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Brain Injury Can Hide Behind ‘Normal’ CT Scan

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Brain injuries may not show up on CT scans. If a child or adolescent suffers persistent, long-lasting, severe headaches after a blow to the head, he or she likely has suffered traumatic brain injury, even if a CT scan appears normal.

So conclude the authors of a scary article published online Tuesday in Journal of Neurosurgery: Pediatrics. The article reports on a case of second impact syndrome (SIS), a condition whose very existence is the subject of dispute.

SIS, says the article, “is a rare, often fatal traumatic brain injury that occurs when a repeat injury is sustained before symptoms of a previous head injury have resolved.” The specific case involved a 17-year-old high school football player. The article doesn’t identify him, but his name is Cody Lehe (pronounced LAY-hee). In October 2006, he was the captain of the Frontier High School football team in Chalmers, Indiana.

On a punt return during a game, Lehe sustained a helmet-to-helmet hit that left him dizzy. He played the remaining 15 minutes of the game but complained of fatigue and persistent headaches over the next several days. Four days after the game, he visited a doctor. Results of a physical exam and  CT scan both appeared normal. The doctor advised him to avoid football practice until the headaches ended.

Instead, Lehe returned to practice that afternoon. His mother, quoted a year afterward in the Cumberland Times-News of Cumberland, Maryland, recalled:

He said he played with worse headaches and took harder hits than that. He was the captain. He was not about to stand on the sidelines just because of a headache. It was his life.

It was almost his death. That practice was uneventful, but the following day, during hitting drills, Lehe collapsed and suffered a seizure. At a local emergency department and then at a trauma and neurosurgical center at Indiana University Health Methodist Hospital in Indianapolis, CT scans revealed bilateral subdural hematomas and mild swelling of the brain. An MRI showed additional abnormalities.

The scans disproved a theory that SIS results from massive brain swelling. Instead, they supported the supposition that it results from hyperemia—excessive blood flow in the brain. Persistent severe headache seems to be the main symptom. Why SIS seems confined almost exclusively to children and adolescents and why it’s so rare remain unresolved questions.

After 98 days in hospitals, Lehe returned home, unable to speak or walk. More than six years later, he can talk but still suffers from speech, cognitive, and physical impairment and uses a wheelchair. (A video here shows him four years post-injury.)

Article co-author Michael Turner, MD, a pediatric neurosurgeon at Goodman Campbell Brain and Spine in Indianapolis, said the lesson of the study was “that there must not be a return to play if the athlete is at all symptomatic.” Dr. Turner, quoted in a Journal of Neurosurgery Publishing Group news release, cautioned:

A normal CT scan will not identify a player who can be released to play.

Related seminar: UCSF Neuro and Musculoskeletal Imaging

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