Working Diagnosis:
Concussion due to rotational body mechanic force and/or ground reaction force

Outcome:
Visual acuity and hearing returned to baseline the following morning. She was evaluated in the office six days later. Her global headache persisted, but the pain had improved to 2/10. She felt slightly off balance, but balance testing was normal. SCAT3 Symptom Severity was improved to 3/132. She successfully returned to competition 12 days after the event.

Author's Comments:
While the vast majority of concussions are caused by direct head trauma, it is important to note the less common mechanisms of injury for concussions, as well. Concussions can potentially occur without direct impact in the setting of acceleration forces on the brain, as suspected in this case. Head injury results from an indirect impact applied to the head and neck when the torso is stopped or accelerated rapidly. The head sustains a combined linear and angular acceleration. It is accepted that these forces cause the brain to move within the skull, causing enough disruption to produce the transient clinical presentation of a concussion.

Editor's Comments:
Learners reviewing this case are encouraged to consider whether they would recommend CT scanning in this case, using the PECARN algorithm (look it up if you don't know what that is). Also one would assume she was quite symptomatic on visual screening with VOMS, which was not reported in this case.

Dix Hallpike Maneuver: The Dix-Hallpike maneuver is the gold standard for diagnosis of benign positional paroxysmal vertigo. The patient begins sitting up, and their head is oriented 45 degrees toward the ear to be tested. The clinician then lies the patient down quickly with their head past the end of the bed and extends their neck 20 degrees below the horizontal, maintaining the initial rotation of the head. The clinician then watches the patient's eyes for torsional and up-beating nystagmus, which should start after a brief delay and persist for no more than one minute. This would indicate a positive test. If the test is negative but clinical suspicion remains high, the patient should be given a chance to recover for at least one minute, and then testing of the other ear can be undertaken. Note, the Dix-Hallpike maneuver should be avoided in a patient with neck pathology, in whom the movements involved could be dangerous to the patient. Cervical instability, vascular problems like vertebrobasilar insufficiency and carotid sinus syncope, acute neck trauma and cervical disc prolapse are absolute contraindications.

References:
A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings.Am J Sports Med. 2014 Oct;42(10):2479-86. doi: 10.1177/0363546514543775.

PECARN algorithm

Talmud JD, Dulebohn, SC. Dix Hallpike Maneuver. Stat Pearls, Sat Pearls Publishing 2018. Bookshelf ID: NBK459307PMID: 29083696

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