What are the diagnosis and management steps for a patient with a suspected concussion?

Diagnosis of Concussion

Concussion diagnosis is primarily clinical, based on observed disorientation or confusion immediately after injury, combined with assessment of balance within 1 day, reaction time within 2 days, and verbal learning/memory within 2 days post-injury. 1, 2

Immediate On-Field/Sideline Assessment

Any athlete or patient suspected of having a concussion must be immediately removed from activity and not allowed to return the same day. 3

Critical Initial Evaluation Steps

• Assess for disorientation or confusion immediately after the event - this is the most reliable immediate indicator of concussion 1, 2
• Evaluate using a graded symptom checklist to objectively document symptom presence and severity 3
• Perform cognitive evaluation including orientation, past and immediate memory, new learning ability, and concentration 3, 4
• Conduct balance testing using standardized tools such as the Balance Error Scoring System (BESS) or Sensory Organization Test (SOT) within the first day 1, 2, 4
• Complete neurological physical examination including cranial nerve assessment, manual muscle testing, and deep tendon reflexes 4

Common Pitfall to Avoid

Do not rely on loss of consciousness (LOC) as a diagnostic requirement - LOC occurs in a minority of concussion cases and is not necessary for diagnosis 2, 3. Many clinicians mistakenly believe concussion requires LOC, leading to missed diagnoses.

Comprehensive Clinical Assessment (Within 48 Hours)

Four Core Diagnostic Indicators

The following indicators, when present, provide the strongest evidence for concussion diagnosis:

1. Observed disorientation or confusion immediately post-event 1, 2
2. Impaired balance within 1 day after injury 1, 2
3. Slower reaction time within 2 days after injury 1, 2
4. Impaired verbal learning and memory within 2 days after injury 1, 2

Concussion Subtype Assessment

Evaluate for all five concussion subtypes during the initial comprehensive assessment, as multiple subtypes commonly coexist and are not mutually exclusive. 1, 2

1. Headache/Migraine Subtype

• Most common acute subtype in both adults and children 1
• Assess for headache characteristics, photophobia, phonophobia, nausea 1

2. Vestibular Subtype

• As common as headache/migraine in children, possibly reflecting vulnerability of developing spatial skills 1
• Evaluate for dizziness, vertigo, balance problems, visual motion sensitivity 1
• Test vestibular ocular reflex (VOR) function 1

3. Cognitive Subtype

• Assess for difficulty concentrating, memory problems, slowed processing speed 1, 2
• Significantly elevated in both children (SMD = 0.66) and adults (SMD = 0.24) compared to controls 1

4. Ocular-Motor Subtype

• Evaluate for convergence insufficiency, accommodation problems, saccadic dysfunction 1
• Significantly impaired in adults (SMD = 0.72) compared to controls 1
• Perform screening ocular examination including visual tracking and convergence testing 4

5. Anxiety/Mood Subtype

• Present in up to one-third of adults and children within initial clinical encounter 1
• Screen for anxiety, depression, emotional lability, irritability 1
• Assess mood, affect, insight, and judgment during mental status examination 4

Associated Conditions to Evaluate

Sleep Disturbance

• Commonly associated with concussion and should be routinely assessed 1, 2
• Inquire about difficulty falling asleep, staying asleep, excessive drowsiness 1

Cervical Strain

• Often accompanies concussion due to shared injury mechanisms 1, 2
• Inspect head and neck for trauma or tenderness 4
• Assess cervical range of motion and perform Spurling maneuver 4
• Palpate for pain/tenderness in cervical spine, paraspinal and suboccipital muscles 1
• Test cervical strength and assess for radicular symptoms 1

Physical Examination Components

Essential Elements

• Cranial nerve examination 4
• Manual muscle testing and deep tendon reflexes 4
• Static or dynamic balance assessment (critical within first day) 1, 2, 4
• Screening ocular examination including visual tracking, convergence, and saccades 4
• Mental status examination including orientation, immediate and delayed recall, concentration, mood, affect, insight, and judgment 3, 4
• Cervical spine examination including inspection, palpation, range of motion, and Spurling maneuver 1, 4

Additional Elements Based on Clinical Suspicion

• Upper motor neuron testing 4
• Cervical proprioception and coordination testing 4
• Pupillary reactivity and visual acuity 4
• Dynamic visual acuity testing 4
• Temporomandibular joint examination 4
• Orthostatic vital signs 4

Role of Diagnostic Testing

Neuroimaging

CT imaging is reserved only for patients where intracranial bleeding is suspected - concussion results from functional rather than structural brain injury 1, 3, 5. Routine neuroimaging is not recommended for uncomplicated concussion 5.

CT scan findings are positive in only 4.7-19% of scanned patients within 24 hours 1, and positive findings correlate with:

• Glasgow Coma Scale score of 13 1
• Post-traumatic amnesia >4 hours 1
• Vomiting 1

Neuropsychological Testing

Neuropsychological testing should be used only as part of comprehensive concussion management, not in isolation 3. Key considerations:

• Most concussions can be managed appropriately without neuropsychological testing 3
• Testing is more sensitive for subtle cognitive impairment than clinical examination alone 3
• Computerized testing must be interpreted by professionals trained in the specific test and its limitations 3
• Comprehensive neuropsychological evaluation is helpful for athletes with persistent symptoms or complicated courses 3
• The ideal timing, frequency, and type of testing have not been determined 3

Biomarkers

There is currently no objective biomarker that definitively diagnoses concussion 2. Limited evidence shows:

• Glasgow Coma Scale score (13-14 vs 15) correlates with serum ubiquitin C-terminal hydrolase within 4 hours 1
• GCS score correlates with glial fibrillary acidic protein breakdown products within 4 hours 1

Critical Timing Considerations

The most reliable diagnostic indicators are present within the first 48 hours post-injury 1, 2. Delayed evaluation may miss critical diagnostic features:

• Balance impairment is most evident within 1 day 1, 2
• Reaction time deficits are most apparent within 2 days 1, 2
• Verbal learning and memory impairment is most detectable within 2 days 1, 2

Most concussion symptoms resolve within 48-72 hours to 10 days 5, 6, though 15-20% develop persistent post-concussion syndrome 7.

Diagnostic Algorithm

1. Immediate assessment (on-field/sideline):

   • Remove from activity immediately 3
   • Assess for disorientation/confusion 1, 2
   • Perform symptom checklist 3
   • Conduct brief cognitive and balance screening 3, 4

2. Within 24 hours:

   • Comprehensive balance testing using BESS or SOT 1, 2
   • Full neurological examination 4
   • Evaluate all five concussion subtypes 1
   • Assess for cervical strain and sleep disturbance 1, 2

3. Within 48 hours:

   • Test reaction time 1, 2
   • Assess verbal learning and memory 1, 2
   • Consider neuropsychological testing if symptoms persist or presentation is complicated 3

4. Ongoing monitoring:

   • Monitor for symptom resolution (typically 48-72 hours to 10 days) 5, 6
   • Reassess if symptoms persist beyond 10 days 7
   • Recognize that predominant subtype may change over time 2

Special Populations

Pediatric Patients

• Children may have more prolonged recovery and are more susceptible to catastrophic injury 3
• Vestibular subtype is as common as headache/migraine in children 1
• Young children require monitoring for signs of excessive body cooling during any cooling interventions 1

Patients with Pre-existing Conditions

Pre-injury mood disorders, learning disorders, ADHD, and migraine headaches complicate diagnosis and management 3. These conditions must be identified during initial assessment as they predict prolonged recovery 3.

Female Athletes

In sports with similar rules, reported concussion incidence is higher in female athletes than male athletes 3, requiring heightened clinical suspicion.