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Second-Impact Syndrome

An extremely rare but life-threatening consequence of premature return-to-play is the second-impact syndrome. This occurs when an athlete who has not completely recovered from an initial concussive event sustains a second head trauma.

The second event may be relatively minor, but a catastrophic increase in intracranial pressure can occur because of dysregulation of cerebral blood flow, which can result in vascular engorgement, cerebellar herniation, and death.

The clinical scenario of this syndrome is unique: The athlete may appear to be stunned and often does not lose consciousness. Within seconds to minutes, the patient collapses, becomes semicomatose, and develops dilated pupils as well as evidence of respiratory failure. Demise occurs much more quickly than in patients with intracranial hemorrhage syndromes. The mortality rate for this condition is approximately 50%, and the morbidity rate is nearly 100%.

At present, at least 17 deaths have been reported as a result of second-impact syndrome. In each case, athletes returned to sports before full resolution of their symptoms. Second-impact syndrome has been shown to occur up to 2 weeks postinjury and is thought to occur most often in athletes younger than 21 years of age.

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