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Concussion

Definition
Concussion is a mTBI induced by direct or indirect biomechanical force transmitted to the head that is characterized by reversible symptoms of dizziness, headache, nausea, imbalance, and loss of consciousness.
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Pathophysiology
Concussion is caused by biomechanical force transmitted to the head in the setting of work environment, motor vehicle crashes, sports and recreation, and falls at home among elderly.
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Disease course
Clinical manifestations include dizziness, headache, nausea, imbalance, loss of consciousness, and on occasions malignant brain swelling. Repeated concussions may cause post-traumatic epilepsy, postconcussion syndrome, and delayed post-traumatic brain degeneration leading to dementia and movement disorders.
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Prognosis and risk of recurrence
Concussion is associated with increased mortality risk in the elderly with adjusted HR 1.25 (95% CI 1.16-1.34).
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Key sources
The following summarized guidelines for the evaluation and management of concussion are prepared by our editorial team based on guidelines from the Living Concussion Guidelines (LCG 2023; 2022; 2017), the American Academy of Ophthalmology (AAO/AAPOS/AACO/AAP 2022), the American College of Radiology (ACR 2021; 2020), the United States Department of Defense (DoD/VA 2021; 2016), the Center for Disease Control (CDC 2018), the American Academy of Pediatrics (AAP 2018), and the Eastern Association for the Surgery of Trauma (EAST 2012).
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Guidelines

1.Screening and diagnosis

Terminology: consider using the terms "history of mTBI" or "concussion" and refraining from using the terms "brain damage" or "patients with mTBI" in communication with patients and the public.
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2.Diagnostic investigations

History and physical examination: as per LCG 2022 guidelines, recognize suspected concussion as soon as possible
A
and refer to a physician/nurse practitioner for diagnosis confirmation.
B
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  • Diagnostic imaging (head CT)

  • Diagnostic imaging (other modalities)

  • Serum biomarkers

  • EEG

  • Assessment of headache

  • Assessment of vision

  • Assessment of cognitive difficulties

  • Assessment of mental health

  • Assessment of sleep-wake disturbances

  • Assessment of fatigue

3.Respiratory support

Hyperbaric oxygen therapy: as per LCG 2023 guidelines, do not offer hyperbaric oxygen therapy for the management of symptoms post-concussion.
D

4.Medical management

Setting of care, initial management, DoD/VA: consider offering a primary care, symptom-driven approach for the evaluation and management of patients with a history of mTBI and persistent symptoms.
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  • Setting of care (prolonged symptoms)

  • Management of vestibular dysfunction (acute mTBI)

  • Management of vestibular dysfunction (post-acute mTBI)

  • Management of visual symptoms

  • Management of headache

  • Management of neck pain

  • Management of cognitive issues

  • Management of mental health issues

  • Management of sleep-wake disturbances

  • Management of fatigue

  • Management of exertion-induced symptoms

5.Nonpharmacologic interventions

Alternative and complementary therapies: insufficient evidence to recommend for or against any of the following interventions in the treatment of patients with symptoms attributed to mTBI:
acupuncture
tai chi
meditation
mindfulness
yoga
massage
chiropractic therapy
cranial electrotherapy stimulation
sensory deprivation tanks
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6.Therapeutic procedures

Transcranial magnetic stimulation: avoid offering repetitive transcranial magnetic stimulation in the treatment of patients with symptoms attributed to mTBI.
D

7.Specific circumstances

Pediatric patients, clinical assessment: use an age-appropriate, validated symptom rating scale as a component of the diagnostic evaluation in pediatric patients with acute mTBI.
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  • Pediatric patients (diagnostic imaging)

  • Pediatric patients (serum biomarkers)

  • Pediatric patients (assessment of vision)

  • Pediatric patients (counseling)

  • Pediatric patients (management of headache)

  • Pediatric patients (management of cognitive issues)

  • Pediatric patients (management of sleep disturbances)

  • Pediatric patients (evaluation of persistent symptoms)

  • Pediatric patients (assessment of recovery)

  • Pediatric patients (return to activity)

  • Pediatric patients (return to school)

  • Pediatric patients (sport-related concussion, prevention)

  • Pediatric patients (sport-related concussion, cervical spine stabilization)

  • Pediatric patients (sport-related concussion, evaluation of prolonged symptoms)

  • Pediatric patients (sport-related concussion, return to sport)

8.Patient education

General counseling, recovery, LCG
Counsel and reassure patients with symptoms persisting after 1 month that a symptom-based approach will facilitate recovery and most patients achieve symptom resolution.
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Provide this education in written, verbal, and/or pictorial formats.
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Counsel patients in a compassionate manner that involvement in litigation is associated with slower recovery.
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  • General counseling (long-term effects)

9.Follow-up and surveillance

Discharge from hospital: as per LCG 2022 guidelines, consider discharging patients presenting to the hospital/clinic acutely with a concussion for home observation if meeting the following clinical criteria:
normal mental status (alertness/behavior/cognition) with clinically improving post-concussive symptoms
no clinical risk factors indicating the need for CT or normal CT result if obtained because of the presence of risk factors.
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  • Evaluation of prolonged symptoms

  • Evaluation of delayed symptoms

  • Return to activity

  • Return to work

  • Return to driving