Brain Concussion (cont.)

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How is concussion diagnosed?

Physical Examination and Testing

Taking a history of what happened to the patient is the important first step in the diagnosis and treatment of a concussion. Understanding the mechanism of injury and the sequence of events afterwards is important in deciding the potential risk for bleeding and swelling in the brain.

The history will try to find out if there was an underlying medical problem that caused the injury. For example, in older patients who fall and hit their head and are briefly unconscious, the question becomes: Did the patient hit their head and get knocked out? Or did they pass out due to a stroke or other problem, then fall and hit their head?

Medications and past history are important considerations. Patients who take blood thinners like warfarin (Coumadin) or dabigatran (Pradaxa) are at higher risk for bleeding when they get hit in the head.

Physical examination will include a complete neurologic examination and may include looking for weakness, paralysis, or change of sensation in the body. Balance and coordination may be evaluated. Vision and hearing may also be checked.

The head will be examined looking for signs of injury including the potential for skull or facial bone fracture. The neck may also be evaluated since neck injury can be associated with head trauma.

The concept of minor head injury refers to patients who have had trauma to their head and are fully awake. The question becomes whether a CT scan of the head is needed to look for bleeding or swelling in the brain. Rules have been developed to guide the health care professional and allow the appropriate use of CT scanning. Both the Canadian CT head rules and the New Orleans rules are effective in screening patients who have had a concussion but do not need an operation.

The Canadian CT rules suggest that a CT is required only if any of the following criteria are met (please note that these criteria apply to patients aged 16 to 65).

High risk for neurosurgical intervention:

  • Glasgow Coma Score <15 at 2 hours after injury *see below
  • Suspected open or depressed skull fracture
  • Any sign of basal skull fracture [blood behind the eardrum, "raccoon eyes" or bruising around the eyes, cerebrospinal fluid leaking from the nose or ears, or Battle's sign (bruising behind the ear)]
  • More than two episodes of vomiting, age >65 years

Medium risk of brain injury on CT:

  • Amnesia before impact of greater than 30 minutes
  • Dangerous mechanism (for example, pedestrian hit by car, thrown from a moving vehicle, fall from height)

These guidelines also do not apply to patients who are taking anticoagulation or blood-thinning medications.

Please note that the rules do not consider loss of consciousness or seizure in determining the potential severity of brain injury.

Glasgow Coma Score (GCS)

The GCS was developed to assess a patient's neurologic status based on speech, eye opening, and movement. The scale is used as part of the initial evaluation of a patient and is meant to be repeated over the course of the patient's care. Since it is relatively easy to do, the GCS can be used by health care professionals with different skill levels to assess changes in patient status.

A normal awake patient has a GCS of 15. A dead patient has a GCS of 3.

Glasgow Coma Scale
Eye Opening
Spontaneous 4
To loud voice 3
To pain 2
None 1
Verbal Response
Oriented 5
Confused, disoriented 4
Inappropriate words 3
Incomprehensible words 2
None 1
Motor Response
Obeys commands 6
Localizes pain 5
Withdraws from pain 4
Abnormal flexion posturing 3
Extensor posturing 2
None 1

X-rays of the skull are not indicated in minor head trauma, since normal X-rays do not mean that there is normal brain function.

Since concussion is defined as a temporary change in brain function, it is important to examine the patient on more than one occasion. Brain function may or may not correlate with the resolution of symptoms. Neuropsychologic testing may be used to assess brain function to decide when to allow a patient to return to full activity.


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