Working Diagnosis:
Multiple cerebral microhemorrhages secondary to: Acute concussion, cumulative effects of multiple concussions and possibly hypertension.

Treatment:
ImPACT testing was above baseline. However, neuropsychological testing showed mild to moderate impairments with left hand fine motor speed, complex attention, frontal executive function and delayed memory recall of complex verbal information.

Outcome:
Repeat MRI Case Photo #2 showed persistent microhemorrhages throughout brain parenchyma. Clinically, the athlete continued to demonstrate persistent headaches and depression. The final recommendation was that the athlete be permanently disqualified from playing football or other contact sports.

Author's Comments:
In a study of 20 patients with mild head injury (loss of conciousness less that 20 minutes and Glascow coma scale of 13-15) showed that 20% had "foci of hypointensity compatible with hemorrhagic shear injury on MRI. Conclusion: possible evidence of diffuse axonal injury that may represent the damage underlying the postconcussion syndrome.

Editor's Comments:
Editor: Modern Weng, D.O

It is interesting to note that this patients ImPACT scores were "above baseline" after the injury whereas he was found to have "mild to moderate impairment on neuropsychological testing" These two results seem contradictory. One would think that his ImPact scores would be below baseline if he truly had significant neuropsychological impairment on exam.

There is certainly very little literature on multiple cerebral microhemorrhages and I wonder, as the literature evolves, if there will be a correlation with this condition and chronic traumatic encephalopathy (CTE).

Since the 1920s, it has been known that the repetitive brain trauma associated with boxing may produce a progressive neurological deterioration, originally termed dementia pugilistica, and more recently, chronic traumatic encephalopathy.

Neuropathologically, CTE is characterized by atrophy of the cerebral hemispheres, medial temporal lobe, thalamus, mammillary bodies and brainstem. There is also ventricular dilatation and a fenestrated cavum septum pellucidum. Microscopically, there are extensive tau-immunoreactive neurofibrillary tangles, astrocytic tangles and spindle-shaped and threadlike neurites throughout the brain.

CTE can only be diagnosed at the time of autopsy.

Given that there is an estimated 3 million concussions a year and that there is now literature that correlates multiple concussions to depression and dementia, it is certainly valid, albeit unfortunate, to suspend this athlete's football career.

References:
Handratta V, et al. Neuroimaging findings and brain-behavioral correlates in a former boxer with chronic traumatic brain injury. Neurcase. 2009 Dec 4:1-10.

McKee AC, et al. Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol. 2009 Jul:68(7):709-35.

Guskiewicz KM, et al. Recurrent concussion and risk of depression in retired professional football players. Med Sci Sports Exerc. 2007 Jun:39(6):903-9

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