VANCOUVER—“Concussion is a public health epidemic,” said Amaal Starling, MD. “Neurologists are seeing more and more concussed patients every day.” At the 68th Annual Meeting of the American Academy of Neurology, Dr. Starling, who is an Assistant Professor of Neurology at the Mayo Clinic in Phoenix, provided a framework and a template for evaluating concussion in the outpatient setting.
Amaal Starling, MD
“Prioritizing these patients into clinic is very important,” Dr. Starling said. She recommended expedited appointments for patients with a suspected concussion. “This will limit symptom exacerbation, provide an avenue for appropriate and quick symptomatic treatment, and prevent premature return to learn and return to play,” which may exacerbate symptoms and prolong recovery.
Outpatient Evaluation of Concussion
The patient history should always include the date of the injury and the injury description, which includes the mechanism of the injury, location of the impact, presence or absence of any whiplash injury, altered mental status or amnesia, as well as symptom progression. “How do the symptoms progress from the time of impact to the time the patient presents in the office?” Dr. Starling asked. “This will help you identify not only those immediate symptoms that occur, but also those delayed symptoms that can occur one to two days later. In addition, it will give you a time course of symptoms to determine if the patient has been worsening, improving, or has stayed about the same.”
Concussion has various symptoms that can be categorized in the following four domains: physical, cognitive, emotional, and sleep. The most frequently reported symptom is headache, followed by dizziness. To capture all of those symptom domains, Dr. Starling recommended using a postconcussion graded symptom checklist. “This can be effective at monitoring symptoms over time.”
It is also important to elicit risk factors for prolonged recovery. “If an individual has a personal history of migraine, they are at risk of having a prolonged recovery after the injury,” Dr. Starling said. “Even if they have no personal history of migraine, but if they have a family history of migraine, those individuals, per studies, have demonstrated a prolonged recovery after a concussion.” Other risk factors for a prolonged recovery include a history of learning disabilities, such as attention deficit disorder or dyslexia, and psychiatric disease, such as premorbid anxiety or depression.
A concussion history is also important because a prior concussion increases the risk of another concussion, as well as the risk of having a prolonged recovery. “Not only do you want to know how many concussions have occurred, but also the symptom duration and recovery course for those concussions.”
Since headache is the most common symptom after a concussion, it is important to evaluate headache when present. “In every headache history, it is important to look for red flags,” said Dr. Starling. She suggested using the mnemonic IFLOP to look for headache red flags in the setting of a concussion. IFLOP stands for Intractable vomiting, Focal neurologic symptoms and signs, changes in Level of awareness, Orthostatic headache, and Progressively worsening headache. When present, headache red flags should signal the need for neuroimaging. “For example, if someone is presenting with an orthostatic headache … I am concerned that they might have a CSF leak and I’ll want to get an MRI of the brain with and without contrast to look for diffuse pachymeningeal enhancement that we can see in that setting,” Dr. Starling said.
Management of a Concussed Patient
According to Dr. Starling, posttraumatic headaches should be treated according to their phenotypes. “If [the headache] has a migraine phenotype, treat it with migraine-specific medications. If it has a more cervicogenic phenotype, treat it that way.” The most common posttraumatic headache phenotype is migraine. That finding has been confirmed in the civilian as well as the military population. “But it is important to screen for other phenotypes that may also occur,” Dr. Starling advised.
Because patients with concussion seem to be at higher risk for medication overuse and medication overuse headache, a pre- and postinjury medication history is also important. “If they are using over-the-counter medications, you’ll want to know what they are using and how much.”
During the initial visit, it is also important to determine whether the patient has had any baseline testing. “If they had any computerized neurocognitive testing, obtain those results, Dr. Starling advised. “If they had a King-Devick test at baseline or pre season, obtain those results. If they have undergone gold-standard neuropsychometric testing or had a baseline neurologic examination or imaging, get those results so that you can compare postinjury [performance] to preinjury [performance].”
Regarding the physical examination in the outpatient setting, vitals are vital, Dr. Starling said. Many concussed athletes have autonomic dysfunction that looks like postural orthostatic tachycardia syndrome (POTS), although the prognosis is typically different. “When getting vitals, it is important to get orthostatic vitals—supine and then standing at one, five, and 10 minutes—to monitor for abnormal changes or an increase in the heart rate with standing.” The physical exam should also look for trigger points or any difficulties with range of motion of the neck. “These [findings] can give you avenues for therapeutic intervention,” Dr. Starling said. Additionally, the Dix–Hallpike maneuver can identify cases of benign paroxysmal positional vertigo, which can be treated with the Epley maneuver.
Mental status should be evaluated as part of a detailed neurologic examination. The Mini-Mental State Exam (MMSE), the Montreal Cognitive Assessment (MoCA), and the Kokmen are well-validated tools for the evaluation of mental status. The Standardized Assessment of Concussion (SAC) is another tool that was developed to assess mental status. The SAC was validated on the sideline and is used by a wide array of health care providers from athletic trainers to the team physicians.
During the cranial nerve examination, Dr. Starling tests for anosmia. “That is concerning for gross structural changes on the inferior surface of the frontal lobe where the olfactory nerve lies.” Abnormalities suggest a need for neuroimaging. A typical pupillary assessment with a swinging pen light test also is an essential part of the evaluation, but Dr. Starling commented that in her patients with mild traumatic brain injury or concussion, she has rarely found any clinically significant abnormalities with that test. “But that’s not true for the evaluation of extraocular movement,” she said. “I look for not only nystagmus, abnormalities of smooth pursuit, and horizontal and vertical saccades, but I also look for near point convergence. Near point convergence of greater than 6 cm is abnormal in the majority of individuals that we will evaluate for concussion.” When it is abnormal, it correlates with oculomotor abnormalities in function. So, these people have more difficulty with oculomotor function in day-to-day life—difficulties with reading and motion sensitivity.
The rest of the cranial nerve examination can also help identify subtle focal deficits. Upper motor neuron exam techniques also can detect subtle changes, and abnormalities can suggest a need for neuroimaging. Dr. Starling also recommended a good screening evaluation of balance, such as the timed tandem gait measure.