What Are the Key Elements of an Initial Pediatric Concussion Evaluation?

VANCOUVER—Initial pediatric concussion evaluations provide an opportunity to recognize premorbid conditions that may be exacerbated by the injury; address problems with prior management, such as excessive rest or NSAID overuse; and identify treatment approaches, according to a seminar delivered at the 45th Annual Meeting of the Child Neurology Society.

Neurologists also may decide whether imaging is warranted and note risk factors for prolonged recovery, said Sharief Taraman, MD, Director of the Children’s Concussion Program at Children’s Hospital of Orange County in Orange, California, and Assistant Clinical Professor of Pediatrics at the University of California, Irvine.

Sharief Taraman, MD

Imaging Likely Not Needed

In most cases, a CT scan is not necessary, Dr. Taraman said. He encouraged neurologists to work with their emergency department colleagues to ensure that patients only undergo CT scans when appropriate. His department uses Pediatric Emergency Care Applied Research Network (PECARN) criteria to determine when a CT scan is warranted. Many patients do not have signs of altered mental status in the emergency department, and “there is really no good reason to scan many of these kids,” he said. Patients also typically do not undergo MRI unless “a significant neurologic finding … suggests that there might have been a stronger mechanism of action.”

History taking is a vital component of initial management, and identifying premorbid conditions is a key factor, Dr. Taraman said. “What we have seen is that concussion symptoms act as a magnifying glass. If I have migraine and I get a concussion, my migraine will likely become exacerbated,” he said. Patients may also present for evaluation of concussion but have an alternate diagnosis that better explains their symptoms. For example, Dr. Taraman described a patient who had persistent symptoms following a concussion. “Listening to the story, it was clearly sleep apnea,” he said. The child underwent polysomnography and received continuous positive airway pressure treatment because he had 40 apneas in an hour.

During the evaluation, neurologists can recognize poor initial management of the injury, such as excessive bed rest or removal from activities. NSAID overuse also is a big problem. Emergency departments may tell patients to take ibuprofen every eight hours for five weeks, which can lead to rebound headaches, Dr. Taraman said.

Facilitate Recovery

Recognition of certain symptoms can inform the patient’s prognosis and suggest ways to speed recovery. For example, neurologists should look for vestibular dysfunction or balance problems and decide whether to address these symptoms. Neurologists also should check for and address cervical strain and ocular dysfunction. Treating severe convergence insufficiency or excess may help patients recover faster.

Anxiety and mood disorders suggest a prolonged recovery. Some patients develop adjustment disorder after concussion. “Interestingly, we see that patients who have more severe traumatic brain injury … are unaware of their deficits,” whereas high-functioning patients who feel slightly off perceive their deficits, which “causes a lot of discomfort for them,” he said.

Symptoms from concussions that involve assaults and litigation tend to take longer to resolve. Some patients’ symptoms persist until litigation ends, although typically not due to malingering but rather due to increased psychological stress.

Poor headache control, sleep disturbances, prior concussions, and a history of prolonged concussion recovery are other risk factors for prolonged recovery.

The Sport Concussion Assessment Tool 3 (SCAT3) is a free, standardized way of assessing symptoms. Developed as a sideline assessment tool, the SCAT3 also works well as a symptoms form, Dr. Taraman said. The tool includes a quick cognitive assessment and balance exam, and online video tutorials explain how to perform the assessment. After assessing a patient’s symptoms, including cognition, concentration, balance, and convergence insufficiency, “then you can decide, how … to triage the patient and start managing them.”

—Jake Remaly

Suggested Reading

Bressan S, Romanato S, Mion T, et al. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med. 2012;19(7):801-807.

Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.

Yengo-Kahn AM, Hale AT, Zalneraitis BH, et al. The Sport Concussion Assessment Tool: a systematic review. Neurosurg Focus. 2016;40(4):E6.