New imaging findings
Physicians at Indiana University School of Medicine and the Northwest Radiology Network (Indianapolis, Indiana) report the case of a 17-year-old high school football player with second impact syndrome (SIS). A rare and devastating traumatic brain injury, SIS occurs when a person, most often a teenager, sustains a second head injury before recovery from an earlier head injury is complete. To the best of the authors' knowledge, this is the first reported case in which imaging studies were performed after both injuries, adding new knowledge of the event. Findings in this case are reported and discussed in "Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Case report," by Elizabeth Weinstein, M.D., and colleagues, published today online, ahead of print, in the Journal of Neurosurgery: Pediatrics.
The patient sustained the first injury when he received a helmet-to-helmet hit from an opposing player during a punt return. Despite immediate symptoms of dizziness and visual disturbance, he continued to play in the game. For the next few days he experienced severe headaches and fatigue. Four days after the game, he consulted a doctor about the headaches. Computerized tomography (CT) scans of the patient's head appeared normal, but he was advised not to return to play until all of his symptoms were gone. The young man chose instead to return to practice immediately.
The following day, despite complaints of headache and difficulty with concentration, the young man participated in hitting drills. After a few hits he was slow standing up, and after several more hits he collapsed, became unresponsive, and suffered a seizure. He was transferred initially to a local emergency department, where a CT examination revealed small, thin subdural hematomas on each side of the brain. The patient received intubation and was treated medically. Shortly thereafter he was airlifted to a tertiary trauma and neurosurgical center at Indiana University Health Methodist Hospital in Indianapolis.
At the tertiary center, the patient was found to be minimally responsive and to have increased intracranial pressure (25-30 mm Hg; normal 5-15 mm Hg). Additional CT scans obtained there confirmed the presence of the subdural hematomas and mild cerebral swelling. Magnetic resonance images of the brain and upper spinal cord showed downward herniation of the brain, subdural hematomas on both sides of the brain, and abnormal diffusion in the medial left thalamus. Structures in the vicinity of the brain's midline, including the thalamus and hypothalamus, had shifted downward. There did not seem to be any blood vessel damage or spinal cord injury. The MR images did not detect cerebral edema.
The patient's injury involved other serious consequences identified during the hospital stay, including prolonged elevated intracranial pressure, areas of brain softening (in both thalami, the medial frontal lobes, and elsewhere), hypotension, renal failure, sepsis, pneumonia, and temporary cardiac arrest. Even with optimal care, the patient remained in the hospital for 98 days and was unable to walk or talk when he was discharged. Three years later, he has regained much of his speech but is very impulsive and is confined to a wheel chair.