Working Diagnosis:
Acute subdural hematoma (ASDH) with midline shift seen on CT brain.

Treatment:
The patient was given 1500 mg of Keppra for seizure prophylaxis, head of bed elevated, cervical collar removed to decrease ICP and initiated on nicardipine drip with preparation for neurosurgical intervention. Emergent decompressive hemicraniectomy and evacuation performed with correction patient's midline shift Case Photo #2 . Patient received two units of fresh frozen plasma intra-operatively given an elevated ACT greater than 140.

No intra- or post-operative complications were noted and the patient was extubated safely after surgery on post-operative day one. Patient was ambulating and eating without difficulty thus discharged home safely on post-operative day two. One-month post-operative CT brain showed continued improvement with no active hemorrhage thus cranioplasty performed without complications.

Outcome:
The patient gradually increased physical activity as tolerated and took a medical exemption from school for the remainder of the fall semester. At three months post-injury, the patient was cleared by neurosurgery to drive and discontinue Keppra. He tolerated free-weight and light cardiovascular activities without difficulty but refrained from Olympic powerlifting and football. He returned to classes at full capacity with plans to graduate in Spring 2022.

Author's Comments:
Although more commonly seen in high school football athletes, the most common cause of catastrophic head injury in collegiate football are acute subdural hematomas (ASDH) (1, 2). Presenting symptoms vary, including levels of consciousness, pain symptoms, and oculomotor findings (3). Cushing's triad of bradycardia, irregular respirations, and widened pulse pressure (>100) is associated with intracranial hypertension and can indicate herniation thus reflecting the potential need for neurosurgical intervention (4).
ASDH in sport settings can mirror epidural hematomas with their "lucid window" and symptoms can differ from the acute trauma setting in other patient demographics, including less severe headache or delayed pain symptoms (5, 6).
Prompt neurological examination should be performed with low-threshold to initiation of the emergency action plan (EAP) when signs of cervical spine damage or traumatic brain injury is present (7). Studies suggest that prompt evaluation of traumatic subdural hematomas result in decreased morbidity and mortality (8). The specific time frame remains unclear, with some reports associating improved mortality with evaluation within the "golden hour" following traumatic brain injury (9), whereas other studies suggest there is no association between the promptness of evaluation and outcome improvement (10).
If a patient is to require neurosurgical intervention, point of care measurements of activated clotting time (ACT) can help identify the need for prophylactic platelet, plasma, and cryoprecipitate to avoid intra- and post-operative coagulopathy complications (11).
Once all post-operative imaging show improvement and resolution, discussion of return to play protocol can be discussed. Serious discussion on avoiding further contact sports with high risk for repeat concussion or brain injury should be considered, even with complete resolution of symptoms (12).

Editor's Comments:
This case highlights the need to be vigilant for acute subdural hematomas in athletes who suffer head trauma. Mortality ranges from 36% to 79% (13). While the athlete in this case had a positive outcome, patients who experience an acute subdural hematoma can have prolonged or permanent sequelae including memory loss, slurred speech, paralysis, blindness, seizures, personality changes, hearing loss, or spasticity (13).

References:
1. Boden BP, Tacchetti RL, Cantu RC, Knowles SB, Mueller FO. Catastrophic head injuries in high school and college
football players. Am J Sports Med. 2007 Jul;35(7):1075-81. doi: 10.1177/0363546507299239. Epub 2007 Mar 9.
PMID: 17351124.
2. Nagahiro S, Mizobuchi Y. Current topics in sports-related head injuries: a review. Neurol Med Chir (Tokyo).
2014;54(11):878-86. doi: 10.2176/nmc.ra.2014-0224. Epub 2014 Oct 31. PMID: 25367588; PMCID: PMC4533345.
3. Bailes JE, Hudson V. Classification of Sport-Related Head Trauma: A Spectrum of Mild to Severe Injury. J Athl Train.
2001 Sep;36(3):236-243. PMID: 12937490; PMCID: PMC155412.
4. Yumoto, Tetsuya et al. "Cushing's sign and severe traumatic brain injury in children after blunt trauma: a nationwide
retrospective cohort study in Japan." BMJ open vol. 8,3 e020781. 3 Mar. 2018, doi:10.1136/bmjopen-2017-020781
5. Forbes JA, Zuckerman S, Abla AA, Mocco J, Bode K, Eads T. Biomechanics of subdural hemorrhage in American
football: review of the literature in response to rise in incidence. Childs Nerv Syst. 2014 Feb;30(2):197-203. doi:
10.1007/s00381-013-2318-y. Epub 2013 Nov 17. PMID: 24240553.
6. Lloyd J, Conidi F. Brain injury in sports. J Neurosurg. 2016 Mar;124(3):667-74. doi: 10.3171/2014.11.JNS141742.
Epub 2015 Oct 16. PMID: 26473777.
7. Grozenski A, Zadell J, Kiel J, Parsons M. Delayed Presentation of an Acute Traumatic Subdural Hematoma in a High
School Football Quarterback. Curr Sports Med Rep. 2021 Jan 1;20(1):16-18. doi: 10.1249/JSR.0000000000000797.
PMID: 33395126.
8. Walcott BP, Khanna A, Kwon CS, Phillips HW, Nahed BV, Coumans JV. Time interval to surgery and outcomes
following the surgical treatment of acute traumatic subdural hematoma. J Clin Neurosci. 2014 Dec;21(12):2107-11.
doi: 10.1016/j.jocn.2014.05.016. Epub 2014 Jul 24. PMID: 25065950; PMCID: PMC4250331.
9. Tien HC, Jung V, Pinto R, Mainprize T, Scales DC, Rizoli SB. Reducing time-to-treatment decreases mortality of
trauma patients with acute subdural hematoma. Ann Surg. 2011 Jun;253(6):1178-83. doi:
10.1097/SLA.0b013e318217e339. PMID: 21494125.
10.Newgard CD, Meier EN, Bulger EM, Buick J, Sheehan K, Lin S, Minei JP, Barnes-Mackey RA, Brasel K; ROC
Investigators. Revisiting the "Golden Hour": An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain
Injury. Ann Emerg Med. 2015 Jul;66(1):30-41, 41.e1-3. doi: 10.1016/j.annemergmed.2014.12.004. Epub 2015 Jan 14.
PMID: 25596960; PMCID: PMC4478150.
11.Moore HB, Moore EE, Chin TL, Gonzalez E, Chapman MP, Walker CB, Sauaia A, Banerjee A. Activated clotting time
of thrombelastography (T-ACT) predicts early postinjury blood component transfusion beyond plasma. Surgery. 2014
Sep;156(3):564-9. doi: 10.1016/j.surg.2014.04.017. Epub 2014 Jun 2. PMID: 24882760; PMCID: PMC4150844.
12.Mizobuchi Y, Nagahiro S. A Review of Sport-Related Head Injuries. Korean J Neurotrauma. 2016 Apr;12(1):1-5. doi:
10.13004/kjnt.2016.12.1.1. Epub 2016 Apr 30. PMID: 27182494; PMCID: PMC4866563.
13. Grozenski, Andrew MD; Zadell, Jesse MD; Kiel, John DO, MPH, CAQ-SM; Parsons, Melissa MD Delayed Presentation of an Acute Traumatic Subdural Hematoma in a High School Football Quarterback, Current Sports Medicine Reports: January 2021 - Volume 20 - Issue 1 - p 16-18 doi: 10.1249/JSR.0000000000000797.

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