Version May 2024
INTRODUCTION — This topic will discuss the clinical manifestations and diagnosis of concussions sustained by children and adolescents. The management of concussions in children and adolescents, the sideline evaluation of concussion, concussions and traumatic brain injury in adults, and postconcussion syndrome are discussed separately:
●(See "Concussion in children and adolescents: Management".)
●(See "Sideline evaluation of concussion".)
●(See "Acute mild traumatic brain injury (concussion) in adults".)
●(See "Postconcussion syndrome".)
DEFINITIONS — Traumatic brain injury (TBI) occurs with head trauma, usually due to contact but also including acceleration/deceleration or rotational forces. Mild TBI is typically defined as a Glasgow Coma Scale (GCS) score of 13 to 15, measured at approximately 30 minutes after the injury or, if longer than 30 minutes, then at initial presentation (table 1), loss of consciousness lasting <30 minutes, post-traumatic amnesia lasting <24 hours, or other transient neurologic abnormalities (eg, seizures or focal signs) [1].
The term "concussion" is often used in the medical literature as a synonym for mild TBI but more specifically describes a pathophysiological state that results in the characteristic symptoms and signs that individuals may experience after a mild TBI. The 2022 Concussion in Sport consensus statement provides components used in clinically defining concussion as follows [2] :
●Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an 'impulsive' force transmitted to the brain.
This injury causes changes in brain metabolism and neurotransmitters that can cause axonal injury, cerebral inflammation, and changes in cerebral blood flow.
●Concussion results in a range of clinical signs and symptoms that may or may not involve loss of consciousness and may be immediate or occur over minutes or hours. Resolution of the clinical and cognitive features follows a sequential course with typical resolution within days. However, recovery can be prolonged.
●No abnormality is seen on standard structural neuroimaging studies (ie, CT or MRI).
●Concussion may occur with but cannot be solely explained by drug, alcohol, or medication use; other injuries such as cervical injuries or peripheral vestibular dysfunction; or other comorbidities such as psychological factors or coexisting medical conditions.
Loss of consciousness in association with concussion does not predict clinical course or long-term cognitive impairment [3-5]. Similarly, the absence of loss of consciousness in a young athlete who has sustained a concussion should not be used to justify more rapid return to play.
Definitions of mild TBI or concussion often do not explicitly require a normal head computed tomography (CT). Some patients who present with mild TBI are found to have significant intracranial abnormalities, including contusion and hemorrhage (subarachnoid, subdural, epidural, or intracerebral), either at presentation or at follow-up. When these are identified, patients are no longer considered to have mild TBI as their primary diagnosis but are more appropriately diagnosed and managed according to the identified lesion (eg, acute subdural hemorrhage). However, such structural injuries can coexist with a concussion. As such, these patients may still be subject to other sequelae of mild TBI.
PATHOPHYSIOLOGY — Animal and human studies demonstrate that concussion results from a rapid rotational acceleration of the brain [6,7]. While most often this rotational acceleration is triggered by a blow to the head, direct impact to the head is not required [3,6,7]. When a concussion is caused by a blow to the head, the location of impact does not appear to correlate with concussion outcomes. As an example, in a national surveillance study of almost 2,000 concussions sustained by high school American football players and reported by athletic trainers, the number of symptoms and duration of concussion was not significantly different regardless of the site of head impact [8]. However, top of the head impact was significantly more likely to cause loss of consciousness than front of the head or side of the head impact (8 versus 3.5 percent).
Rotational acceleration of the brain is hypothesized to cause a shear strain of the underlying neural elements with the following associated and sequential effects [9]:
●Neuronal depolarization – Opening of sodium-potassium channels within the axonal membrane of affected neurons leads to a massive influx of sodium and efflux of potassium. Calcium-dependent release of excitatory amino acids, particularly glutamate, further stimulates potassium efflux. This process results in the effective depolarization of affected neurons, leading to depolarization of downstream neurons, a phenomenon similar to spreading depression [10-13].
●Local lactic acid accumulation – As ionic homeostasis is disrupted, affected neurons are suppressed and cannot fire normal, purposeful action potentials until ionic homeostasis is restored [9-11,14]. Sodium-potassium pumps work to restore homeostasis, a process that requires adenosine triphosphate (ATP). Given the massive degree of the induced ion fluxes, a large amount of ATP is required to operate the sodium-potassium pump. This increased demand for ATP, which is derived ultimately from glucose, results in an increase in glycolysis, leading to local lactic acid accumulation.
●Decreased cerebral blood flow with mismatch of cerebral glucose supply and demand – Concomitantly, there is a decrease in cerebral blood flow for a period of days to weeks after concussion [12,15]. Since glucose is delivered to the brain via the blood stream, the increased demand for glucose and its end product, ATP, go unmet. This supply-demand mismatch is thought to result in the cognitive dysfunction and symptoms of concussion.
Most elements of this hypothesis are derived from an animal model of brain injury known as fluid percussion, in which a craniotomy is performed, a syringe is attached to the skull so that the fluid in the syringe is continuous with the cerebrospinal fluid, and an impact to the plunger of the syringe generates a pressure wave through the brain [9-12]. It is unclear whether the effects caused by fluid percussion can be generalized to those caused by the rapid, rotational acceleration of the brain experienced by athletes suffering sport-related concussions [16,17].
Although shear stress is the leading hypothesis for the pathophysiology of concussion, it is not the only one. A detailed discussion of the proposed pathophysiology of concussion, including the evidence base for competing theories, is provided in the references [18-21].
EPIDEMIOLOGY — Among surveyed United States middle school and high school children, the self-reported lifetime prevalence of concussion is approximately 20 percent [22,23]. The Centers for Disease Control and Prevention report that as many as 3.8 million sport-related traumatic brain injuries occur annually [24]; the vast majority of traumatic brain injuries that occur in sports are concussions [25,26]. Furthermore, a significant proportion of sport-related injuries sustained by athletes of all ages are concussions [27-30]. For example, in a prospective observational study that captured American football injuries from approximately 4000 athlete-seasons for youth, 12,000 athlete-seasons for high school players, and 4300 athlete-seasons for college players, concussions accounted for 4 to 10 percent of all injuries [30]. Among elementary and school-age children, sports and other recreational injuries remain a frequent cause of concussion [31].
The incidence of concussion is highest among boys playing collision sports, such as rugby, American football, ice hockey, and lacrosse [22,23,27,29,32-34]. Among girls, those who participate in soccer, lacrosse, and field hockey have the highest incidences of concussion [27,29]. Concussion also frequently accompanies motor vehicle collisions and injuries sustained during other recreational activities (eg, bicycle riding, skateboarding, ice skating, or skiing) in children and adolescents. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Epidemiology'.)
Since 2000, there has been a dramatic increase in the diagnosis of concussion among pediatric and adolescent athletes in the outpatient and emergency department settings [35-38]. Estimates suggest that sports and recreational activities account for 25 to 50 percent of concussions that report to the emergency department [35,39,40]. Similar increases in the number of concussion diagnoses made by athletic trainers have also been observed [8,41], a fact that is significant since many sport-related concussions are managed by athletic trainers rather than by physicians and other clinicians [27].
Observational studies suggest that the incidence of sport-related concussion is higher for high school and college female athletes than male athletes when sports governed by similar rules for both females and males are compared [34,42-45]. Based on a meta-analysis of 38 studies, girls' soccer and basketball are associated with a higher incidence of sport-related concussion than boys' soccer and basketball [44].
Primary care providers are frequently called upon to care for athletes suffering from sport-related concussions [27,31,46]. As an example, in one observational study of 1056 high school students with sport-related concussions, approximately 60 percent of patients were managed by a primary care physicians and other clinicians, while about 10 percent were managed by a specialist (eg, sports medicine physician, neurosurgeon, or neurologist) [27]. In another study of concussion in children 5 to 11 years of age, the primary care provider performed the initial evaluation in nearly 50 percent of patients [31]. Current estimates suggest that more than 750,000 patients each year are diagnosed in the outpatient setting with minor head injury; more than half of them are children or adolescents [36].
CLINICAL MANIFESTATIONS — Children and adolescents who sustain a concussion may manifest a variety of acute clinical findings. The most common symptoms include (table 2) [8,28,47-50]:
●Headache
●Confusion and disorientation (eg, walking in the wrong direction, not aware of the time, date, or place)
●Difficulties with memory (eg, asking the same question over and over again)
●Blank stare or "stunned" appearance
●Inattentiveness (eg, difficulty following instructions or focusing on a task)
●Slow or incoherent speech
●Dizziness
●Gait abnormalities and imbalance (stumbling, falling)
●Vomiting
●Emotional lability (eg, inappropriate laughing or crying)
Although most studies of clinical findings of concussions in children have focused on adolescents (12 years of age and older), studies performed in children 5 to 11 years of age with concussion indicate similar types and frequency of clinical features [31,51].
Among children four years old and younger, the diagnosis of concussion is challenging because it primarily relies upon parental observation. However, limited evidence suggests that the types and frequency of clinical features may be similar to those of older children including somatic symptoms (eg, vomiting, nausea, or headache), sleeping disturbance, emotional changes, and visio-vestibular symptoms [52]. The diagnosis of concussion in young children requires careful neurologic assessment to avoid missing a clinically important traumatic brain injury. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Evaluation' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'Evaluation'.)
EVALUATION
Approach — Our approach to the evaluation of children and adolescents with a potential mild traumatic brain injury (TBI) is largely consistent with the diagnostic recommendations provided by the Centers for Disease Control and Prevention Pediatric mTBI Guideline and the American Academy of Pediatrics [47,53]. Although this discussion focuses on concussions sustained during sport, the approach to the evaluation of concussion sustained from other types of head trauma is similar, although the severity of symptoms and course of recovery vary. In addition, those not engaged in organized athletics are less likely to have baseline measures from prior to injury. Furthermore, the role of exercise in recovery is largely unexplored in non-athletes.
Preparticipation assessment — Expert consensus regards preparticipation assessment as of "limited use" in children and adolescents because of neurocognitive development and considers it not essential for making most clinical decisions [2].
However, preparticipation assessment is performed by some experts to obtain a baseline against which post-injury measures can be compared to assist in the identification of a potential concussion. For example, the authors find baseline testing most helpful for young athletes participating in collision and contact sports, including American football, soccer, field hockey, ice hockey, and lacrosse. Other experts see a role for selected athletes playing collision sports who have preexisting conditions such as depression, anxiety, learning disorders or previous concussions.
The goal of preseason assessments is to provide baseline measures of the following for each athlete:
●Neurologic examination – These are usually conducted as part of the pre-participation physical examination by a physician, physician assistant, or a nurse practitioner.
●Sideline assessment tools – Although tests vary, most sideline tests include measurements of orientation, symptoms, gross cognition, and physical examination findings (table 3 and table 4).
•Symptom inventories – These measures are derived from age- appropriate sideline concussion instruments and include:
-Post-Concussion Symptom Scale (PCSS) [54]
-Standardized Assessment of Concussion (SAC) (table 3 and table 4) [55-57].
-Post-Concussion Symptom Inventory [58,59]
-Sport Concussion Assessment Tool version 5 SCAT5 and Child SCAT5 [60] or Sport Concussion Assessment Tool version 6 SCAT6 [61] and Child SCAT6 [62] (transition from version 5 to version 6 is in process pending validation of version 6)
•Balance, eg, the Balance Error Scoring System (BESS) – The BESS is useful for detecting the often subtle changes in balance that may occur after sport-related concussions [3,47,63-66]. With the eyes closed, the athletes are asked to do the following on both soft and firm surfaces over 20 seconds with the hands placed on the iliac crests (picture 1):
-Single-leg stance
-Double-leg stance
-Tandem stance
Errors are recorded each time athletes open their eyes, lift their hands off of their iliac crests, stumble, move into greater than 30 degrees of hip flexion or abduction, lift their heel or forefoot, or remain out of position for more than five seconds.
●Neurocognitive function – The 2022 expert consensus statement regards routine baseline assessment of neurocognitive function as of limited use in young athletes because of developmental changes over time [2]. Effective diagnosis and management of concussion in young athletes can be performed without it. Nevertheless, some experts routinely perform baseline testing prior to participation in contact and collision sports for young athletes otherwise at high risk, including those with prior sport-related concussions, because the ability to diagnose and manage a concussion during subacute or office assessment is likely enhanced if a properly performed baseline test is available for comparison. The authors perform longitudinal assessments to account for changes in baseline testing related to neurocognitive development. For a limited number of high-risk patients, we repeat testing every year for ages 5 to 12 and every 2 years for ages 13 to 18. (See 'Follow-up evaluation' below.)
Based upon observational studies and clinical experience, sports concussions have demonstrable negative effects on reaction time, processing speed, attention, and memory [67]. These changes can be detected by traditional neuropsychological and computerized neurocognitive testing with a high degree of validity, especially if properly performed and interpreted baseline results are available.
Furthermore, a large proportion of young athletes with underlying conditions have a symptom burden on baseline testing that would qualify for the diagnosis of mild or moderate concussion after trauma. Thus, having baseline scores in these patients helps to distinguish a concussion from high baseline symptom burden and, in patients who have sustained a concussion, inform management decisions. As an example, in a large observational study of almost 32,000 high school athletes with no concussion in the past six months and who underwent baseline computerized baseline testing, 21 to 47 percent of boys with a prior history of psychiatric illness or migraines and 33 to 72 percent of girls with a prior history of substance abuse, psychiatric illness, or attention deficit disorder with hyperactivity had symptom scores that would meet criteria for prolonged concussion [68]. For patients with these conditions, neurocognitive testing before sports participation provides more information that may help clarify the etiology of symptoms in these patients if a concussion is sustained and assist with proper management.
Thus, many, but not all, sports medicine specialists support preseason baseline neurocognitive testing for young athletes participating in contact sports (eg, basketball, soccer) or collision sports (eg, American football, rugby, lacrosse, or hockey).
Although validity of these tests have been established, many factors affect test outcomes, including the mood and motivation of the athlete, the testing environment, method of administration, concurrent illnesses, and expertise of the person evaluating the results [47,67,69]. Thus, these assessments need to be interpreted by properly trained clinicians.
The following helps ensure validity of these assessments:
•Properly train the clinician performing the preparticipation evaluation.
•Assessments administered at baseline should be the ones that will be used during concussion evaluation including both sideline and subsequent office assessments.
•Perform the assessments in an environment as similar as possible to that in which the post-injury assessments are likely to be performed (eg, on the field or at rink side).
•Document and store assessments securely but with the ability for immediate sideline comparison in an injured athlete (eg, secured laptop or tablet device).
Regardless of the type of baseline testing, an honest effort by athletes is a prerequisite. Athletes who are motivated to remain in the game could intentionally do poorly on baseline testing in an effort to evade clinical detection of subsequent concussion. Obviously, this would put the athlete at risk and undermines the effective clinical relationship of the medical team. Efforts have been made to build internal quality control measures that make this type of "sandbagging" difficult [66]. However, if clinicians administering the tests are not properly trained, such sandbagging may go undetected.
Sideline evaluation — Any potential sign of concussion occurring soon after a head trauma during a sports event should lead to prompt removal of the child or adolescent from competition and further assessment [2,47]. Concussion, unlike many sport-related injuries, is a diagnosis that must be excluded through a negative review of current symptoms and normal examination before return to play. In other words, any athlete being evaluated on the sideline for a suspected concussion must prove to the evaluator that they do not have a concussion. They do so through the absence of symptoms and a normal examination. If there is any doubt, then the child should not return to play until further evaluation confirms or excludes the diagnosis of a concussion. (See "Sideline evaluation of concussion", section on 'Diagnosis'.)
Children and adolescents who sustain a concussion may manifest a variety of acute clinical findings (table 2).The immediate signs and symptoms suggesting a sport-related concussion and the sideline assessment of concussion, including indications for emergency department evaluation, are discussed in greater detail separately. (See "Sideline evaluation of concussion", section on 'Clinical presentation' and "Sideline evaluation of concussion", section on 'Indications for emergency department evaluation'.)
Concussion, unlike many sport-related injuries, is a diagnosis that must be excluded through a negative review of current symptoms and normal examination before return to play. In other words, any athlete being evaluated on the sideline for a suspected concussion must prove to the evaluator that they do not have a concussion. They do so through the absence of symptoms and a normal examination. If there is any doubt, then the child should not return to play until further evaluation confirms or excludes the diagnosis of a concussion. (See "Sideline evaluation of concussion", section on 'Diagnosis'.) When available, some experts use preparticipation baseline scores of cognitive function and balance performance to identify a concussion [47]. Updated testing may be a way to account for ongoing neurocognitive development (eg, every year for ages 5 to 12 and every 2 years for ages 13 to 18 for high-risk athletes) (see 'Preparticipation assessment' above):
●Sport Concussion Assessment Tool version 5 and [60] or Sport Concussion Assessment Tool version 6 SCAT6 [61] and Child SCAT6 [62] (transition from version 5 to version 6 is in process pending development of expert consensus and validation of version 6)
●Standardized Assessment of Concussion (SAC) (table 3 and table 4) [55-57]
●Balance Error Scoring System (BESS) (picture 1) [63,70]
A difference from baseline relative to scores taken after a suspected concussion can support the diagnosis in children with physical findings of concussion. However, these and other scores have not been well validated in children [71]. Even in older adolescents and adults, the sensitivity of standardized examinations can vary widely. Thus, the clinician should not use these assessments as the sole criteria for making the diagnosis of a concussion and should employ all clinical findings [5,67].
When baseline scores are not available, then comparison with typical performance for age on the specific tool may be a reasonable but less accurate substitute [47]. In the absence of baseline testing or when the baseline evaluations are not available for use on the sideline, the clinician must rely on clinical judgement to determine subsequent management decisions.
It may not be possible to make a definitive diagnosis of concussion on the sideline. However, a preliminary clinical diagnosis can generally be made on the basis of the history (including mechanism of injury), symptoms, and examination findings. Further sideline management of athletes with a possible concussion is discussed in detail separately. (See "Sideline evaluation of concussion", section on 'Management'.)
Emergency department evaluation — Patients presenting to the emergency department after a head injury are typically referred because of concerns for conditions other than concussion, primarily cervical spine injury, intracranial hemorrhage, or skull fracture. (See 'History' below and "Sideline evaluation of concussion", section on 'Indications for emergency department evaluation'.)
In addition to performing a history and physical examination to assess the likelihood of concussion as described below, key considerations during acute evaluation of a patient with blunt head trauma include the following:
●Presence of multiple trauma – Evaluation should proceed as for any pediatric trauma patient with rapid identification of any potentially life-threatening injuries (table 5). In most instances, patients with possible concussion will be awake with normal vital signs. (See "Approach to the initially stable child with blunt or penetrating injury", section on 'Head trauma'.)
●Cervical spine assessment – Patients with possible neck injury, including those with neck pain or neurologic symptoms (eg, paresthesias, numbness, or paralysis) should undergo cervical spine motion restriction until injury is excluded clinically or radiographically. (See "Pediatric cervical spinal motion restriction".)
An algorithm for clinical clearance of the cervical spine (algorithm 1) and guidelines for clearance using imaging in the reliable (algorithm 2) and unreliable (algorithm 3) pediatric patient are provided. (See "Evaluation and acute management of cervical spine injuries in children and adolescents".)
Evaluation of athletes with possible neck injury and/or cervical spine injuries is discussed in detail separately. (See "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Evaluation' and "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete".)
●Risk for serious intracranial injury – Clinical findings can categorize children and adolescents into risk categories for intracranial injury, which guide the approach to emergency neuroimaging as follows (see "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'Clinical judgment'):
•High risk – Patients who have any one of the following findings warrant prompt neuroimaging to exclude serious intracranial injuries (eg, epidural hematoma, subdural hematoma, parenchymal hemorrhage, or cerebral contusion):
-Focal neurologic findings
-Skull fracture, especially findings of basilar skull fracture (eg, raccoon eyes, post-auricular hematoma [Battle sign], hemotympanum, otorrhea, or suspected CSF rhinorrhea)
-Seizure
-Persistent alteration in mental status
-Prolonged loss of consciousness (see "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Loss of consciousness' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'Loss of consciousness')
In addition to patient report, eye witness reports or video evidence should also be used to determine if LOC or seizures occurred. However, significant loss of consciousness is unlikely in patients who clearly remember details of the incident. Loss of consciousness, particularly with a duration greater than one minute and concussive seizures are uncommon among children and adolescents with sport-related concussions, occurring in <10 percent and approximately 1 percent of patients, respectively [27-29,72-76]. Thus, young athletes with these findings warrant prompt evaluation for possible intracranial injury.
•Moderate risk – Patients with headache, vomiting, a questionable or brief loss of consciousness, or injury caused by a high-risk mechanism warrant observation to determine if symptoms improve or worsen. Those with worsening symptoms warrant neuroimaging. However, many children or adolescents with suspected concussion will improve during the observation period and not require imaging. (See "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'Clinical judgment'.)
•Low risk – Neuroimaging should be avoided in patients with no loss of consciousness, a normal mental status, no signs of basilar skull fracture, no vomiting, no other concerning factors, and a headache that is improving or responds to oral ibuprofen or acetaminophen (table 6). These children and adolescents are at very low risk for serious intracranial injury. (See "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'Clinical judgment'.)
Patients with signs of serious intracranial injury on physical examination or neuroimaging warrant initial management for severe head injury and prompt involvement of a neurosurgeon with pediatric expertise. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Ongoing management'.)
●Neurologic examination – The patient should undergo a detailed neurologic assessment, including mental status, cognitive functioning, gait, and balance. Cranial nerve, sensory, and motor findings are usually normal in concussed children and adolescents. Any focal neurologic deficits noted on physical examination should prompt the clinician to evaluate for traumatic brain and/or spinal cord injuries. (See "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Neurological assessment' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation".)
All patients suspected of a concussion should undergo assessment of balance and gait to ensure safety prior to discharge. The Balance Error Scoring System (BESS) (picture 1) [63,70] provides a method of performing a standardized assessment of balance. Alternatively, a complex tandem gait (heel-toe tandem gait forwards and backwards with eyes open and then closed) may be used.
Once cervical spine and serious intracranial injury have been excluded by history, physical examination, and, in patients with concerning features, appropriate imaging, the diagnosis of concussion is typically made based upon history and the presence of concussion symptoms that represent a change from baseline. (See 'Diagnosis' below.)
Formal testing with visio-vestibular examination (eg, the vestibular-ocular motor screening examination [VOMS] [77] (movie 1)) or cognitive assessment is time consuming, and we do not routinely use them during the emergency department assessment of children with concussion [53,67]. These assessments may be helpful for selected patients when the diagnosis of concussion is uncertain, especially those who present several days after an injury or who have prolonged concussion symptoms (eg, lasting more than three to four weeks). Visio-vestibular screening also helps identify deficits that are amenable to specific management strategies [31]. (See "Concussion in children and adolescents: Management", section on 'Persistent symptoms'.)
If performed, standardized cognitive testing is most helpful when a preinjury baseline assessment is available for comparison. Specific tools validated for assessment of concussion in children are discussed separately. (See 'Sideline evaluation' above.)
Follow-up evaluation — Clinicians frequently evaluate children and adolescents who have sustained a mild head injury while playing sports or other activities and are asked to make determinations regarding return to school and fitness for play. For most patients, a careful history and physical examination, including the use of child-specific standardized assessments in selected patients can identify those patients with concussion and provide the basis for continued monitoring and rehabilitation.
The approach to physical and cognitive rest as part of the management of a concussion is discussed in detail separately. (See "Concussion in children and adolescents: Management".)
History — Key historical features to identify in children and adolescents with a suspected concussion include:
●Mechanism of injury – The location and force of impact and presence of high-risk mechanisms (eg, double head hit such as a blow to the head during a tackle followed by the head hitting the ground) can assist with predicting symptoms and determining the likelihood that a concussion has occurred. (See "Sideline evaluation of concussion", section on 'Mechanism of injury'.)
●Neurologic symptoms – Although a rare occurrence, the clinician should ask about numbness, tingling, or paralysis at any time after the injury, even if transient. If present, there is a possibility of serious spinal cord injury, including spinal cord injury without radiographic abnormality (SCIWORA). Children with this history warrant cervical spine motion restriction and prompt imaging of the spinal cord. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging'.)
●Symptoms suggesting concussion – The signs and symptoms of concussion in children and adolescents are nonspecific (table 2) [8,28,47-50]. Age-appropriate symptom scales are reliable in children and are recommended by the Centers for Disease Control and Prevention guidelines as diagnostic aids during outpatient evaluation, whenever available [53,67]. We use the Post-Concussion Symptom Scale (PCSS) [54] and the Child SCAT5 [60], which includes the Health and Behavior Inventory. The 2022 Consensus Statement on Concussion Sport has also introduced version 6 of the Sport Concussion Assessment Tool SCAT6 [61] and Child SCAT6 (designed for children ages 8 to 12 years) [62] to be used for assessment in the first 72 hours after a concussion (and up to a week) as well as the Sport Concussion Office Assessment Tool (SCOAT6 [78] and Child SCOAT6 [children ages 8 to 12 years] [2,79]) designed for follow-up assessment at 72 hours and for serial evaluations in the following weeks. Transition from version 5 to version 6 of the SCAT and Child SCAT is in process pending validation of version 6.
●Timing of symptoms – Signs and symptoms of concussion occur soon after the inciting blunt head trauma. For sport-related concussions, the athletes or eye witnesses (eg, coach, family member, or trainer) typically can identify a distinct moment of injury after which their signs and symptoms developed. Although a moment of injury cannot always be recalled, failure to identify such an injury should prompt the clinician to consider other potential etiologies. (See 'Diagnosis' below and 'Differential diagnosis' below.)
●Prior history of head injury or concussions – Children and adolescents with prior concussions may be at increased risk for prolonged postconcussion symptoms and may need more gradual return to activities. (See "Concussion in children and adolescents: Management".)
Physical examination — Important elements of the physical examination for assessing patients with possible concussion are described below. In addition to this assessment, a complete neurologic examination should also be performed as discussed separately. (See "Detailed neurologic assessment of infants and children".)
●Observation – Look closely for signs of disequilibrium and lack of coordination. During the evaluation, be aware of concerning abnormalities such as inattentiveness, confusion, atypical emotionality (eg, crying or laughter that is inappropriate or out of character for the child per the caregiver), or problems following instructions or focusing on a task.
●Memory and attentiveness – After the initial symptom review, assess memory and attentiveness. Deficits in recall and concentration are common with a concussion. This assessment may be done using a brief standardized test when subtle deficits are suspected. We use computerized neurocognitive assessments or the Post-Concussion Symptom Scale (PCSS) [54] and the Child SCAT5 [60], which includes the Health and Behavior Inventory. Standardized cognitive testing is best able to establish the diagnosis of concussion when a preinjury baseline is available. The 2022 Consensus Statement on Concussion Sport has also introduced version 6 of the Sport Concussion Assessment Tool SCAT6 [61] and Child SCAT6 (children ages 8 to 12 years) [62] to be used for assessment in the first 72 hours after a concussion (and up to a week) as well as the Sport Concussion Office Assessment Tool (SCOAT6 [78] and Child SCOAT6 [children ages 8 to 12 years] [2,79]) designed for follow-up assessment at 72 hours and for serial evaluations in the following weeks. Transition from version 5 to version 6 of the SCAT and CHILD SCAT is in process pending validation of version 6. (See 'Preparticipation assessment' above.)
●Visual and-vestibular assessment – Visual and vestibular assessments (movie 1 and table 7) [80] and complex tandem gait (heel-toe tandem gait with eyes open and closed) may be helpful in confirming the diagnosis of a concussion [81]. Expert consensus is that assessment for vestibular-ocular motor symptoms (VOMS) is optional to include with the SCAT6 and Child SCAT6 during concussion assessment [2]. Patients with VOMS are at risk for prolonged symptoms and frequently need academic adjustments at school [31,80]. (See "Concussion in children and adolescents: Management", section on 'Return to learn'.)
●Balance – Balance may be assessed using the Balance Error Scoring System (BESS) (picture 1) or complex tandem gait (heel-toe tandem gait forwards and backwards with eyes open and then closed).
Ancillary studies — Evidence is limited regarding the specific contribution of other studies in establishing the diagnosis of concussion in children and adolescents. In most patients, no additional studies are necessary, and the diagnosis is established based upon clinical findings.
Potential investigations include the following:
●Structural neuroimaging – Because concussion is a disturbance of brain function as opposed to a gross structural injury, structural neuroimaging techniques, such as CT and traditional magnetic resonance imaging (MRI), do not reveal concussive brain injury and should not be routinely performed unless a concern for a structural intracranial injury (eg, subdural or epidural hematoma) exists [2]. (See 'Emergency department evaluation' above.)
Indications for acute neuroimaging for children with minor head trauma are discussed separately. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Approach'.)
Neuroimaging may be appropriate for selected athletes in whom neurologic signs and symptoms (eg, headache or ataxia) are increasing in intensity despite appropriate management, or in whom the symptoms persist beyond the typical time (three to four weeks) for recovery from sport-related concussions. In such patients, MRI is typically performed to avoid radiation exposure. (See "Concussion in children and adolescents: Management", section on 'Worsening symptoms'.)
●Functional MRI and other advanced imaging techniques – In preliminary studies, functional MRI, proton magnetic resonance spectroscopy, and whole brain diffusion tensor imaging have been associated with specific cognitive deficits in children with concussion [82]. As an example, in an observational study of 15 children with concussions who were compared to 15 matched controls, blood-oxygen-level-dependent functional MRI demonstrated significantly reduced task related activity in a variety of brain regions in the concussed patients [83]. However, these techniques are not readily available and require further study to determine their usefulness relative to clinical assessment in evaluating children and adolescents with concussion [82].
●Electrophysiologic recording – Motor evoked potentials, cortical magnetic stimulation, quantitative electroencephalography, and event-related potentials (ERP) show consistent abnormalities in concussed patients based upon small observational studies [67,84]. However, these techniques are not widely available outside of specialized centers and their clinical usefulness is unclear.
●Biomarkers – Serum and cerebral spinal fluid biomarkers (eg, S-100, neuron specific enolase, neurofilament light, tau protein, glial fibrillary acidic protein, and myelin basic protein) have been proposed as a way to detect cellular malfunctioning present in concussion [85]. However, evidence regarding their usefulness is primarily derived from animal and human studies of severe traumatic brain injury. Further study is needed to determine generalizability of those findings to pediatric patients with concussion [85].
DIAGNOSIS — A diagnosis of concussion is based upon the following:
●A history of trauma that results in rapid acceleration of the brain, either direct head trauma or, less commonly, a blow to another part of the body with rapid rotation of the head [3,6,86].
●Onset of signs and symptoms of concussion (table 2) soon after the injury, which represent an acute change from baseline.
●Standardized assessments of symptoms and neurologic examination including age-appropriate symptom scales, balance assessment and neurocognitive function (eg, neuropsychological testing) [5,67].
●Exclusion of structural intracranial injuries (eg, cerebral contusion, subdural hematoma, epidural hematoma, or subarachnoid hemorrhage) by clinical findings and clinical course, with or without neuroimaging.
●In the absence of a clear history of a classic mechanism of injury, exclusion of other medical diagnoses with similar features (table 8). (See 'Emergency department evaluation' above and 'Differential diagnosis' below.)
Physical examination findings using instruments that assess memory and attentiveness such as the SCAT5 or Child SCAT5, the visio-vestibular system (table 7 and movie 1), and balance (tandem gait or Balance Error Scoring System [BESS] (picture 1)) are helpful for confirming the diagnosis of concussion. The 2022 Consensus Statement on Concussion Sport has also introduced version 6 of the Sport Concussion Assessment Tool SCAT6 [61] and Child SCAT6 (for children ages 8 to 12 years) [62] to be used for assessment in the first 72 hours after a concussion (and up to a week) as well as the Sport Concussion Office Assessment Tool (SCOAT6 [78] and Child SCOAT6 [designed for children ages 8 to 12 years] [79]) designed for follow-up assessment at 72 hours and for serial evaluations in the following weeks. Transition from version 5 to version 6 of the SCAT and CHILD SCAT is in process pending validation of version 6 [2]. (See 'Physical examination' above.)
The manifestations of concussion can be obvious or subtle. When subtle, the diagnosis can be challenging. Many pediatric patients are unaware of the symptoms and potential seriousness of concussions and may disguise or hide their symptoms from clinicians. Anticipatory guidance that stresses the importance of identifying concussions to avoid serious brain injury and provides the number and degree of abnormalities on physical examination and/or standardized assessments can frequently convince the patient, their caregivers, and, when applicable, coaches that a concussion has occurred. This feedback lays the groundwork for adhering to treatment, return to school, and return to play recommendations. (See 'Preparticipation assessment' above.)
DIFFERENTIAL DIAGNOSIS — The signs and symptoms of concussion are nonspecific and the presentation is varied (table 2). Thus, care must be taken to ensure an accurate diagnosis. (See 'Diagnosis' above.)
Conditions that may have acute, subacute, or chronic presentations that resemble concussions are provided in the table (table 8).
Acute conditions — When acutely evaluating a child or adolescent with a possible concussion, the clinician should be aware of several life-threatening alternative etiologies that may exhibit similar findings. In patients with a witnessed head trauma, serious intracranial injury is the primary concern. In instances where a definite trauma is not witnessed, patients with acute illness, other than concussion, may be misdiagnosed as having a concussion simply because they participate in contact or collision sports or other activities that place them at risk for concussion.
Intracranial injury — The clinical findings of serious intracranial injury (eg, subdural or epidural hematoma) and concussion overlap. Pediatric patients with prolonged loss of consciousness, seizures, persistent altered mental status, an abnormal neurologic examination, worsening headache, or repeated vomiting are at an increased risk for intracranial injury and usually warrant emergent neuroimaging. (See 'Emergency department evaluation' above.)
Heat illness — Similar to pediatric patients with concussion, children and adolescents with heat illness may have headache, vomiting, confusion, and, in patients with heat stroke, abnormal mental status (table 9). Elevated temperature and signs of dehydration are typically seen in athletes with heat illness, which distinguishes it from concussion. (See "Heat stroke in children", section on 'Clinical features'.)
Hypoglycemia — Children and adolescents with hypoglycemia may feel weak, hungry, and sweaty. As blood glucose continues to fall, they may develop agitation, confusion, and altered mental status, which may mimic a concussion. Insulin dependent diabetic patients are at greatest risk during athletic competition or other exertion. Any patient with persistent or worsening altered mental status warrants measurement of a rapid blood glucose. Clinical findings and initial emergent management of hypoglycemia is provided in the rapid overview (table 10). (See "Approach to hypoglycemia in infants and children".)
Dehydration — While severe dehydration with altered mental status is rare in athletes or otherwise active children, patients with mild to moderate dehydration may develop headache, nausea, and vasovagal or orthostatic syncope. Furthermore, a crossover study of 24 adult patients that compared euvolemic and dehydrated patients did find that dehydration was associated with visual memory deficits, although performance on the Standardized Assessment of Concussion and the Balance Error Scoring System was not significantly different [87]. Resolution of symptoms with rehydration helps to differentiate dehydration from a concussion. (See "Clinical assessment of hypovolemia (dehydration) in children", section on 'Clinical assessment'.)
Syncope — Syncope or presyncope in association with exercise is concerning for a cardiac etiology (eg, arrhythmia, cardiomyopathy, or structural heart disease) (table 11). In many instances, the patient has a sudden loss of consciousness followed by rapid recovery. Children and adolescents with this history warrant careful history, cardiac examination, and an electrocardiogram. Syncope associated with dehydration and/or change in posture suggests vasovagal or orthostatic syncope. Constitutional findings often seen in patients with concussion, such as confusion, memory deficits, nausea, and headache are relatively uncommon in patients with syncope. (See "Emergency evaluation of syncope in children and adolescents", section on 'Evaluation'.)
Subacute or chronic conditions — Most pediatric patients will recover readily from concussions. However, a significant minority of children and adolescents will have prolonged symptoms. Given the nonspecific nature of concussion symptoms, consideration of alternative diagnoses or potential comorbidities is warranted (table 8). (See "Concussion in children and adolescents: Management", section on 'Prognosis'.)
Primary headache — Headache is the most commonly reported symptom of concussion [28,29,88]. Headache, however, is a nonspecific symptom that can be caused by several other etiologies including cervicogenic (ie, arising from the upper cervical joint or cervical musculature [89,90]), migraine, tension, and other posttraumatic syndromes (eg, occipital neuralgia, temporomandibular joint injury, or dysesthesias associated with a scalp laceration). Furthermore, headaches can also be caused by infection (eg, sinusitis), emotional stress, and many other potential etiologies [89,91]. (See "Headache in children: Approach to evaluation and general management strategies", section on 'Etiology'.)
Given the similar mechanism between whiplash cervical injuries and concussions, cervicogenic headaches and incomplete recovery from concussion can be hard to distinguish. However, tenderness on palpation of the upper cervical spine or lateral musculature and improvement with local measures (eg, padded rigid cervical collar) suggests whiplash as the primary cause.
The diagnosis of primary headache disorders is made clinically, based upon the criteria of the International Headache Society as listed (see "Headache in children: Approach to evaluation and general management strategies", section on 'Clinical presentation' and "Headache in children: Approach to evaluation and general management strategies", section on 'Diagnosis'):
●Migraine headache (table 12) (see "Headache in children: Approach to evaluation and general management strategies", section on 'Migraine')
●Tension-type headache (table 13) (see "Headache in children: Approach to evaluation and general management strategies", section on 'Tension-type headaches')
●Cluster headache (table 14) (see "Headache in children: Approach to evaluation and general management strategies", section on 'Cluster headaches')
The diagnosis of secondary headaches, including those caused by a concussion, depends upon identification of the underlying condition. (See "Headache in children: Approach to evaluation and general management strategies", section on 'Secondary headache'.)
Psychiatric disorder — Psychiatric disorders pose a significant challenge for assessment and diagnosis of sport-related concussion because some athletes report psychiatric symptoms on standardized assessments for concussion at baseline [68,92-96]. Thus, a history of witnessed rotational head trauma with signs and symptoms of concussion soon after the injury are essential to distinguish psychological symptoms arising from concussion from primary disease. In addition, taking a history regarding prior psychiatric disorder, recreational drug use, and accurate baseline testing of psychological symptoms are an important means of determining if behavioral symptoms are new or changed from baseline. (See 'Preparticipation assessment' above.)
The clinician should also monitor previously healthy patients with prolonged symptoms of concussion for signs of psychiatric illness. Concussion can cause significant stress to student athletes, particularly in those cases where recovery is slow. Those who were previously performing at high levels in the classroom and athletic field can be dismayed by the loss of identity while they are asked to institute cognitive and physical rest. Students can also feel distressed by the realization that school work is more difficult to complete, and grades are more difficult to maintain during recovery. In addition, students often feel pressure to keep up on their class work during a busy academic year. The buildup of assignments missed during recovery can be daunting.
Athletes that suffer prolonged recoveries after a concussion also go from consistent exercise to prolonged periods of inactivity. This change in activity alone can result in sleep disruption, irritability, change in appetite, change in body weight, and depressed mood [97-99].
In addition to history and change from known baseline, psychiatric testing or referral is appropriate when psychological symptoms are impeding recovery or when a specific psychiatric disorder is suspected. (See "Concussion in children and adolescents: Management", section on 'Persistent symptoms'.)
The approach to diagnosis of the following disorders that commonly complicate concussion in the young athlete is discussed separately:
●Attention deficit hyperactivity disorder (see "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis", section on 'Diagnosis')
●Depression (see "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Diagnosing depressive disorders')
●Anxiety, acute stress, and posttraumatic stress disorders (see "Anxiety disorders in children and adolescents: Assessment and diagnosis", section on 'Screening and assessment' and "Acute stress disorder in adults: Epidemiology, clinical features, assessment, and diagnosis", section on 'Diagnosis')
Overtraining/burnout — Overtraining with resultant burnout is an important condition in young athletes that may go unrecognized, especially those competing at the elite level [100]. Neuropsychological symptoms of overtraining include sleep disturbance, emotional lability, decreased concentration, and decreased interest in training and competition. Although these symptoms have similarity with those seen in concussed athletes, they tend to develop over time and cannot typically be tied to an identifiable head trauma.
Malingering — Preliminary evidence suggests that some children exaggerate their symptoms after a mild traumatic brain injury. As an example, in a series of 191 patients ages 8 to 17 years who underwent computerized medical symptom validity testing a median of six weeks after mild traumatic brain injury, 12 percent failed the test, indicating feigning or exaggeration of symptoms. In adjusted analysis, test failure was associated with female sex and a preinjury history of anxiety [101]. Thus, school age children with prolonged symptoms after a concussion warrant neuropsychological validity testing to ensure that reported symptoms are truly related to their head injury.
Limited pediatric evidence from case studies indicates that, similar to adults, potential reasons for feigning symptoms after head injury include secondary gain (eg, avoiding school or sports), somatization, and depression [102]. Malingering due to monetary gain from litigation or disability claims initiated by their caregivers (malingering by proxy) has also been reported in children as young as nine years of age [101,103,104].
Uncorrected vision — Any new symptoms of vision problems soon after a head trauma with rotary acceleration are usually due to a concussion. However, based upon our experience, patients with prolonged symptoms of concussion will occasionally improve after vision assessment and correction of refractive errors.
ADDITIONAL RESOURCES — The following resources provide additional educational materials related to concussion and mild traumatic brain injury in children and adolescents:
●Additional educational materials from the Centers for Disease Control and Prevention are available for athletes, parents/primary caregivers, and coaches at Heads Up: Concussion in Youth Sports.
●The Centers for Disease Control and Prevention Pediatric mTBI Guideline, provider tools, and patient and family resources are available here.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Increased intracranial pressure and moderate-to-severe traumatic brain injury" and "Society guideline links: Minor head trauma and concussion" and "Society guideline links: Sports-related concussion".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Concussion in children and teens (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition – From a clinical standpoint, concussion is defined as trauma-induced brain dysfunction without demonstrable structural injury based upon physical examination findings alone or neuroimaging, when indicated. Concussion results from a rapid rotational acceleration of the brain. While most often this rotational acceleration is triggered by a blow to the head, direct impact to the head is not required. (See 'Definitions' above and 'Pathophysiology' above.)
●Preparticipation assessment – Expert consensus regards preparticipation assessment as of "limited use" in child and adolescent athletes and considers it not essential for making most clinical decisions. However, preparticipation assessment is performed by some experts to obtain a baseline against which post-injury measures can be compared to assist in the identification of a potential concussion, primarily for children and adolescents playing collision sports. It may also have a role in patients with preexisting conditions such as depression, anxiety, learning disorders or previous concussions. (See 'Clinical manifestations' above and 'Preparticipation assessment' above.)
In addition to preseason neurologic examination and baseline scores on measures of symptoms (table 4) and balance (picture 1), the authors routinely perform baseline neurocognitive testing in young athletes participating in contact sports but ensure proper administration and interpretation by personnel with appropriate expertise as well as updated assessments to account for neurocognitive development. However, baseline neurocognitive assessment is controversial, particularly with regard to cost effectiveness. (See 'Preparticipation assessment' above.)
●Sideline evaluation – Any potential sign of concussion occurring soon after a head trauma during sports should lead to prompt removal of the child or adolescent from competition and further assessment. (See 'Sideline evaluation' above.)
●Emergency department evaluation – For patients presenting for acute evaluation, key considerations included assessment for multiple traumas, cervical spine injury, signs of serious intracranial injury, and the presence of neurologic deficits. Once cervical spine and serious intracranial injury have been excluded by history, physical examination, and, in patients with concerning features, appropriate imaging, the diagnosis of concussion is typically made based upon history and the presence of concussion symptoms that represent a change from baseline. (See 'Emergency department evaluation' above.)
●Follow-up evaluation – During the follow-up assessment, a careful history and physical examination can identify children and adolescents with concussion and provide the basis for continued monitoring and rehabilitation. Standardized assessments of cognition are helpful to confirm the diagnosis. Some experts also use baseline assessments are available. Visio-vestibular and balance screening, such as the vestibular-ocular motor screening examination (VOMS) (table 7 and movie 1), and complex tandem gait (heel-toe tandem gait with eyes open and closed) may also be helpful in confirming the diagnosis of a concussion. (See 'Follow-up evaluation' above.)
●Diagnosis – A diagnosis of concussion is based upon the following (see 'Diagnosis' above):
•A history of trauma that results in rapid rotational acceleration of the brain, either direct head trauma or less commonly, a blow to another part of the body with rapid rotation of the head.
•Onset of signs and symptoms of concussion (table 2) soon after the injury, which represent an acute change from baseline.
•Standardized assessments of symptoms, visio-vestibular findings, balance, and neurocognitive function (eg, neuropsychological testing).
•Exclusion of structural intracranial injuries (eg, cerebral contusion, subdural hematoma, epidural hematoma, or subarachnoid hemorrhage) by clinical findings and clinical course, with or without neuroimaging.
•In the absence of a clear history of a classic mechanism of injury, exclusion of other medical diagnoses with similar features (table 8). (See 'Emergency department evaluation' above and 'Differential diagnosis' above.)
●Differential diagnosis – Conditions that may resemble concussions are provided in the table (table 8). In patients with a witnessed head trauma, serious intracranial injury is the primary concern. In instances where a definite trauma is not witnessed, patients with acute illness, other than concussion, may be misdiagnosed as having a concussion simply because they participate in contact or collision sports or other activities that place them at risk for concussion. (See 'Differential diagnosis' above and 'Acute conditions' above.)
●Specialty referral – A significant minority of children and adolescents have prolonged recoveries that take longer than the typical 14 to 21 days. Persistent symptoms warrant consideration of alternative diagnoses and potential comorbidities (table 8) and consultation with a concussion specialist. (See 'Subacute or chronic conditions' above and "Concussion in children and adolescents: Management", section on 'Indications for subspecialty referral or consultation'.)
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