James J. Kinderknecht, M.D. Baxter B. Allen, M.D. Kenneth Perrine, Ph.D.

1. Overview of Concussion Epidemiology 13 th Annual Sports Medicine for the Young Athlete James J. Kinderknecht, M.D. Hospital for Special Surgery

2. HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. James J. Kinderknecht, M.D. Disclosure: I DO NOT have a financial relationship with any commercial interest.

25. HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. Baxter B. Allen, M.D. Weill Cornell Medical College Disclosure: I DO NOT have a financial relationship with any commercial interest.

26. Baxter B. Allen, MD Research Associate in Child Neurology Weill Cornell Medical College

27. Blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. Not all blows or jolts to the head result in a TBI. Severity …. may range from "mild," i.e., a brief change in mental status or consciousness to "severe," i.e., an extended period of unconsciousness or amnesia after the injury. TBI can result in short or long-term problems with independent function. Traumatic brain injury (TBI) CDC 7/06

28. Mod Mild Severe Sports concussion ? “ Minimal” Glasgow Coma Scale Consensus Statement on Concussion in Sport. 3 rd International Conference on Concussion in Sport held in Zurich, Nov 2008

29. Loss of consciousness < 30 minutes or amnesia <24 hours or altered mental status at time of injury Glasgow Coma Scale (GCS) score 13-15, measured ≥30 mins after injury lower GCS = moderate to severe ACADEMIC EMERGENCY MEDICINE 2006 Current Pharmaceutical Design, 2001, 7, 1475 Concussion

30. Deformation of elastic brain within rigid skull Sudden acceleration or deceleration Focal contusions, hematomas, diffuse injury Neuronal axonal processes Not necessarily transection early Derangement of cytoskeletal elements Microtubules, neurofilaments Interrupt transport Delayed, progressive proteolysis Primary v secondary injury ACADEMIC EMERGENCY MEDICINE 2006 Current Pharmaceutical Design, 2001, 7, 1475

31. COUP - CONTRECOUP INJURY

32. Biomechanical investigations dating back to the beginning of the 20th century suggest that concussion results from a rotational motion of the cerebral hemispheres in the anterior–posterior plane, around the fulcrum of the fixed-in-place upper brain stem. N Engl J Med 2007;356:166-72. Mechanism of Concussion Viano et al

37. TAKAHASHI H. Changes in extracellular potassium concentration in cortex and brain stem during the acute phase of experimental closed head injury. J Neurosurg 55:708-717, 1981

41. Diffuse Axonal Injury (DAI) – The severe end of the spectrum

46. CHRONIC mTBI Acute (n=28) Chronic (n=17) R ACR 18% 59% L ACR 14% 24% Both 14% 18% Journal of Head Trauma Rehabilitation. July 2010 (In Press)

47. Smits M. Microstructural brain injury in post-concussion syndrome after minor head injury. Neuroradiol 2010; 10 MD mean diffusitivity FA fractional anisotropy SLF superior longitudinal fasciculus IFO inferior frontal fasciculus ILF inferior longitudinal fasciculus Severity of post-concussive symptoms significantly correlates with ↓white matter integrity (↑in diffusivity ➙↓anisotropic diffusion.)

51. Diffusion anisotropy maps and diffusion tensor imaging-based white matter trac- tography of a representative boxer (A and B ; 27 years old) and a control (C and D ; 29 years old). Intensity is proportional to anisotropy and color shows the direction. The boxer has decreased anisotropy in CC and anterior and posterior limb of IC compared with the healthy control subjects. Fiber tracking showed overall fewer trackable white matter fibers in this boxer ’s brain (B ) compared with that of a control subject (D ). The difference in fibers through the corpus callosum is particularly striking. Am J Neuroradiol 27:2000 – 04 Oct 2006

52. Bijur PE. Cognitive Outcomes of Multiple Mild Head Injuries in Children. J Dev Behav Pediatr 1996. 17:143.

53. Alzheimer ’s disease, mild cognitive impairment Synergistic interaction of environmental and genetic factors in dementia. Data do not suggest the 2 factors influence clinical presentation or course Functional Neurology 2006; 21(4): 223-228 APOE4 and TBI

54. Schmidt OI. Closed head injury—an inflammatory disease? Brain Res Rev 2005; 48: 388

55. HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. Kenneth Perrine, Ph.D. Weill-Cornell College of Medicine Disclosure: I DO NOT have a financial relationship with any commercial interest.

56. Neurocognitive Testing for All? Kenneth Perrine, Ph.D. Department of Neurological Surgery Weill-Cornell Medical College Consultant: NY Jets, NY Islanders

62. Spatial Ability: Construction and Memory

63. Spatial Ability: Visual Synthesis