Evaluation for Concussion
Any person with signs or symptoms of concussion must be immediately removed from activity and evaluated by a healthcare professional—they should never return to play the same day, even if symptoms resolve. 1
Immediate Recognition and Red Flags
When evaluating for suspected concussion, immediately assess for signs requiring emergency activation (call EMS):
- Loss of consciousness
- Worsening or severe headache
- Repeated vomiting
- Altered mental status or confusion
- Seizure activity
- Visual changes
- Focal neurological deficits
- Skull deformities or swelling suggesting fracture
These indicate potential life-threatening complications (epidural hematoma, subdural hematoma, skull fracture, brain edema) requiring hospital evaluation 1.
Clinical Diagnosis Components
Concussion diagnosis is clinical—no single test can diagnose or clear a concussion. 2 The evaluation should systematically assess multiple domains:
1. Symptom Assessment
Document presence and severity of:
- Physical: Headache (most common), dizziness, nausea, balance problems, visual disturbances, sensitivity to light/noise
- Cognitive: Confusion, feeling "dazed" or "foggy," difficulty concentrating, memory problems, slowed processing
- Emotional/Behavioral: Irritability, emotional lability, personality changes
- Sleep: Drowsiness, sleep disturbance, fatigue 3, 4
2. Cognitive Testing
Brief neuropsychological assessment focusing on:
- Memory function: Immediate recall (more reliable than standard orientation questions like time/place/person in sports settings) 3
- Attention and concentration
- Information processing speed
Tools include Standardized Assessment of Concussion (SAC) or Maddocks questions for sideline evaluation 3. Note: These abbreviated tools are for rapid sideline assessment only and do not replace comprehensive neuropsychological testing 3.
3. Balance and Vestibular-Ocular Assessment
- Gait stability and coordination
- Balance testing (shows impairment post-injury)
- Vestibular-ocular motor screening 2
4. Physical Examination
Observe for:
- Poor coordination or abnormal gait
- Slurred speech
- Vacant stare or glassy eyes
- Inappropriate behavior or responses
- Decreased performance ability 3
Neuroimaging Decisions
Routine neuroimaging is NOT indicated for uncomplicated concussion 4. Conventional CT/MRI is typically normal in concussion 3.
Indications for CT/MRI:
- Prolonged disturbance of consciousness
- Focal neurological deficits
- Seizure activity
- Persistent or worsening clinical symptoms
- Suspicion of structural lesion (skull fracture, intracranial hemorrhage) 3
Do NOT use:
- Skull radiographs (inadequate sensitivity, cannot detect intracranial injury) 5
- SPECT scanning in acute evaluation 5
- Routine MRI in acute setting 5
Multimodal Assessment Approach
The most effective evaluation combines multiple assessment domains simultaneously 6. In the absence of a single validated diagnostic test, use consensus-derived multimodal tools like the Sport Concussion Assessment Tool (SCAT) or Child SCAT for pediatric patients 6.
Key Algorithm:
- Establish mechanism: Direct or indirect trauma to head with appropriate force
- Document temporal relationship: Symptoms must have temporal connection to injury
- Assess all clinical domains: Physical, cognitive, emotional, sleep
- Rule out emergent pathology: Screen for red flags requiring imaging
- Perform objective testing: Cognitive, balance, vestibular-ocular
- Consider baseline comparison: If available (particularly valuable in pediatric/para athletes) 7
Critical Pitfalls to Avoid
- Never rely on loss of consciousness alone—it occurs in minority of concussions and is not required for diagnosis 3, 4
- Standard orientation questions are unreliable in sports settings compared to memory assessment 3
- Do not use single assessment tool in isolation—diagnosis requires integration of multiple domains 2
- Avoid same-day return to play regardless of symptom resolution—this is a central tenet across all guidelines to prevent second-impact syndrome 8
- Do not leave patient alone—regular monitoring for deterioration is essential 3
Special Populations
Pediatric athletes require more conservative evaluation with consideration for:
- Baseline testing given variable presentation
- Extended monitoring period
- Modified assessment tools (Child SCAT validated for this population)
- Greater precaution given developing brain vulnerability 7
Para athletes with pre-existing neurological conditions need individualized baseline assessments and may present with atypical symptoms 7.
Documentation Requirements
Record:
- Mechanism and timing of injury
- All symptoms across domains
- Objective test results (cognitive, balance, vestibular)
- Protective equipment used at time of injury
- Previous concussion history 3, 4
The evaluation is complete when you have sufficient clinical information to make the diagnosis and determine whether emergency intervention is needed, while establishing baseline for monitoring recovery.