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Concussion , from the Latin concutere ("to shake violently") or the Latin concussus ("action of striking together"), is the most common type of traumatic brain injury. The terms mild brain injury , mild traumatic brain injury ( MTBI ), mild head injury ( MHI ), and minor head trauma and concussion may be used interchangeably, although the latter is often treated as a narrower category. The term "concussion" has been used for centuries and is still commonly used in sports medicine, while 'MTBI' is a technical term used more commonly nowadays in general medical contexts. Frequently defined as a head injury with a transient loss of brain function, concussion can cause a variety of physical, cognitive, and emotional symptoms.

Treatment of concussion involves monitoring and rest. Symptoms usually go away entirely within three weeks, though they may persist, or complications may occur. Repeated concussions can cause cumulative brain damage such as dementia pugilistica or severe complications such as second-impact syndrome.

Due to factors such as widely varying definitions and possible underreporting of concussion, the rate at which it occurs annually is not known; however it may be more than 6 per 1,000 people. Common causes include sports injuries, bicycle accidents, car accidents, and falls; the latter two are the most frequent causes among adults. Concussion may be caused by a blow to the head, or by acceleration forces without a direct impact. The forces involved disrupt cellular processes in the brain for days or weeks. On the battlefield, MTBI is a potential consequence of nearby explosions.

It is not known whether the concussed brain is structurally damaged the way it is in other types of brain injury (albeit to a lesser extent) or whether concussion mainly entails a loss of function with physiological but not structural changes. Cellular damage has reportedly been found in concussed brains, but it may have been due to artifacts from the studies. A debate about whether structural damage exists in concussion has raged for centuries and is ongoing.

Classification

No single definition of concussion, mild head injury, or mild traumatic brain injury is universally accepted, though a variety of definitions have been offered. In 2001, the first International Symposium on Concussion in Sport was organized by the International Olympic Committee Medical Commission and other sports federations. A group of experts called the Concussion in Sport Group met there and defined concussion as "a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces." They agreed that concussion typically involves temporary impairment of neurological function which quickly resolves by itself, and that neuroimaging normally shows no gross structural changes to the brain as the result of the condition.

According to the classic definition, no structural brain damage occurs in concussion; it is a functional state, meaning that symptoms are caused primarily by temporary biochemical changes in neurons, taking place for example at their cell membranes and synapses. However, in recent years researchers have included injuries in which structural damage does occur under the rubric of concussion. According to the National Institute for Health and Clinical Excellence definition, concussion may involve a physiological or physical disruption in the brain's synapses.

Definitions of mild traumatic brain injury (M.T.B.I) have been inconsistent since the 1970s, but the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10) described MTBI-related conditions in 1992, providing a consistent, authoritative definition across specialties. In 1993, the American Congress of Rehabilitation Medicine defined MTBI as 30 minutes or fewer of loss of consciousness (LOC), 24 hours or fewer of post-traumatic amnesia (PTA), and a Glasgow Coma Scale (GCS) score of at least 13. In 1994, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined MTBI using PTA and LOC. Other definitions of MTBI incorporate focal neurological deficit and altered mental status, in addition to PTA and GCS.

Concussion falls under the classification of mild TBI. It is not clear whether concussion is implied in mild brain injury or mild head injury. "MTBI" and "concussion" are often treated as synonyms in medical literature. However, other injuries such as intracranial hemorrhages (e.g. intra-axial hematoma, epidural hematoma, and subdural hematoma) are not necessarily precluded in MTBI or mild head injury, but they are in concussion. MTBI associated with abnormal neuroimaging may be considered "complicated MTBI". "Concussion" can be considered to imply a state in which brain function is temporarily impaired and "MTBI" to imply a pathophysiological state, but in practice few researchers and clinicians distinguish between the terms. Descriptions of the condition, including the severity and the area of the brain affected, are now used more often than "concussion" in clinical neurology.

Although the term "concussion" is still used in sports literature as interchangeable with "MHI" or "MTBI", the general clinical medical literature now uses "MTBI" instead.

Controversy exists about whether the definition of concussion should include only those injuries in which loss of consciousness occurs. Historically, concussion by definition involved a loss of consciousness, but the definition has changed over time to include a change in consciousness, such as amnesia. The best-known concussion grading scales count head injuries in which loss of consciousness does not occur to be mild concussions and those in which it does to be more severe.

Grading systems

Main article: Concussion grading systems

At least 41 systems exist to measure the severity, or grade, of a mild head injury, and there is little agreement among professionals about which is the best. Several of the systems use loss of consciousness and amnesia as the primary determinants of the severity of the concussion.

The decision about when to allow athletes to return to contact sports is frequently based on the grade of concussion. Injured athletes are prohibited from returning to play before they are symptom-free during rest and exertion and their neuropsychological tests are normal again, in order to avoid a risk of cumulative effects.

Three grading systems are followed most widely: one was developed by Robert Cantu, one by the Colorado Medical Society, and a third by the American Academy of Neurology. Each divides concussion into three grades, as summarized in the following table:

Signs and symptoms

Concussion can be associated with a variety of symptoms, which typically occur rapidly after the injury. Early symptoms usually subside within days or weeks. The number and type of symptoms a person suffers varies widely.

Physical

Headache is the most common MTBI symptom. Other symptoms include dizziness, vomiting, nausea, lack of motor coordination, difficulty balancing, or other problems with movement or sensation. Visual symptoms include light sensitivity, seeing bright lights, blurred vision, and double vision. Tinnitus, or a ringing in the ears, is also commonly reported. In one in about seventy concussions, concussive convulsions occur, but these are not actual post-traumatic seizures and are not predictive of post-traumatic epilepsy, which results from structural brain damage. Concussive convulsions are thought to result from temporary loss of brain function rather than from structural damage and are usually associated with a good outcome.

Cognitive and emotional

Cognitive symptoms include confusion, disorientation, and difficulty focusing attention. Loss of consciousness may occur but is not necessarily correlated with the severity of the concussion if it is brief. Post-traumatic amnesia, in which the person cannot remember events leading up to the injury or after it, or both, is a hallmark of concussion. Confusion, another concussion hallmark, may be present immediately or may develop over several minutes. A patient may, for example, repeatedly ask the same questions, be slow to respond to questions or directions, have a vacant stare, or have slurred or incoherent speech. Other MTBI symptoms include changes in sleeping patterns and difficulty with reasoning, concentrating, and performing everyday activities.

Affective results of concussion include crankiness, loss of interest in favorite activities or items, tearfulness, and displays of emotion that are inappropriate to the situation. Common symptoms in concussed children include restlessness, lethargy, and irritability.

Mechanism

The brain is surrounded by cerebrospinal fluid, one of the functions of which is to protect it from light trauma, but more severe impacts or the forces associated with rapid acceleration may not be absorbed by this cushion. Concussion may be caused by impact forces, in which the head strikes or is struck by something, or impulsive forces, in which the head moves without itself being subject to blunt trauma (for example, when the chest hits something and the head snaps forward).

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