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Management of Concussion

The management of concussion has three crucial considerations. First, immediate neurologic emergencies must be identified. Second, the devastating scenario of second-impact syndrome must be prevented, and the risk of recurrent concussive episodes should be minimized.

Finally, the cumulative effects of repeated concussion, which may lead to CTBI, must be avoided. The identification of neurologic emergencies may be possible with a careful patient history and physical examination, but algorithms to prevent second-impact syndrome, recurrent MTBI, and CTBI remain ill-defined.

Current guidelines for concussion management are based on parameters that lack a rigorous, evidence-based foundation. This results, in large part, from a traditional lack of markers to diagnose the severity of brain injury or to prognosticate recovery. At this time, which of the signs and symptoms of concussion predict the most ominous outcome is unclear.

Recent research, for example, has disputed the commonly held assumption that loss of consciousness is the most severe symptom of concussion.As such, much research has been directed toward identifying empirical markers of recovery from concussion. A goal of this research is to determine the acute recovery curves for specific signs and symptoms that occur with concussion.

The movement toward evidence based concussion management with a foundation of more empirical markers includes the use of standardized assessment of concussion scoring forms, neuropsychological testing, and functional MRI. The correlation between symptoms and markers such as neuropsychological function as well as the relationship between neurocognitive function, postconcussive symptoms, and chronic sequelae remain unknown.

For example, recent work has demonstrated the persistence of neurocognitive derangement in the setting of postconcussive patients who are free of symptoms. However, it is difficult to generalize the results of these studies, because there may be different recovery patterns and risks in different age groups and patient populations. Thus, the clinical application of this emerging data remains unclear.

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