concussions in high school; and a new blood test to diagnose concussions

​MMWR just published an assessment of self-reported concussions from playing sports or being physically active in high school students in the US (see https://www.cdc.gov/mmwr/volumes/67/wr/mm6724a3.htm?s_cid=mm6724a3_w )

Details:

--in an attempt to get better data, the CDC looked at the 2017 national US  Youth  Risk Behavior Survey (a bienneial, cross-sectional school-based survey, which now includes a question about concussion), since much of the medical data (eg from EDs) miss untreated concussions and much of the high-school athlete data miss concussions sustained outside of school-based sports

--during the 12 months before the survey, the number of students with at least one concussion overall was 15.1% (which translates of about 2.5 million), 13% among females and 17.1% in males. this decreased by grade (surprisingly to me, in reverse order: 17% grade 9; 15.2% grade 10; 15.3% grade 11; 12.2% grade 12

--similar numbers by race/ethnicity, but 21.4% who played at least one team sport had at least one concussion vs 5.6% if not. and the more team sports, the more concussions (up to 30.3% of those on 3 or more sports teams)

--by numbers of concussions in the past 12 months:

    --1: 9.1% (8% female/10.2% male, and still most in 9th grade)

    --2: 3.0% (2.6% female/3.3% male)

    --3: 1.0% (0.8% femlae/1.2% male)

    ​-->3: 2.0% (1.5% female/2.4% male) [Black and Hispanic students were more likely to report >3 concussions]

Commentary:

--high school athletes have an increased susceptibility to concussions and longer recovery times, vs older athletes

--and, continuing to play with a concussions seems to increase the risk fo subsequent and more serious concussions

    --one concern is that a study of high school students found that 40% reported that their coaches were unaware of their symptoms [and may well have continued to play with concussions]

--there are the obvious limitations of this data: it is self-reported and not validated (though self-report is probably a strength as well), and does not apply to non-high school students

so, this is a huge problem. Millions of kids get concussions, with their potential complications (cognitive, affective, behavioral changes...), at an age where they take longer to recover, and when much of their future is determined (ie, if they don't do well in school, they have an even harder uphill battle in life). and, this has broader social effects, especially with this very large number of kids. the report appropriately emphasizes fostering a culture of safety explicitly addressing concussion prevention and management; educating students, parents, coaches, and health care providers about the risks of concussions; and identifying programs, policies and practices to prevent concussions.  i would add that perhaps some sports themselves should be eliminated, or at least modified in order to reduce concussion risk (and, for example, the use of bicycle helmets has been shown to help)...

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and, speaking of concussions, the FDA just authorized the marketing of a blood test to evaluate concussions, also known as mild traumatic brain injury (mTBI) in adults. see https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm596531.htm

Details:

--the Brain Trauma Indicator is a measurement of 2 protreins: UCH-L1 (Ubiquitin C-terminal Hydrolase-L1) and GFAP (Glial Fibrillary Acidic Protein) that are released from the brain into the blood and need to be measured within 12 hours of head injury

--a multi-center prospective clnical study of 1947 individual blood samples from adults suspected of mTBI found:

    --the test predicted the presence of CT-documented intracranial lesions in 97.5%

    --it predicted the absence of CT-documented intracranial lesions in 99.6%

Commentary:

--it seems that this test is quite good at ruling-out intracranial lesions when the test is negative

--test results can be available within 3-4 hours of being ordered

--in 2013 there were 2.8 million TBI-related ED visits, hospitalizations or deaths (50,000 TBI-related deaths); 75% of these injuries were considered mild (ie, concussions), most with negative CT scans

--the use of this blood test would be expected to decrease the need for CT scans in a least on-third of patients suspected of having a concussion, reducing radiation exposure

geoff

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