What is the difference between a concussion and a contusion in terms of management and treatment?

Concussion vs. Contusion: Key Differences in Management and Treatment

Concussion and contusion are fundamentally different injuries requiring distinct management approaches: concussion is a functional brain disturbance without structural injury visible on standard imaging that requires cognitive and physical rest followed by graded return to activity, while contusion is a structural brain injury with actual bruising/bleeding visible on neuroimaging that may require neurosurgical intervention and hospitalization.

Pathophysiology and Definition

Concussion

• Represents a functional disturbance rather than structural injury to the brain, with no abnormality visible on standard structural neuroimaging studies 1
• Results from biomechanical forces transmitted to the head causing a neurometabolic cascade that increases local energy demand in the presence of decreased cerebral blood flow and mitochondrial dysfunction 1
• Defined as traumatically induced transient disturbance of brain function with Glasgow Coma Scale scores of 13-15, with or without loss of consciousness for less than 30 minutes 1
• Symptoms typically resolve spontaneously following a sequential course, though 15-20% develop persistent symptoms beyond 2 weeks 1

Contusion

• Represents actual structural brain injury with bruising and bleeding of brain tissue visible on CT or MRI imaging
• Involves direct parenchymal damage with potential for mass effect, edema, and secondary complications
• May require neurosurgical monitoring or intervention depending on size and location
• Recovery trajectory is fundamentally different from concussion due to structural tissue damage

Diagnostic Approach

Concussion

• Remains a clinical diagnosis made by healthcare providers familiar with concussion recognition 2
• Imaging is reserved only when intracranial bleeding is suspected based on clinical examination 2
• Assessment includes graded symptom checklists, cognitive evaluation (orientation, memory, concentration), balance testing, and neurological examination 2
• Standard structural neuroimaging will be normal by definition 1

Contusion

• Requires neuroimaging (CT or MRI) for diagnosis and monitoring
• Clinical examination must identify red flags warranting immediate imaging: repeated vomiting, worsening headache, focal neurologic deficits, altered mental status, seizures 3, 4
• Serial imaging may be necessary to monitor for expansion or complications
• May require neurosurgical consultation even without immediate intervention

Acute Management (First 24-48 Hours)

Concussion

• Implement moderate physical and cognitive rest for 24-48 hours to allow initial recovery during the acute neurometabolic cascade 5, 3, 4
• Avoid strict prolonged rest exceeding 3 days as this can worsen outcomes and be detrimental to recovery 5, 3
• Remove immediately from play—"When in doubt, sit them out!" 3
• Acetaminophen may be used for symptom management (avoid NSAIDs/aspirin due to theoretical bleeding risk) 4
• Implement "cognitive rest" including temporary reduction in school workload, avoidance of video games, computer use, television, and loud music 4

Contusion

• Requires hospitalization for neurological monitoring in most cases
• Serial neurological examinations to detect deterioration
• Repeat imaging as clinically indicated to assess for expansion
• May require neurosurgical intervention for evacuation if causing mass effect
• Strict activity restriction until cleared by neurosurgery
• Management of intracranial pressure if elevated

Return to Activity Protocol

Concussion

After initial 24-48 hour rest period, begin gradual progressive return following this specific stepwise protocol 3, 4:

1. Light aerobic exercise (walking, swimming, stationary cycling) staying below symptom-exacerbation threshold 3, 4
2. Sport-specific exercise (skating drills in hockey, running drills in soccer) 3
3. Non-contact training drills (passing drills, resistance training) 3
4. Full-contact practice following medical clearance 3
5. Return to competition 3

• Each step requires minimum 24 hours before progression 3, 4
• If symptoms recur, return to previous asymptomatic level and rest 24 hours before attempting progression again 3, 4
• Supervised, non-contact aerobic exercise below symptom threshold is particularly beneficial for adolescents with acute concussion 5, 4
• Allow return to full activity only when the individual has returned to premorbid performance, remains symptom-free at rest, and shows no symptom recurrence with increasing physical exertion 5, 3, 4

Contusion

• No standardized return to activity protocol exists as management is individualized based on injury severity, location, and complications
• Requires neurosurgical clearance before any return to physical activity
• May require months of complete rest from contact activities
• Neuropsychological testing typically required before clearance
• Many patients with significant contusions may be permanently disqualified from contact sports
• Return decisions must account for structural brain damage and risk of catastrophic reinjury

Management of Persistent Symptoms

Concussion

• Implement multidisciplinary management for symptoms persisting beyond 10 days 3
• Treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular rehabilitation, vision therapy, cognitive behavioral therapy, and pharmacological management 6
• Graded physical exercise, vestibular rehabilitation, and manual therapy for neck pain when present 4
• Referral to specialist in traumatic brain injury if symptoms persist beyond 3 weeks 4

Contusion

• Persistent symptoms may reflect ongoing structural pathology requiring repeat imaging
• Multidisciplinary rehabilitation similar to moderate-severe TBI protocols
• May require formal neuropsychological rehabilitation programs
• Long-term neurosurgical follow-up to monitor for late complications (post-traumatic epilepsy, hydrocephalus)

Critical Pitfalls to Avoid

For Concussion

• Never allow same-day return to play after diagnosed concussion 1, 2
• Do not return to play while taking medications for concussion symptoms as this indicates incomplete recovery 1, 3, 4
• Avoid high-intensity physical activity during recovery as this is detrimental 5, 4
• Do not rely solely on patient-reported symptoms without objective assessment 3
• Be more conservative with younger athletes (<18 years) due to potential catastrophic effects on the maturing brain 4

For Contusion

• Never discharge without appropriate imaging to rule out structural injury
• Do not assume clinical improvement means radiographic stability—repeat imaging is often necessary
• Never clear for contact sports without neurosurgical consultation
• Recognize that contusion patients are at higher risk for post-traumatic epilepsy and require counseling

Key Distinguishing Factor for Management

The fundamental management difference is that concussion requires a time-based, symptom-guided graduated return to activity protocol starting after 24-48 hours of rest 5, 3, 4, while contusion requires structural healing confirmed by imaging and neurosurgical clearance with no standardized timeline, often resulting in prolonged or permanent activity restriction.