Working Diagnosis:
Sports-related structural brain injury secondary to multicompartment intracranial hemorrhages, cerebral edema, and acute hypoxic ischemic injury.

Treatment:
Emergent placement of an external ventricular drain and a decompressive hemicraniectomy.

Outcome:
Our patient was admitted to the Neuro ICU following a traumatic brain injury sustained during a football game. He experienced a witnessed seizure on the sideline and was found to have intracranial hemorrhage and cerebral edema. He underwent emergent decompressive procedures to reduce intracranial pressures. Despite these interventions, his neurological status failed to improve. His hospital course was further complicated by many episodes of neurostorming and the development of acute respiratory distress syndrome.

After thoughtful discussions and reflection on his clinical trajectory, the family made the difficult decision to transition to palliative care. He passed away one month after the injury.

Author's Comments:
Despite advances in football equipment, intracranial hemorrhages remain a serious concern. Acute subdural hematomas were linked to 86 percent of football-related brain injury fatalities from 1945-1990. Subarachnoid hemorrhages carry a 43 percent mortality rate. 49 percent of athletes with catastrophic brain injuries have lasting deficits and do not return to football. Return to play following burr holes is typically at 6 months, while post-craniotomy guidelines are more conservative, with 40 percent advising low-contact sports. Most importantly, recognizing decorticate posturing is critical as rapid decompression can preserve brain tissue and function.

Editor's Comments:
The sports medicine team on the sideline must be prepared to respond quickly and efficiently to various types of emergencies to minimize the impact on the patient's life. The effects of violent collisions can be reduced by the use of proper helmets, but these are primarily designed to prevent skull fractures. They cannot reduce the acceleration and deceleration forces that have been implicated in concussions and subdural hematomas. Between 2005 and 2014, 26 high school and college football players died from brain injuries, with a rate of 2.6 deaths per year. Of the 22 high school athletes, 4 had a documented concussion within the month prior to their fatal injury, and injury progression was consistent with second impact syndrome in 3 of those athletes. While helmet and equipment technology innovation is extremely important, injury surveillance and research aimed at minimizing the occurrence of potentially devastating injuries must continue to receive equal emphasis.

References:
Kucera KL, Yau RK, Register-Mihalik J, et al. Traumatic brain and spinal cord fatalities among high school and college football players in the United States, 2005 to 2014. MMWR Morb Mortal Wkly Rep. 2017;65:1465-1469. doi:10.15585/mmwr.mm6552a2

Eyenga VC, Esene IN, Bikono EA. Acute subdural hematoma in a footballer following a head-ball of the ball: a rare neurosurgical complication. Egypt J Neurosurg. 2023;38:78. doi:10.1186/s41984-023-00252-7
Available from: https://ejns.springeropen.com/articles/10.1186/s41984-023-00252-7

Mallereau CH, Todeschi J, Lefevre E, Chibbaro S, Proust F, Cebula H. Is physical activity a trigger factor for subarachnoid hemorrhage? Neurochirurgie. 2022;68(3):315-319. doi:10.1016/j.neuchi.2021.06.011
Available from: https://www.sciencedirect.com/science/article/abs/pii/S0028377021001727

Boden BP, Tacchetti RL, Mueller FO, et al. Catastrophic head injuries in high school and college football players. Am J Sports Med. 2007;35(7):1075-1081. doi:10.1177/0363546507299239

Zuckerman SL, Solomon GS, Sills AK. Sport-related structural brain injury and return to play: systematic review and expert insight. Neurosurgery. 2021;88(6):E495-E504. doi:10.1093/neuros/nyab041

Yengo-Kahn AM, Solomon GS, Proctor MR, et al. Sport-related structural brain injury: three cases of subdural hemorrhage in American high school football. World Neurosurg. 2017;106:1055.e5-1055.e11. doi:10.1016/j.wneu.2017.07.072

Return To The Case Studies List.