Progress in neurological surgery
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Concussions have long been understood to be an invisible injury. Indeed, conventional imaging techniques [computed tomography and magnetic resonance imaging (MRI)] are largely ineffective in elucidating concussive injuries. More advanced techniques are being used experimentally to help delineate the underlying pathophysiology of concussive injuries on metabolic as well as ultrastructural levels. ⋯ Each technique is briefly described, followed by a summary of the findings specific to concussive injuries. Overall, there is mounting evidence to suggest that each technique has utility in describing and explaining postinjury changes in the brain. Overall, concussive injuries are evident using the various aforementioned neuroimaging modalities and suggest at a minimum the concussed brain is different in the acute and subacute postinjury phases with several other studies suggesting that changes are persistent well beyond, especially in those patients with persistent symptoms.
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There is no other sport that has come under greater scrutiny surrounding the incidence and treatment of concussion than football, and there is no other professional sports league that has experienced more intense focus of its handling of concussions than the National Football League (NFL). The NFL has received significant criticism of their management of concussion in players from both the popular press and the medical community. However, those working with active NFL players have changed their assessment and treatment of these injuries as the knowledge of concussions has evolved over time. We review the current approach to the management of concussions in the professional football player.
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The clinical presentation of concussion can vary widely as patients experience any number of symptoms including headache, dizziness, cognitive symptoms of difficulty with concentration and memory, sleep dysregulation, and mood disturbances. The variability in clinical presentation underscores the importance of thorough history-taking to clearly understand the clinical picture and to allow individualization of the treatment plan. ⋯ For those individuals whose symptoms persist or significantly impair quality of life, pharmacologic intervention may be warranted. Though few studies have investigated the use of pharmacology for treatment of postconcussion syndrome specifically, targeted treatment of medications known to improve selected symptoms can be considered.
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Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative syndrome, which is caused by single, episodic, or repetitive blunt force impacts to the head and transfer of acceleration-deceleration forces to the brain. CTE presents clinically as a composite syndrome of mood disorders and behavioral and cognitive impairment, with or without sensorimotor impairment. Symptoms of CTE may begin with persistent symptoms of acute traumatic brain injury (TBI) following a documented episode of brain trauma or after a latent period that may range from days to weeks to months and years, up to 40 years following a documented episode of brain trauma or cessation of repetitive TBI. ⋯ The brain of a CTE sufferer may appear grossly unremarkable, but shows microscopic evidence of primary and secondary proteinopathies. The primary proteinopathy of CTE is tauopathy, while secondary proteinopathies may include, but are not limited to, amyloidopathy and TDP proteinopathy. Reported prevalence rates of CTE in cohorts exposed to TBI ranges from 3 to 80% across age groups.
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Over the last few decades, structural imaging techniques of the human brain have undergone significant strides. High resolution provided by recent developments in magnetic resonance imaging (MRI) allows improved detection of injured regions in patients with moderate-to-severe traumatic brain injury (TBI). In addition, diffusion imaging techniques such as diffusion tensor imaging (DTI) has gained much interest recently due to its possible utility in detecting structural integrity of white matter pathways in mild TBI (mTBI) cases. ⋯ The detection of white matter damage in concussion remains challenging, and development of imaging biomarkers for mTBI is still in great need. In this chapter, we discuss our experience with high-definition fiber tracking (HDFT), a diffusion spectrum imaging-based technique. We also discuss ongoing developments and specific advantages HDFT may offer concussion patients.