When Concussion Hits

A 24 year old goalkeeper playing in the Champions League final in Ukraine is hit in the head by an opponent.  Later he makes two errors costing his side two goals.  His team lose 3-1.  5 days later he is diagnosed with having a concussion.  There is later speculation about whether this concussion caused his errors.  

Before we go on there has also been some interesting discussion on human factors including this article in The Times on focus and how too much can affect our performance.

What is concussion?

Concussion is usually used to describe a mild traumatic brain injury particularly the signs and symptoms an individual may experience after a mild traumatic brain injury.  Mild TBI is described as a GCS of 13-15 following a head injury.  

NHS UK list the following as symptoms of a concussion (1):

  • a headache that doesn't go away or isn't relieved with painkillers 
  • dizziness
  • nausea or vomiting
  • feeling stunned, dazed or confused
  • memory loss – you may not remember what happened before or after the injury 
  • clumsiness or trouble with balance 
  • unusual behaviour – you may become irritated easily or have sudden mood swings 
  • changes in your vision – such as blurred vision,  double vision or "seeing stars" 
  • being knocked out or struggling to stay awake

Most cases of concussion are mild (2) with contact sports having a relatively high incidence (3).

Concussion is believed to be caused by a functional rather than structural deficit following the brain hitting against the hard bony walls of the skull (4).

The diagnosis of concussion involves a full history and examination. Even so, over 80% of sufferers may not recognise their condition (5). 

There are a number of diagnostic tools designed to help recognising concussion none are designed to rule out concussion and neither are superior to clinical examination and history taking (6). 

It is important to remember the NICE CT Head criteria CG176.  Check out our Adult Head Injury episode.  Concussion should be diagnosed only if there is no suspicion of serious head injury or it has been ruled out with imaging.  

Concussion advice

The Charity Headway recommend the following for anyone diagnosed with concussion: 

  • Do make sure you stay within reach of a telephone and medical help
  • Do have plenty of rest and avoid stressful situations  Do show this booklet to a friend or family member who can monitor your condition
  • Do take painkillers such as paracetamol for headache
  • Don’t stay at home alone for 48 hours after leaving hospital
  • Don’t drink alcohol until you feel better
  • Don’t take aspirin or sleeping tablets without consulting your doctor
  • Don’t return to work until you feel ready
  • Don’t play any contact sport for at least three weeks without consulting your doctor
  • Don’t drive until you feel you have recovered. If in doubt consult your doctor 

Headway have an excellent booklet which you can find here

Post-concussion syndrome (PCS) is a symptom complex that includes headache, dizziness, neuropsychiatric symptoms, and cognitive impairment (7).  It affects 30-80% of patients with mild TBI.  Most cases resolve within 3 months.  MRI Brain should be used in prolonged cases to rule out more sinister causes.  Most clinicians will treat patients with PCS symptomatically (8).

Learning Points

  1. Concussion is a functional deficit following mild traumatic brain injury which is common
  2. There are many different symptoms of concussion which patients need to be advised about; diagnosis is through history and examination; no diagnostic score can be used to rule out concussion
  3. Post-concussion syndrome is vague and usually resolves within 3 months 


(1) https://www.nhs.uk/conditions/concussion/

(2) Vos PE, Battistin L, Birbamer G, Gerstenbrand F, Potapov A, Prevec T, Stepan ChA, Traubner P, Twijnstra A, Vecsei L, von Wild K, European Federation of Neurological Societies; EFNS guideline on mild traumatic brain injury: report of an EFNS task force; Eur J Neurol. 2002;9(3):207

(3) Guerriero RM, Proctor MR, Mannix R, Meehan WP 3rd; Epidemiology, trends, assessment and management of sport-related concussion in United States high schools; Curr Opin Pediatr. 2012 Dec;24(6):696-701

(4) McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorák 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; Br J Sports Med. 2013;47(5):250

(5) Delaney JS, Abuzeyad F, Correa JA, Foxford R; Recognition and characteristics of concussions in the emergency department population; J Emerg Med. 2005;29(2):189

(6) Giza CC, Kutcher JS, Ashwal S, Barth J, Getchius TS, Gioia GA, Gronseth GS, Guskiewicz K, Mandel S, Manley G, McKeag DB, Thurman DJ, Zafonte R; Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology; Neurology. 2013;80(24):2250. Epub 2013 Mar 18

(7) Bazarian JJ, Wong T, Harris M, Leahey N, Mookerjee S, Dombovy M; Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population; Brain Inj. 1999;13(3):173

(8) Evans RW, Evans RI, Sharp MJ; The physician survey on the post-concussion and whiplash syndromes; Headache. 1994;34(5):268





Being Head Smart

You see a 15 year old who attends the Emergency Department with a persistent headache.  They have read an article in a newspaper and since then they're concerned they have a brain tumour.  They ask you what you'd look for in case it was a brain tumour.  You wonder where you'd go to find this information.  You'd like some support and don't know where to look.

The Brain Tumour Charity was formed in 2013.  HeadSmart UK-wide campaign based on research funded by The Brain Tumour Charity at The University of Nottingham.  It has fantastic resources on its website.  The focus is on spotting the red flags of brain tumours and how as clinicians we refer and how urgently.

  • Same day referral from primary care if high risk of brain tumour/life threatening symptoms
  • 2 week referral if lower risk but on differential list


In the latest Take Aurally podcast we were lucky to have Dr Shaarna Shan from HeadSmart join Jamie and Dr Colin Gilhooley our resident Paediatric SpR to discuss the charity, its formation and the diagnosis and referral process of Paediatric brain tumours.  

Learning Points 

  1. Consider brain tumours in any child with headache, visual disturbance, motor signs and symptoms, growth and endocrine symptoms, increasing head circumference, behavioural change, diabetes insipidus, seizures or altered GCS
  2. Remember symptoms can fluctuate
  3. Ask about pre-disposing conditions - personal or family history of brain tumours, sarcoma, leukaemia or early onset breast cancer; Tuberous sclerosis, Neurofibromatosis or other familial genetic syndromes

Remember to check out the HeadSmart website this catchy tune: