Working Diagnosis:
Stable, mild, post-traumatic encephalomalacia of the bilateral parietal lobe. Case Photo #3

Treatment:
The Sports Medicine team and pediatric neurologist recommend limited, as needed medication management, cranial osteopathic manipulative treatment, acupuncture, and alleviation of life stressors. Follow-up with the pediatric neurologist and further surveillance were advised.

Outcome:
The pediatric neurologist concluded that there was no contraindication to participation in non-contact sports, but recommended against football, a contact sport. The Sports Medicine team had not medically cleared the athlete for Division I football at this time. The decision was complicated due to a lack of clear, evidence-based guidance. More research is needed to establish guidelines.

Author's Comments:
This case focuses primarily on preparticipation exam clearance as opposed to the management of post-traumatic encephalomalacia. ImPACT testing and neuropsychological testing were not performed but are indicated and recommended. Neuroimaging abnormality is infrequently seen in athletes with a history of sport-related concussion. There is insufficient evidence at present (United States Preventive Services Task Force Grade I) for routine screening (or imaging) for post-traumatic encephalomalacia. More research is needed to see if screening athletes with a history of sport-related concussion for post-traumatic encephalomalacia would be beneficial.

This case uniquely calls attention to the fact that there is currently no written consensus on the clearance status of any collegiate-level athlete with mild lasting brain abnormalities on advanced imaging related to sport-related concussion with normal clinical presentation, and emphasizes the need for further research. It is the job of the Sports Medicine team to protect the athlete and to make decisions regarding participation status that will take into account the overall health of the athlete during the athletic career and thereafter.

Editor's Comments:
Encephalomalacia is the softening or loss of brain tissue after cerebral trauma including injury, ischemia, and infection. Stigmata of traumatic brain injury associated with concussion on MRI, when present, usually occurs in areas prone to coup-contrecoup forces such as the frontal lobe, anterior temporal lobe, and the occipital pole. The fluid-attenuated inversion recovery (FLAIR) MRI is the most sensitive sequence in detecting traumatic lesions. Focal areas of encephalomalacia are not thought to progress but may serve as a nidus for seizure activity. A formal neuropsychological evaluation can assist the team physician in elucidating any cognitive deficits related to the history of several concussions and mild abnormalities found on MRI.

References:
Bigler ED, Abildskov TJ, Goodrich-Hunsaker NJ, Black G, Christensen ZP, Huff T, Wood, Dawn-Marie G, Hesselink JR, Wilde EA, Max JE. Sports Medicine and Arthroscopy Review. Structural Neuroimaging Findings in Mild Traumatic Brain Injury. 2016;24(3):e42-e52

Castellani RJ, Smith M, Bailey K, Perry G, Dejong JL. Neuropathology in Consecutive Forensic Consultation Cases with a History of Remote Traumatic Brain Injury. J of Alzheimer’s Disease. 2019;72(3):683-691

Ellis MJ, Leiter J, Hall T, et al. Neuroimaging Findings in Pediatric Sports-Related Concussion. J Neurosurg Pediatr. 2015;16:241-247

Morgan CD, Zuckerman SL, King LE, et al. Post-concussion syndrome (PCS) in A Youth Population: Defining the Diagnostic Value and Cost-Utility of Brain Imaging. Childs Nerv Syst. 2015;31:2305-2309

9 1/2 Need-to-Know Facts About Traumatic Brain Injury. Accessed on July 8, 2020 at https://www.brainline.org/article/9-12-need-know-facts-about-traumatic-brain-injury

AOASM Virtual CME Conference presentation May 1, 2020 [photo 3]

Sethi NK. Neuroimaging in contact sports: Determining brain fitness before and after a bout. S Afr J Sports Med. 2017;29:1-4

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