Working Diagnosis:
Subdural Hematoma
Subarachnoid Hemorrhage

Treatment:
The patient received one-gram bolus of levetiracetam for seizure prophylaxis and continued on 500 mg BID.

Outcome:
The patient was admitted to the pediatric intensive care unit (PICU) for neurologic monitoring and supportive care. On hospital day two, he developed two generalized tonic-clonic seizures, each lasting approximately sixty seconds. The seizures were self-limiting and he did not require any abortive medications. One seizure did result in cyanosis with an SpO2 in the 60's requiring bag-valve-mask ventilation. Levetiracetam dose was increased and he was started on phenytoin. Repeat brain imaging showed stable intracranial pathology.
He remained seizure free and was discharged home on hospital day eight with a seizure prophylaxis regimen consisting of levetiracetam and phenytoin as well as a pain control regimen of oxycodone and gabapentin.
Three weeks post injury he had not yet returned to school due to persistent headaches and concentration difficulties. At that time, he was taking daily narcotics and gabapentin for headache pain control. We had concerns that his headaches at this point were due to analgesic overuse. Therefore, he was instructed to wean of the narcotic pain medication and gabapentin as tolerated until follow up in concussion clinic the following week. At four weeks post injury, the patient had successfully weaned off pain medication within forty-eight hours of his previous visit and was able to return to school. At that time , he had returned to his neurological baseline. He also began implementing physical activity back into his routine under the guidance of a physical therapist. Repeat MRI at this time showed improvement of his SDH and resolution of his SAH. We planed to hold him out of contact and collision sports (i.e. basketball) until four months post injury at which time we repeated an MRI to evaluate for gliosis. There was no evidence of gliosis, however there was dural enhancement consistent with a resolving SDH. At that time, we advised to avoid collision sports until the end of the school year. We advised that he could return to full basketball participation during the summer months. He has remained seizure free during this time period as has been able to wean off of his antiepileptic medications under the guidance of a pediatric neurologist.

Author's Comments:
This case highlights the importance of identifying on the field head injuries of athletes. The risks of second impact syndrome, as this case demonstrates, do occur. This case is also a reminder that overuse of analgesic medications in post-concussive headaches can prolong symptoms. Proper management of athletes with concussions post injury is essential in return to daily activities as well as return to play.

Editor's Comments:
Key points:
1. Highlights the importance of removing from play after concerning head injury and of serial examinations/observation.
2. Narcotics are not generally used in concussion management and may have contributed to prolonged school absence. Weaning off clearly helped the patient.

References:
1) Baandrup L, Jensen R. Chronic post-traumatic headache--a clinical analysis in relation to the International Headache Classification 2nd Edition. Cephalalgia 2005; 25:132.
2) Lane JC, Arciniegas DB. Post-traumatic Headache. Curr Treat Options Neurol 2002; 4:89.
3) Kinnaman KA, Mannix RC, Comstock RD, Meehan WP. Management strategies and medication use for treating paediatric patients with concussions.Acta Paediatr. 2013 Sep;102(9):e424-8

Acknowledgments:
Andrew Peterson, MD

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