Neuropsychological Effects
of Head Trauma in College
Athletes
Anthony C. Santucci, Ph.D.
Manhattanville College
Purchase, NY
Outline of Talk
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Brief review of neuroanatomy
Sources of brain damage
Collisions in sports
Effects of collisions on the brain
Concussions
Description of recent study from my lab
Anatomy of a Neuron
Microstructure of a Neuron
Meninges of the Brain
Midline View of the Brain
Sources of Brain Damage
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Vascular Accident (“stroke”)
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Hemorrhage – bleeding in the brain
Infarct – brain damage due to deprivation of blood
supply resulting from vascular constriction or
obstruction (i.e., ischemia)
Diseases
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Progressive neurodegenerative disorders
(Alzheimer’s, Pick’s, or Parkinson’s disease)
Viral infection (e.g., spongiform encephalopathy)
Sources of Brain Damage (con’t)
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Penetrating Wounds or Open-Head
Injuries (e.g., gunshot, metal rod impalement,
etc.; often are “sharp force trauma”)
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Genetic Abnormalities (e.g., Huntington’s
disease, etc.)
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Tumors (e.g., glioma, meningioma, etc.)
Closed Head Injuries (i.e., Diffuse Axonal
Injury -- axonal shearing; rotational/gravitational
force -- “whiplash,” or contusions caused by
“blunt force trauma”)
Definition of Closed Head Injury
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Closed Head Injuries: biomechanical
deformation of brain tissue
Closed Head Injuries can be caused by:
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a foreign object concussing the head, i.e., blunt force
trauma or “collision” (e.g., with another person’s head
or body, hit by ball)
the head being concussed against a rigid object, i.e.,
blunt force trauma (e.g., goal post, boards, etc.), or
the head being subjected to a sudden & severe
rotational and/or gravitational force (e.g., “whiplash”);
most likely cause of Diffuse Axonal Injury (DAI) in
traumatic brain injury
Brain Vasculature as it Relates
to Head Trauma
Bridging Veins
Collisions in Contact Sports
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Participating in contact sports, especially
football, ice hockey, gymnastics, wrestling, &
boxing, makes one vulnerable to a closed head
injury especially that derived from collisions
(e.g., football causes approximately minor head
injuries in approximately 20% of its participants
[Cantu, 1998]).
Collisions involving the head in sports can occur
in a variety of ways including…
Head-to-Ground
Head-to-Elbow
Back-to-Ground (reverberation)
Head-to-Ground
Head-to-Shoulder
Head-to-Body
“Heading”
Top-to-Ground
(compression)
Head-to-Head
Front-to-Side
Front-to-Top
Top-to-Side
Front-to-Front
Blunt Force Trauma-Induced
Contusions
Extensive blunt force trauma
sustained in a vehicle accident
The cerebral crest is
especially vulnerable to
damage caused by blunt
force trauma
Fall-induced blunt force trauma causing contra coup injury
Hematomas
Subdural hematoma
Epidural hematoma
Subarachnoid hematoma from contra coup injury
Diffuse Cerebral Edema
(i.e., swelling)
Edema producing widened
gyri and narrower sulci
Acute closed cranial cavity edema producing
herniation (pushing through) of the hippocampus
Boxing & Diffuse Cerebral Edema
Edema
Neurocascade Events are Evidenced by Impact Trauma
Schematic Courtesy of UCLA’s Brain Research Institute
Rotational & Gravitational Force Injuries
Diffuse Axonal Injury
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DAI frequently results from sudden accelerationdeceleration impact that produces rotational
forces, most often causing white matter lesions
DAI produces an anatomic & metabolic cascade:
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→ shearing of axons → edema → axoplasmic leakage
→ disruption of axonal transport → degeneration of the
axon → neuron death
DAI is often undervisualized using current brain
imaging techniques
DAI is a frequent cause of persistent vegetative
state & morbidity
MRI scan demonstrating multiple foci of damage signal at the graywhite matter junction (arrow) and within the corpus callosum in a
patient with DAI.
MRI scan demonstrating numerous small focal hemorrhages
(arrows) consistent with DAI.
Noncontrast CT scan of a trauma patient with multiple petechial
(pinpoint) hemorrhages (arrows) consistent with DAI.
Other Possible Effects
Produced by Collisions
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Second-impact syndrome (SIS)
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Occurs when a second concussion is sustained while the athlete
is still symptomatic and healing from a previous concussion. The
second injury may occur from days to weeks following the first.
Loss of consciousness is not required. The second impact is
more likely to cause brain swelling and other widespread
damage, and can be fatal. (Note, some authors contend this
syndrome is the result of complications derived from Diffuse
Cerebral Edema and, as such, should not be classified as a
separate medical condition.)
Intra-cerebral hemorrhage
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Bleeding that occurs within the brain that can affect neurological
and mental functioning
Effects of Concussions
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Posttraumatic amnesia (anterograde amnesia)
Retrograde amnesia
Mental Confusion & Disorientation
Headache
Nausea/Vomiting
Visual disturbance (blurred vision, double vision)
Dizziness
Slurred speech
Drowsiness
Loss of Consciousness
Problem of Defining Concussion
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There is no widely accepted definition of
concussion, especially that of Postconcussion
Syndrome i.e., residual effects of concussion)
Committee of Head Injury Nomenclature of the
Congress of Neurological Surgeons:
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“Concussion is a clinical syndrome characterized by
immediate & transient post-traumatic impairment of
neural functions, such as alteration of consciousness,
disturbances of vision, equilibrium, etc. due to
brainstem involvement.”
However, other definitions exists:
Other Definitions of
Concussion
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Other definitions are based on:
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Duration of unconsciousness
Duration of post-traumatic amnesia
Cantu (1986) based his definition on both
duration of unconsciousness or amnesia
Cantu (1986) (adapted from Cantu, 1998)
Grade
Grade 1
(mild)
Loss of
Consciousness
Duration of
Amnesia
None
Less than 30
minutes
Grade 2
(moderate)
Less than 5
minutes
or
Grade 3
(severe)
5 minutes or
greater
or
30 minutes
or greater
but less than
24 hr
24 hr or
more
American Academy of
Neurology
AAN defines concussion as a "alteration of mental
status due to a biomechanical force affecting the
brain." The AAN definition does not require a loss of
consciousness. The AAN guidelines, break down
concussion into three grades:
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Grade 1: Transient confusion; NO loss of consciousness;
symptoms clear in less than 15 minutes.
Grade 2: Transient confusion; NO loss of consciousness;
Concussion symptoms or mental status abnormalities last
longer than 15 minutes.
Grade 3: Any loss of consciousness, either brief (seconds) or
prolonged (minutes).
5-Grade Classification System (athleticadvisor.com)
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Grade 0
 results when the head is struck or moved rapidly;
characterized by a post injury headache and difficulty with
concentration
Grade 1
 athlete appears stunned; no loss of consciousness (LOC);
sensory difficulties resolve < 1min; “bell-rung”
Grade 2
 characterized by headache; cloudy senses > I min but no
LOC; tinnitus, amnesia, irritability, confusion, or dizziness
may be present
Grade 3
 LOC < 1 min; not comatose; same symptoms as grade 2
Grade 4
 Grade 4 concussions are characterized by LOC of greater
than one minute. The athlete will not be comatose, and will
also exhibit the symptoms of the grade 2 and 3
concussions
Return-to-Play Decisions
(Cantu, 1998)
Severity
Grade 1
Number of Concussion Sustained
First
Second
Third
May return if
asymptomatic for
1 week
May return after 2
weeks if
asymptomatic for
at least 1 week
Grade 2
Return after being Wait at least 1
asymptomatic for month; may return
1 week
then if
asymptomatic for 1
week; consider
terminating season
Grade 3
Wait at least 1
month; may return
if asymptomatic
for 1 week
Terminate season;
may return next
year if
asymptomatic
Terminate
season; may
return next year if
asymptomatic
Terminate
season; may
return next year if
asymptomatic
Alternate 3-Grade Return-to-Play System
(Familypracticenotebook.com)
I. Grade 1
A.First Grade 1 Concussion
1.Return to play if asymptomatic for 15-20 minutes
B.Second Grade 1 Concussion
1.Requires formal examination by medical doctor
2.Return to play if asymptomatic for 1 week
C.Third Grade I Concussion
1.Terminate season
D.Requires formal examination by medical doctor
II. Grade 2
A.First Grade 2 Concussion
1.Requires formal examination by medical doctor
2.Return to play if asymptomatic for 1 week
B.Second Grade 2 Concussion
1.Return to play if asymptomatic for 1 month
C.Third Grade 2 Concussion
1.Terminate Season
III. Grade 3
A.First Grade 3 Concussion
1.Urgent neurological exam hospital ER
2.Consider head CT
3.Return to play guidelines
a.No participation for one month minimum
b.May return to play if asymptomatic for 1-2 weeks
B.Second Grade 3 Concussion
1.Terminate Season
C.Third Grade 3 Concussion
1.Terminate Sport
Rationale for Study
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Head trauma sufficiently severe enough to
produce a diagnosable concussion would be
associated with changes in neuropsychological
function, especially that within the memory
domain
Assessed whether such neuropsychological
alterations would be dependent upon:
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Severity & frequency of concussion
Time since concussion
Method
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Participants
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UG participants in contact sports [lacrosse, soccer,
ice hockey, &/or field hockey] with either:
 A recent history of concussion (< 2 yrs) (N=5;
3M,2F)
 A non-recent history of concussion (> 2 yrs) (N=6;
3M,3F)
 No history of concussion (N=9; 6M,3F)
UGs who did not participate in a contact sport and
who had no history of concussion (N=8; 5M,3F)
Participant Demographics
Materials & Procedure
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General Concussion Reference Form
Subject Questionnaire Form
Repeatable Battery for the Assessment of
Neuropsychological Status (RBANS;
Randolph, 1998)
Postconcussion Syndrome Checklist
Stroop Task
Materials & Procedure (con’t)
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RBANS
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Uses standardized norms to assess five cognitive
domains:
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IMMEDIATE MEMORY
DELAYED MEMORY
VISUOCONSTRUCTIONAL/SPATIAL ABILITY
LANGUAGE
ATTENTION
Each sub-scale score contributes to an OVERAL
TOTAL SCORE
Results on the RBANS
Results on the Stroop Test
Correlation Matrix for the two
Athlete Concussed Groups
PostConcussion # of Yrs Since
Checklist
Last Concussion
Attention
-.65*
Delayed
Memory
Total
-.61*
-.59*
+.53#
Immediate
Memory
*p < .05; #p = .10
Correlation Matrix for the
Athlete/Recent Concussed Group
PostConcussion
Checklist
Delayed
Memory
Severity/
Frequency of
Head Injury
-.90*
+.90*
Processing
Speed on
Stroop
*p < .05
Conculsions
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Recent heady injury is associated with
alterations in neuropsychological function,
especially that which lie in the memory domain
These neuropsychological effects appears to
resolve with time
Provocatively, participation in contact sports may
produce sub-clinical cognitive impairments in the
absence of a diagnosable concussion
presumably resulting from the cumulative effects
of multiple mild brain trauma
Limitations to the Research
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Small N
Did not include football athletes
Used UGs at a Division-III school
Relied on self-report data for concussion
information
Did not have pre-injury data
Used only one neuropsychological test
Future Research
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We are presently looking more closely at whether
concussed athletes show changes:
 In EEG waves, esp. within the frontal and
temporal lobes
 In spatial memory with altering levels of task
difficulty
 On another neuropsychological test, this time
assessing solely attention (d2 Test of Attention)
Thank You