Choosing Wisely: Imaging Recommendations for Concussions
Caitlyn C. Mooney, MD
Choosing Wisely is an initiative of the American Board of Internal Medicine and supported by multiple medical societies, including the American Medical Society for Sports Medicine. Each society was asked to contribute five diagnostic tests or treatments that both physicians and patients should question. The highlight for this quarter is the AMSSM’s “number one” recommendation:
Avoid ordering a brain CT or brain MRI to evaluate an acute concussion unless there are progressive neurologic symptoms, focal neurological findings on exam or there is concern for a skull fracture.
The impact that results in a concussion does not cause large structural changes, but rather results in a chemical change in the brain resulting in widespread change of functioning. Thus, a concussion is a clinical diagnosis meaning that there is no current imaging or blood test to diagnose a concussion. Even the most sensitive MRI and CT scanners that are currently available are not able to pick up on the small changes that occur in the brain in concussions. For these reasons imaging is not routinely performed during the assessment. The diagnosis of a concussion should be made by a qualified healthcare professional who is knowledgeable in diagnosing and treating concussions. The diagnosis is based on the athletes reported symptoms as well as a thorough physical exam. Physical exams can be normal following a concussion. A health care provider may order a CT scan of the brain if they are worried about a more severe head injury including a brain bleed or a skull fracture. Immediately following an injury a CT scan is the scan of choice as it is fast, readily available and children do not require sedation to have it done. It can quickly assess for a more serious injury that may need prompt treatment.
CT scans are not routinely done for concussions as they are typically normal, are expensive and expose the patient to a large amount of radiation. Some symptoms that may increase concerns for a more serious injury include worsening headache, seizures, multiple episodes of vomiting, trouble walking, weakness or a neurological exam that points to a disruption of a certain part of the brain. After the initial post injury period if symptoms continue to occur or worsen a MRI may be performed. MRIs can pick up on smaller injuries such as small bleeds, scarring, bruising, structural abnormalities, or pre-existing conditions in the brain that could be affecting the athlete and his/her recovery. Thus the most important thing to do in the case of a concussion is to be evaluated by a healthcare professional familiar with concussions. A professional of this kind will evaluate and manage the care of the athlete to progress him/her towards a safe return to their sport.
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