep into the cortex and so while cognitive and memory dysfunction may result, consciousness is retained. Forces strong enough to penetrate through to the mesencephalic brainstem result in loss of consciousness. It is important to remember that the above theory and biomechanical concepts are largely based on primate research and not on humans. The observation that brainstem signs can occur in the absence of significant “cortical” symptomatology and that cortical signs can occur in the absence of significant “brainstem” symptomatology means that the centripetal theory explains some but not all of the varied clinical semiology of concussion. It is generally accepted that traumatic decerebration, short duration traumatic coma (loss of consciousness) and impact seizure are brainstem release phenomena in which cortical inhibition of normally suppressed brainstem activity is lost due to diffuse cerebral injury. It may also be that the above phenomena are primarily due to failure of activity in the mesencephalic reticular formation and with loss of brainstem reflex response without widespread cortical involvement.  The amnestic symptoms noted during a concussion have been postulated to be due to a transient interruption or disturbance in the ascending cortical projections at the level of the mesencephalon. It is hence intriguing to think of a “brainstem concussion” distinct from a “cortical concussion” each with different clinical semiology and symptom complex 4.


The above described clinical semiology of an acute concussion in boxing has not been described thus far in the medical literature. While this “stunned brain syndrome” is unnerving to witness as a physician neurologist because of its dramatic presentation and rapid evolution; the syndrome is self-limited with the boxer returning to baseline neurological function usually in the ring itself. It likely has the bulk of its anatomical focus in the brainstem with some cortical and subcortical contribution.


Understanding the neuroanatomical correlates of an acute SRC as in boxing has important implications for our conceptual understanding of concussion and acute management of these injuries in the ring.




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Reemergence of remote concussion symptoms in amateur athletes after minor head bumps-a report of 2 cases

Nitin K Sethi, MBBS, MD, FAAN

Department of Neurology, New York Presbyterian Hospital Weill Cornell Medical Center, New York, U.S.A.





The 2012 Zurich Consensus Statement defined concussion as a complex pathophysiological process affecting the brain induced by biomechanical forces. Concussive and post-concussion symptoms are currently thought to reflect a functional rather than structural disturbance typically resolving spontaneously with no imaging abnormality. The majority of patients with concussion recover within a 7-to-10 day period, in some symptoms persist beyond the 1 month generally accepted time frame for recovery. Some patients recover within the above generally accepted time frame but show reemergence of concussion symptoms after minor head bumps. Two such cases in amateur athletes are reported here.








Case report

A 34-year-old right handed lacrosse player suffered a mild grade of concussion about 1 year ago when while playing, he was struck on the head by an opponent’s stick. No immediate loss of consciousness was reported. He experienced headache and light headedness for 1 day with spontaneous resolution.  After a month, there was sudden reappearance of headache. His physician ordered MRI brain and MRA brain, both of which were reported normal. Headaches again self-resolved. Since then he reports headache only when he bumps his head into something, usually a trivial bump or when he exercises. A 64-year-old right handed amateur skier reported slipping and falling on ice about 8 years ago. Landed on his head and said he was “out” for about 15-30 seconds. When he came to, he felt nauseated. Next day consulted a neurologist. CT scan head was normal. Went back to work after 1 week. Since then every time he bumps his head, symptoms of nausea, feeling like he is in a funk, light and sound sensitivity return. Sometimes these last for about 1 week with spontaneous resolution. Consulted a neurologist, migraine was suspected and he was prescribed anti-migraine medication which didn’t work.






The 2012 Zurich Consensus Statement defines concussion as a complex pathophysiological process affecting the brain triggered by biomechanical forces. 1Typically most people recover from a concussion within 2 weeks of the injury. In about 10 to 20 percent of cases symptoms of concussion may persist longer. Post-concussion syndrome (PCS) refers to the persistence of concussion symptoms beyond the acute post-injury period and includes a constellation of disparate symptoms such as headache, nausea, dizziness, attention and concentration problems, impairment of short term memory, a sensation of fatigue (both physical and mental), light and sound sensitivity, irritability, insomnia and emotional liability. 2, 3 Studies have identified older age, high initial concussion symptom load, duration of loss of consciousness and post-traumatic amnesia, pre-existing anxiety and depression as predictors of persistent PCS.4, 5 The reemergence of remote concussion symptoms after minor head bumps has not been reported in the medical literature. These are patients who report typical concussion symptoms following head trauma which typically resolve within the normal time frame of acute post-injury period. However these asymptomatic patients periodically report the reemergence of their remote concussion symptoms with the inciting trigger typically reported to be a minor bump to the head or some other cognitive or physical stressor such as going to a rock concert or an increase of stress at work or home.


The underlying etiopathogenesis of this phenomena remains largely enigmatic and speculative. Whether this is a variant of persistent PCS is unclear.4, 5 While in persistent PCS there is usually no return to baseline after the inciting concussion event, the patients reported have reemergence of their remote concussion symptoms only following a minor head trauma typically low velocity and low intensity bumps to the head with return to pre-morbid baseline and functioning in-between. Underlying migraine predisposition has also been postulated as one possible etiology. 6, 7 While this is a viable hypothesis, the patients reported above had no pre-morbid migraine symptomatology (no headaches prior to the concussion). They also lacked the typical prodrome, ictal and postictal symptomatology of either classical or common migraine attacks. The third explanation for the reported phenomena is that it is a manifestation of a conversion disorder (neurologic symptoms or deficits that develop unconsciously and nonvolitionally and usually involve motor or sensory function).


The reemergence of the remote concussion symptoms is incompatible with known pathophysiologic mechanisms or anatomic pathways. The onset, exacerbation, maintenance or reemergence of these symptoms is likely directly attributable to mental factors, such as stress and anxiety. The treatment involves reassurance after judicious diagnostic testing to rule out any organic etiology.







  1. McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvoøák J, Echemendia RJ, Engebretsen L, Johnston K, Kutcher JS, Raftery M, Sills A, Benson BW, Davis GA, Ellenbogen RG, Guskiewicz K, Herring SA, Iverson GL, Jordan BD, Kissick J, McCrea M, McIntosh AS, Maddocks D, Makdissi M, Purcell L, Putukian M, Schneider K, Tator CH, Turner M. Consensus statement on concussion in sport: The 4th International Conference on Concussion in Sport held in Zurich, November 2012.British Journal of Sports Medicine. 2013; 47(5):250–258.


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  1. Makdissi M, Darby D, Maruff P, Ugoni A, Brukner P, McCrory PR. Natural history of concussion in sport: Markers of severity and implications for management. American Journal of Sports Medicine. 2010; 38(3):464–471.


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  1. Mihalik JP, Register-Mihalik J, Kerr ZY, Marshall SW, McCrea MC, Guskiewicz KM. Recovery of posttraumatic migraine characteristics in patients after mild traumatic brain injury.American Journal of Sports Medicine. 2013; 41(7):1490–1496.



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Can boxing be made safer? Yes but the culture needs to change

N K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, United States of America



Disclosure and Disclaimer: N.K Sethi serves as Chief Medical Officer for the New York State Athletic Commission (NYSAC). The views expressed are his only and do not reflect the views of the NYSAC.

KEY WORDS: boxing; traumatic brain injury; concussion; death



Recently the boxing world has been mourning the loss of a number of boxers in the ring or in the immediate aftermath of a bout.  As physicians we take an oath to always protect the health of our patients and while ringside medicine is practiced in a different arena than within the confines of a hospital or ER, our duties and obligations to protect the health and safety of the fighters should never waiver for when they enter that ring or cage, they entrust us with their most precious possession of health. Few realize the pressures doctors work under at ringside. Once I had to make the difficult decision to stop a bout on medical grounds with only 30 seconds left on the clock in the last round. I stopped the fight only to be berated by the fighter’s corner like I have never been before. The F word was used repeatedly for what I had done and I was told in rather colorful language of what they thought of my action. I remained calm and stepped away after ensuring the fighter was safe.


As I see it, when I “hung up my gloves” at the end of a long night, I had the satisfaction of knowing that I had done the job which I am entrusted with to the best of my capability. That job is to protect my fighter first and foremost. As a fan, yes I may see it differently and want the fight to go down to the end but we are not there in the capacity of a fan of the sport, we are there as doctors with one and only one job to protect the fighter.


Yes 30 seconds in boxing do matter. In boxing one punch can be the difference between life and death. One punch can kill! So while we as ringside physicians endure the wrath of the corners, the media and sometimes the fighter himself let us not let this discourage or intimidate us to comprise on fighter safety. In the end there is nothing like going to bed with a feeling of a job well done.


We have to continuously strive to provide the best medical care and attention to the fighters. Analyzing what we do and improving our current medical policies and protocols should be an ongoing task. The more time I spend ringside, the more I realize that boxing is a unique sport for a physician to be involved in and that the odds are stacked against us ringside.  In the office or hospital/ ER setting, a patient comes to us mostly voluntary seeking help and care. On questioning, he/she gives us a detailed history. The family is at times there to supplement the history. Contrast that to the ringside where on direct questioning, frequently the patient (boxer) and his family (corner) falsely deny that anything is wrong and are often upset and angry that we even dared to ask the question. After a fight is over, it is not infrequent to encounter a boxer and his corner who refuse to go to the ER for medical evaluation. “I am fine doc, I am not going” is the deviant answer. These boxers and their corner staff fail to appreciate that symptoms in some people with head injuries don’t show up immediately! (walking, talking and dying syndrome). That is the reason why physicians recommended to observe people after a head injury for 24 hours.


When I last checked, none of us physicians have X-ray vision so how are we expected to make a medical call from a distance without the benefit of an honest history or a quick examination?  Many do not realize that once a brain bleed has occurred and the pupils are unreactive (fixed) and dilated, there is precious little we physicians can do ringside to “save” that athlete. Even if that athlete reaches the hospital alive in a timely fashion as a result of our collective efforts, the resulting decompressive surgery is carried out as a last ditch palliative life-saving procedure. That athlete shall never be the same again and will have significant residual neurological deficits. Our goal should be to prevent such a devastating injury from ever occurring in the first place and not just to manage it after it has unfortunately occurred.


A few years ago, I wrote a short letter  titled “Boxing can be made safer” in response to an editorial in a leading neurology journal calling for a ban on boxing and MMA. I argued passionately that boxing and MMA can be made safer with improved medical policies designed to protect the health and safety of the combat sport athlete. I still stand by my stated position that boxing can be made safer but the change has to come from inside. In the National Football League (NFL), the culture has already changed from a previously held view of “suck it up and shake it off” to one of “if you feel something, sit it out“. Athletes are now encouraged to report their symptoms of concussion/traumatic brain injury (even if minor and subjective) to the athletic trainers and doctors on the sidelines.


The word “No mas” (Spanish for “No more”) gained boxing notoriety when Sugar Ray Leonard fought Roberto Duran II on November 25, 1980. At the end of the eighth round Durán turned away from Leonard towards the referee and quit by apparently saying, “No más“.  Duran’s stature was never the same again after he uttered those 2 words. Over the years, the boxing culture has evolved to one of never saying “No mas”. The fighter’s mentality is never to quit no matter what the circumstances. Doing so brings disgrace to the fighter, his family and his corner. This mentality and culture needs to change, Boxers and corner staff should be educated and encouraged to actively recognize and report to the ringside physician any subjective symptoms of concussion and TBI such as headache, subjective feeling of dizziness or light headedness, blurring of vision, double vision, confusion and a feeling of fogginess. “When in doubt, sit it out” is not equivalent to “No mas”. “For he that fights and walks away, may live to fight another day” historically attributed to Demosthenes, a Greek orator should be the new mantra of boxing. There is no shame in this; just smartness.


The boxing culture needs to change and this change shall come over time with education. As physicians it is our duty to educate the boxing community and I hope physicians who practice ringside medicine shall join me in this effort.


Together we can make a difference and making boxing safer.






More about concussions. Not everything becomes apparent after closed head injury!

In this post I shall dwell on the important issue of concussion. A concussion usually refers to loss of consciousness following a closed head injury. By closed head injury I mean that nothing penetrates into the brain. The skull is usually intact. The duration of loss of consciousness is frequently used to grade the severity of closed head injury/ concussion into mild, moderate and severe. However this grading is quite arbitary and other factors have to be borne in mind such as the age of the patient, the mechanism of injury, the force of injury, presence of pre-existing neurological disease such as dementia and whether protective head gear was worn by the person (such as a helmet).

Concussions are common and can occur in many common day to day activities contrary to common belief that concussions only occur in the setting of a motor vehicle accident (MVA) in the case of civilian life or on the battlefield. Concussions are commonly sustained during sports. Indulgence in some sports especially contact sports such as boxing, ultimate fighting (mixed martial arts), American football, rugby, soccer and wrestling to name only a few are more likely to result in a concussion.

So concussions are common and hence the recent heightened concerns about the short term and long term impact of concussions on the brain. Some of you may be well aware of terms such as chronic traumatic encephalopathy (CTE), boxers encephalopathy, dementia pugilistica and “punch drunk syndrome”.  They all imply that concussions do have a significant adverse effect on the brain. There is now ample evidence to indicate that multiple concussions (sustained in a person’s lifetime) cause memory and other cognitive problems. They may also predispose to dementia and a secondary Parkinsonian syndrome.

So it is imperative that concussions be recognized early so that the patient can receive adequate medical attention. This is expecially true on the playing field (whether it is a school, college or a professional sport arena). The fear is that many concussions go undetected and the player is allowed to return to play prematurely and risk a second (at times fatal) concussion. For concussions to be recognized in a timely fashion parents, coaches, personal trainers and other team officials need to be trained to identify concussions. A cursory examination is NOT enough and there is a recent thrust to have every player be examined by a physician. The physician after examining the player and considering the mechanism of injury and whether the player has sustained a prior concussion (in that game itself or in the recent past) shall then determine when the player can return back to play.

So not everything is apparent after a closed head injury. If you or any of your loved ones has sustained a concussion, bring them to the attention of a qualified physician. A big onus remains on parents who should demand more close supervision in school during play.

Nitin Sethi, MD

Bumps to the head: minor concussion and post concussive symptoms

Recently I have seen a few patients in my office with minor concussions. They all pressented with post concussive symptoms and hence that shall be the focus of my post on this gorgeous June day.  So what is a concussion and what is a “minor” concussion? Concussion is usually a closed head injury with temporary loss of brain function or rather loss of consciousness. By closed head injury, I mean that nothing penetrated the brain. Example of a penetrating head injury shall be a gun shot wound to the head.  Do not get me wrong here-obviously a penetrating head injury shall likely result in loss of consciousness and temporary or permanent loss of some brain function.

That said the word concussion is more commonly used for closed head injuries. Let me give you a few prime examples of concussion.  I am a big fan of boxing and the UFC. Anyone who watches these sports has seen a concussion. Boxer A walks into a stiff jab thrown by Boxer B. Down he goes and is out for the count. The ringside doctor jumps into the ring to examine him. Flips his eyes open and flashes a light into both of them.  After a momentary loss of consciousness, our fallen boxer comes to. Open his eyes but has a dazed look. He is able to answer the ringside doctors questions (show me two fingers with your left hand). He struggles to his feet but his legs are wobbly.  The referee consults the doctor and decides to halt the fight.  So what happened to our boxer? He just sustained a concussion.

Concussions can be graded into mild, moderate and severe. This is quite arbitrary. If the loss of consciousness is more than half an hour the concussion is graded as severe. Minor concussions, which shall be the focus of our talk henceforth, are usually associated with either no or momentary loss of consciousness.  Let me give you a few examples of minor concussions. Walking into a door, bumping your head against a low lying ceiling or a car door are all examples of minor closed head injury with or without concussion.  Majority of patients walk away from such an injury and never seek any medical attention because they experience no ill-effects. A few though  are not so lucky and post the head injury are plagued by headache (post concussive headache), problems with memory and concentration (especially when they are multi-tasking) and a myriad of other complaints such as subjectively feeling off balance, difficulty with sleeping and mood changes such as irritability. All these symptoms after a closed head injury/ concussion are included under the umbrella of post concussive symptoms.

In my next post, I  shall discuss post concussive syndrome and its treatment.

Nitin Sethi, MD

Epidural hematoma: when a “minor” head injury may prove to be fatal

Epidural hematoma: when a “minor” head injury may prove to be fatal


Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065


Many of you must have read about the tragic demise of actress Natasha Richardson from blunt (closed) head trauma she sustained after falling on a ski slope. While exact details about the extent and nature of her injuries are unclear, it drew attention to blunt (closed) head trauma. I shall discuss about the same here.

Broadly speaking head injuries can be of two types: penetrating head injuries and closed head injuries. An example of a penetrating head injury is a gun shot wound to the head or when a person is involved in a motor vehicle accident with significant polytrauma (including fracture of the skull and bleeding into the brain). Penetrating head injuries are usually easily identified by first responders (emergency medical services such as the ambulance crew responding first to the call). Usually there is an obvious scalp laceration and blood is seen oozing from the site of the injury. Later when the patient is transferred to the hospital, the extent of the injury can be better documented. For this usually a CT scan of the brain is done (at times a MRI brain may be carried out). Penetrating head injuries vary depending upon the mechanism of injury (example velocity, trajectory and size of the bullet in the case of gun shot wounds to the head). Patients with penetrating head trauma are critical and require urgent stabilization usually in an intensive care setting.

It is the closed head injuries though which can be a little deceiving and that is where I shall like to steer this discussion. The mechanism of closed head injuries is usually blunt trauma to the head (example a fall, a blow to the head while boxing and so on). One special type of closed head injury is a concussive injury from an improvised explosive device (IED). These IED related injuries have become the signature injury in the battlefields of Iraq and Afghanistan. But moving away from the battlefield, closed head injuries are frequent. Most of them are mild as the ones sustained while playing contact sports like football or boxing or when you get up in the middle of the night to go get a glass of water only to bump your head against a door. One “sees stars” for a while but is none the worse for wear apart from a bruised head and maybe ego (especially if you are like me and love to box). But can seemingly innocuous looking closed head injuries prove to be fatal? Can a “minor” fall or blow to the head kill you?

Well yes and this brings us to epidural hematomas. Let us assume you suffer a “minor” closed head injury. What you may ask exactly is “minor” closed head injury. Well it usually refers to an injury in which there is no prolonged loss of consciousness (example is a concussion after a blow to the head or a fall). As the scalp is not lacerated there is no obvious external bleeding. The patient may suffer a minor black out (loss of consciousness for a few seconds to minutes) but soon is awake and seems alert and able to answer questions.

 Imagine a boxer, who walks into a straight right. BOOM!!! Down he goes. The referee counts him out. It is a KO. The ring side doctor rushes in. The boxer eyes are glazed but he is coming around and slowly is able to get up and walk out of the ring unassisted. Nothing but a bruised ego and a black eye. He shall live to fight another day you may say as a spectator but the next day you read in the papers that the boxer was found dead in his bed. What happened here? Well the answer is simple. Even though the boxer seemed to have a suffered a “minor” closed head injury, a far more sinister injury process started silently in the brain. The blow to the head caused one of the small arteries (usually a branch of the middle meningeal artery) to start leaking blood. This blood starts collecting in the potential space between the brain and the skull (we call this the epidural space and hence a collection of blood in this space is called an epidural hematoma). As the leak is small, the patient seemingly recovers and looks fine. He may answer questions appropriately and hence may decide not to seek further medical attention. This interval where the patient (in our case our boxer) looks fine and seems to have recovered from the head blow is called the LUCID INTERVAL (the patient is lucid, makes sense and looks normal). But things are already starting to go wrong. The small leak from the ruptured blood vessel leads to progressive accumulation of blood in the epidural space. When the epidural hematoma becomes large, it has no place to expand (remember there is a rigid bony skull which prevents the blood from coming out). So the underlying brain starts getting squashed. This leads to a depression in the level of consciousness as the pressure inside the brain increases. If the elevated intracranial pressure is not brought down urgently the patient may die (we call this herniation of brain due to elevated intracranial pressure).

Could our boxer have been saved? Yes by all means. If he had been kept under observation (sometimes we like to observe patients with closed head trauma overnight in the hospital), then the first signs of raised intracranial pressure would have been picked up. Usually this is a change in the level of consciousness (the boxer would have become drowsy or hard to wake up, may have complained of headache). An urgent CT scan would have revealed the epidural collection of blood and neurosurgical evacuation of the blood would have been carried out (the skull is opened and the blood is drained out. The bleeding vessel is identified and cauterized to achieve homeostasis).

So what are the take home points from our boxer’s story?

-some “minor” looking closed head injuries can indeed prove to be fatal.

-patients should be observed after a closed head injury. If the decision is made not to go to the hospital, have a friend or family member check on the patient at multiple points.

-the earliest change in the patient’s level of consciousness warrants a stat transfer to the nearest hospital and further investigations.

Concussion during sports and return to play decisions

                                      Concussion during sports and return to play decisions

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

I recently read an article in the Archives of Neurology ( Vol 65, Sep 2008) by Dr. Lester Mayers about return to play (RTP) criteria after athletic concussion. As concussions are relatively common sport related injuries (especially in contact sports like football, rugby and boxing) I thought it would be a good idea to review some of the salient points of the article in this forum.

Concussion is a common type of traumatic brain injury and has been referred to by other names such as mild traumatic brain injury, mild head injury and minor head trauma. No good defination for concussion exists though it is frequently described as head injury with transient loss of brain function (usually a short period of loss of consciousness occurs).

Let me explain with the help of an example. I love to box (true one of the few neurologist who actually likes boxing). Lets assume I am going a couple of rounds in the ring with another guy.  A southpaw with a mean right hand. First round here we go!!!. I got my right and left combinations going. Hmmm feeling good and then it happens. I walk into his right. BOOOOOM!!! My knees give in and I hit the canvas. I see stars shining and birds twittering. The referee is asking me “Are you okay? Are you okay?” I look dazed and then slowly come around and answer I am fine. I am helped out of the ring, the fight is over!!! THERE I JUST HAD MY FIRST CONCUSSION!!!

Can I return to play/ box after a 10 mins break?

 Or rather should I return to play after a break?

Is it safe?

 Am I okay?

All these questions are addressed by Dr. Mayers in his review. Traditionally return to play decisions are made by the field side by the team physician or in the case of boxing by the doctor at the ringside. This is usually a clinical judgement with doctors relying on the documentation of resolution of symptoms at rest and during exertion to provide an estimate of the appropiate time for the athletes to resume practice and play (return to play).

A stepwise process was outlined by the Canadian Academy of Sports Medicine:

Step 1: no activity, no play and complete rest till asymptomatic and with a normal neurological examination–if your clear this then Step 2: light aerobic exercise permitted, no resistance training–if you clear this then Step 3: can return to sports specific training and resistance training—if patient remains asymptomatic then can be cleared for Step 4: non-contact training can begin–if patient remains asymptomatic then he is cleared for Step 5: full contact training —if he still remains asymptomatic then he is cleared for Step 6-full play!!! (As you can imagine these criteria are for professional atheletes but also apply for others)

As you can see there are steps to be followed before return to play can be allowed. If you fail one step you go back to the previous step and remain there till you feel better and are ready to proceed further.

Why is this important? Studies have shown that even simple concussions cause cerebral dysfunction (reflecting damage to the brain at the celluar level) and that it takes a minimum of 4 weeks for the brain to revert back to normal. If RTP occurs earlier, the athlete is at risk for a recurrent concussion and further brain damage. Even death can occur (we have all heard of boxers who die during or shortly after a bout).

Learning points from Dr. Mayers review:

1) Concussions are common.

2) Concussions can be serious and even fatal.

3) Concussions lead to cerebral dysfunction and damage to the brain at the cellular level.

4) Return to play decision should be made by a doctor skilled in this task.  A postconcussion RTP interval of at least 4 weeks is imperative (Dr. Mayers takes pain to point out that even more time may be needed to permit complete brain healing and recovery).

My advise to you:

1) Treat a concussion with respect and see a doctor if you suffer one.

2) You may feel you are okay but you are not. The brain takes time to heal completely from a concussion.

3) Do not return to play. See a doctor and get his advise. Let him decide what the return to play interval should be.

Post Concussive Syndrome

In this post I thought I would talk a little about what is called post concussive syndrome (PCS). Before we discuss PCS, we need to understand just exactly what is a concussion. Unfortunately though there has been realms of data generated on this, the word concussion still remains quite ill-defined in the medical literature. Basically it refers to a brief loss of consciousness. Lets use an example. You are in the ring against Iron Mike. You have your right and left going but walk into one of Iron Mike’s jabs. Boom your legs give away under you and you are on the mat unconscious seeing “stars”. You are “out” for a few seconds and then boom you come out and are looking up at the referee to ask “where am I? what happened to me?”

Concussion may then also be referred to as a minor head trauma or rather a minor closed head trauma accompanied by brief loss of consciousness. Closed since there is no breach in the skull. The head injury occurs but nothing penetrates the skull. Concussions are thus common and they may occur during a MVA, sports related concussions are common (injuries during football, ice-hockey, boxing and other contact sports where blows to the head may occur). The exact mechanism why there is that bried period of unconsciousness which then resolves and the person wakes up is not fully elucidated. The thinking is that during the concussion, the brain is subjected to mechanical and kinetic forces which “shake” the brain inside the rigid cranium. The brain though is free to move inside the skull, it is attached by the brainstem which is relatively immobile. So as the brain turns on its axis, there is transient dysfunction of the brainstem and this leads to loss of consciousness and the person blacks out.

Concussions are usually not life threatening and the patient comes around in a few seconds to a few minutes. Those associated with a prolonged period of unconsciousness though need to be evaluated in the hospital to make sure there is nothing serious or structural such as an intracranial hemorrhage (bleed) into the brain or outside the brain but inside the skull (epidural hematoma).  There are guidelines with respect to sports related concussion injuries and usually the doctor at the side of the play field makes a decision whether it is safe for the player to play again during that game or should he sit out the rest of the game. Multiple concussive injuries increase the risk of sudden death (no one quite knows by what exact mechanism) and hence concussive injuries in professional players like those who play football do deserve special attention.

Let us now turn to what is called PCS. Again there has a lot which has been written about PCS but this syndrome is ill-defined and its etiology is far from clear. Patients who have suffered a concussion frequently complain of memory problems following the concussion. Apart from memory difficulties these patients may complain of mood changes been too irritable or short tempered, balance problems and unsteady gait, dizziness, headaches, fatigue and lack of energy. This constellation of signs and symptoms with a preceeding history of concussion is what has been referred to as PCS. When these patients present to neurologists, we investigate them but most of the time all the tests come back as “normal”. Their imaging studies like CT scan head and MRI brain are normal.

PCS is usually treated symptomatically. If headache is the major complain we treat the headache. If dizziness is the major complaint we treat with an antivertigo drug. At times low dose antidepressants may be helpful. The natural history of this condition is good and most patients recover in due course and are able to go back to their day to day life.

Nitin Sethi, MD