Cathra Halabi, MD February 14, 2020 Patient Presentation A - - PDF document

Cathra Halabi, MD February 14, 2020 Patient Presentation A 42-year-old man with a history of migraine experienced severe headache, anxiety, and difficulty concentrating. Two months ago, he was involved in a mid-air collision with another athlete during a recreational basketball game. There was no blunt head impact. He felt stunned for several moments, then required assistance while walking to the sideline due to imbalance. He did not play for the rest of the game and was driven home. Over the next 1-2 days, he developed a throbbing headache with nausea and photosensitivity. He presented to his local urgent care clinic and was advised to rest until symptom remission. Despite excessive sleep, he felt fatigued with cognitive fog. He abstained from basketball and any other physical exertion due to symptom exacerbation. He took 1 week off of work as his company’s executive though he worked from home, then returned to a typical

• schedule. Usual activities in the office exacerbated the headaches, requiring frequent

breaks and longer days. He could not focus or multitask though his colleagues did not note significant change. He felt uncharacteristically irritable and emotionally labile which further intensified his distress. He was delivering a routine presentation for his company board, as he had done on a quarterly basis for 10 years, when he suffered a first anxiety

• attack. He was advised by his board to take additional time off.

He again presented to his local urgent care clinic. Subsequent brain MRI without gadolinium was normal. He was referred to a neurologist for persistent headaches. His general examination was normal. On neurological examination, he was embarrassed by tearfulness and subjectively felt unsteady with Romberg and tandem gait maneuvers. In addition, exam maneuvers requiring eye movements prompted discomfort and nausea. He asked if he would ever be able to return to work. He asked if he was developing dementia. A diagnosis was provided and a plan was implemented. References

• 1. Blennow K et al. Nat Rev Dis Primers. 2:16084, 2016.
• 2. Giza CC et al. Neurology. 80:2250, 2013.
• 3. Brody DL. Oxford Press, 2019.
• 4. Gardner RC, Yaffe K. Mol Cell Neurosci. 66:80, 2015.

Cathra Halabi, MD February 14, 2020 Case Discussion The patient likely sustained a concussion during the mid-air collision with his fellow

• teammate. In addition to blunt head trauma (such as from falls or other community

accidents), whiplash, body-checking, and blast injuries from a variety of mechanisms can generate forces that are transmissible to and through the brain, disrupting neurological

• function. Signs and symptoms may be apparent immediately or may emerge over 1-2
• days. A proportion of patients will experience prolonged recovery beyond commonly

quoted timeframes of 1 week to 3 months. The terms concussion and mild traumatic brain injury (mTBI) are often used interchangeably but concussion is considered to be the mildest form of mTBI. Concussion/mTBI may cause a range of debilitating symptoms and functional impairment. The term “persistent post-concussive symptoms” is preferred over “post-concussion syndrome” as the latter may actually reflect alternative diagnoses including exacerbated premorbid medical conditions (such as migraine) and may also include maladaptive perspectives toward recovery. Concussion/mTBI is currently a purely clinical diagnosis. Heterogeneity in clinical manifestations reflect complex pathophysiologic mechanisms and patient-level features including age at time of injury and comorbid conditions or vulnerabilities. In concussion specifically, current clinical neuroimaging modalities yield normal results. Concussion/mTBI is a treatable condition. A systematic, domain-based approach assists the clinician in maintaining organized diagnostic and therapeutic strategies. Individual diagnoses within domains should be considered where possible for targeted treatment (e.g., post-traumatic migraine, exacerbated or de novo anxiety, insomnia). Judicious use

• f diagnostic tools should be tailored to the patient. Tools include neuroimaging,

neuropsychological testing, and serum neuroendocrine studies in appropriate cases. An active recovery approach is favored over prolonged rest. Active recovery approaches include escalating exposures to usual activities and escalating “doses” of subthreshold or threshold aerobic exercise. These strategies should be implemented with guidance from interdisciplinary colleagues such as physical or occupational therapists, since symptom provocation may prevent an individual patient from adhering to treatment plans. Concussion/mTBI has increasingly been linked to elevated risk for developing neurodegenerative disease. There are numerous patient-level factors that affect this risk. Many individuals with neurodegenerative conditions have never sustained a concussion/mTBI, and many individuals with history of concussion/mTBI do not develop neurodegenerative disease. However, it is important to recognize refractory or

progressive neurobehavioral symptoms despite optimal management strategies for prompt referral to the appropriate specialist(s). References

• 1. Blennow K, Brody DL, Kochanek PM, et al: Traumatic brain injuries. Nat Rev Dis
• Primers. 2:16084, 2016.
• 2. Harmon KG, Clugston JR, Dec K, et al: American Medical Society for Sports

Medicine Position Statement on Concussion in Sport. Clin J Sport Med. 29:87, 2019.

• 3. Giza CC, Kutcher JS, Ashwal S, et al: Summary of evidence-based guideline

update: Evaluation and management of concussion in sports: Report of the guideline development subcommittee of the American Academy of Neurology.

• Neurology. 80:2250, 2013.
• 4. Guideline for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms.

Third Edition, 2018. https://braininjuryguidelines.org/concussion/fileadmin/media/adult-concussion- guidelines-3rd-edition.pdf

• 5. Scholten J, Vasterling JJ, Grimes JB. Traumatic brain injury clinical practice

guidelines and best practices from the VA state of the art conference. Brain

• Injury. 31: 1246, 2017.
• 6. Gardner RC, Yaffe K. Epidemiology of mild traumatic brain injury and

neurodegenerative disease. Mol Cell Neurosci. 66:80, 2015.

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Challenging Case

Cathra Halabi, MD

Assistant Clinical Professor of Neurology Founder & Director, Neurorecovery Clinic Neurovascular Division, Department of Neurology Weill Institute for Neurosciences

Financial Disclosures

• None

Case Presentation: Chief Complaint

A 42-year-old man with a history of migraine experienced severe headache, anxiety, and difficulty concentrating.

Case Presentation: HPI

Day 0:

• The patient sustained a mid-air collision with another athlete

during recreational basketball game. No blunt head impact.

• He felt stunned for several moments, then required assistance

while walking to the sideline due to imbalance. Day 0-2:

• The patient developed headache, nausea, photosensitivity.
• He presented to his local urgent care clinic and was advised to

rest until symptom remission.

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Case Presentation: HPI, continued

Day 0-7:

• The patient had excessive sleep, fatigue, cognitive fog.
• There was symptom exacerbation with physical, cognitive, or

emotional exertion. Day 0-14:

• He could not focus or multitask. He felt uncharacteristically

irritable and emotionally labile.

• He had a first ever panic attack during routine, longstanding

activities.

Case Presentation: HPI, continued

Day 35:

• He again presented to local clinic. Imaging was ordered.

Day 39:

• Subsequent brain MRI without gadolinium was normal.
• He was referred to a neurologist for persistent headaches.

Day 56: First neurology evaluation.

Case Presentation: Additional History

Allergies: None. Medications: None. Past Medical History: Migraine. Social History: Executive, avid recreational athlete, no tobacco products, rare alcohol use, no recreational drug use. Family History:

• Migraine (mother)
• Possible undiagnosed anxiety disorder (brother)
• Unspecified learning disability (brother)

Case Presentation: Review of Systems

Review of Systems:

It’s complicated. Stay tuned.

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Case Presentation: Examination

• Vital Signs: Normal.
• General Examination: Normal.
• Neurological Examination: Technically normal.

– MS: Tearful. – CN: Nausea with eye movements. – SENS: Discomfort and unsteadiness with Romberg. – GAIT: Discomfort and unsteadiness with tandem gait.

What is the diagnosis?

• A. Concussion
• B. Post-concussive syndrome
• C. Persistent post-concussive symptoms
• D. Anxiety

Concussion Post-concussive syndrome Persistent post-concussiv... Anxiety

2% 7% 38% 53%

The patient sustained a concussion during the mid-air collision due to transferred force despite absence of head impact. He is experiencing persistent post- concussive symptoms (C), of which anxiety is one.

Definitions: Concussion/mTBI

Ontario Neurotrauma Foundation VA/DoD CPG CDC/ACEP Brain Trauma Foundation AAN Sports Concussion Guidelines ACRM

mTBI involves disruption of brain function due to some external non- penetrating force that is transmitted to the brain. +/- LOC, but if present the duration must be <30 min. (GCS 13-15) Peri-trauma amnesia must be <24 hours. There may be AMS and/or physical symptoms immediately after the index event, sometimes with emergence of impairments within 1-2 days.

Ontario Neurotrauma Foundation VA/DoD CPG CDC/ACEP Brain Trauma Foundation AAN Sports Concussion Guidelines ACRM 2018 2016 2016/2008 2014 2013 1993

Definitions: Concussion/mTBI

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Concussion is a clinical diagnosis. Concussion is a treatable condition.

“Post-concussion syndrome” Recovery Curves Vary

Use the term persistent post-concussive symptoms to more accurately reflect the presentation.

• Immediate:

week 1

• Acute:

week 1-6

• Subacute:

week 7-12

• Chronic:

>12 weeks 10-15% of individuals will experience symptoms chronically.

Review of Systems: it’s complicated

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POST TRAUMATIC HEADACHE COGNITIVE IMPAIRMENT OTHER PAIN MOOD IMPAIRMENT “DIZZINESS” FATIGUE VISION CHANGE SLEEP DISTURBANCE HEARING CHANGE ANOSMIA NEUROENDOCRINE DYSFUNCTION “HISTORY OF PRIORS” POST TRAUMATIC HEADACHE Migraine COGNITIVE IMPAIRMENT OTHER PAIN MOOD IMPAIRMENT “DIZZINESS” FATIGUE VISION CHANGE SLEEP DISTURBANCE HEARING CHANGE ANOSMIA NEUROENDOCRINE DYSFUNCTION “HISTORY OF PRIORS” POST TRAUMATIC HEADACHE Migraine COGNITIVE IMPAIRMENT OTHER PAIN MOOD IMPAIRMENT “DIZZINESS” Vertigo, imbalance, orthostatic sx FATIGUE VISION CHANGE SLEEP DISTURBANCE HEARING CHANGE ANOSMIA NEUROENDOCRINE DYSFUNCTION “HISTORY OF PRIORS” POST TRAUMATIC HEADACHE Migraine COGNITIVE IMPAIRMENT Executive dysfunction, “fog” OTHER PAIN MOOD IMPAIRMENT “DIZZINESS” Vertigo, imbalance, orthostatic sx FATIGUE VISION CHANGE SLEEP DISTURBANCE HEARING CHANGE ANOSMIA NEUROENDOCRINE DYSFUNCTION “HISTORY OF PRIORS”

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POST TRAUMATIC HEADACHE Migraine COGNITIVE IMPAIRMENT Executive dysfunction, “fog” OTHER PAIN MOOD IMPAIRMENT Exacerbated OR de novo “DIZZINESS” Vertigo, imbalance, orthostatic sx FATIGUE VISION CHANGE SLEEP DISTURBANCE HEARING CHANGE ANOSMIA NEUROENDOCRINE DYSFUNCTION “HISTORY OF PRIORS” POST TRAUMATIC HEADACHE Migraine COGNITIVE IMPAIRMENT Executive dysfunction, “fog” OTHER PAIN MOOD IMPAIRMENT Exacerbated OR de novo “DIZZINESS” Vertigo, imbalance, orthostatic sx FATIGUE VISION CHANGE SLEEP DISTURBANCE HEARING CHANGE ANOSMIA NEUROENDOCRINE DYSFUNCTION “HISTORY OF PRIORS”

Brain injury, *HA, mood disorder, learning disability, substance, family history

POST TRAUMATIC HEADACHE

• -Treat specific HA disorder

COGNITIVE IMPAIRMENT

• -Query & address confounders
• -Diagnostics/Consults/Tx PRN

MOOD IMPAIRMENT

• -Query & address confounders
• -Diagnostics/Consults/Tx PRN

“DIZZINESS”

• -Localize then Diagnostics PRN
• -Vestibular PT

GENERAL STRATEGIES Reassurance, education, no EtOH, +exercise POST TRAUMATIC HEADACHE

• -Treat specific HA disorder

COGNITIVE IMPAIRMENT

• -Query & address confounders
• -Diagnostics/Consults/Tx PRN

MOOD IMPAIRMENT

• -Query & address confounders
• -Diagnostics/Consults/Tx PRN

“DIZZINESS”

• -Localize then Diagnostics PRN
• -Vestibular PT

SLEEP DISTURBANCE

• -Sleep hygiene, Consults/Tx PRN

NEUROENDOCRINE DYSFUNCTION [Test at least 6-12 months after injury] GENERAL STRATEGIES Reassurance, education, no EtOH, +exercise

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POST TRAUMATIC HEADACHE COGNITIVE IMPAIRMENT OTHER PAIN MOOD IMPAIRMENT “DIZZINESS” FATIGUE VISION CHANGE SLEEP DISTURBANCE HEARING CHANGE ANOSMIA NEUROENDOCRINE DYSFUNCTION “HISTORY OF PRIORS”

Question: Persistent post-concussive symptoms may be approached by:

• A. Addressing sleep disturbance
• B. Brain MRI and MRA of the head

and neck

• C. Formal neuropsychological

testing

• D. All of the above

A d d r e s s i n g s l e e p d i s t u r b . . . B r a i n M R I a n d M R A

• f

t h . . . F

• r

m a l n e u r

• p

s y c h

• l
• g

i c a . . . A l l

• f

t h e a b

• v

e

25% 73% 2% 0%

mTBI

Time

Out of work/school/play/combat ?Window of vulnerability Persistent symptoms Cognitive impairment Neurodegenerative disease CTE

mTBI

Time

Out of work/school/play/combat ?Window of vulnerability Persistent symptoms Cognitive impairment Neurodegenerative disease CTE

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mTBI +

Time

Cognitive impairment Neurodegenerative disease

Age Cognitive reserve APOE 4, other genes Neuroinflammation Ab Tau *Etc, TBD*

CTE

Practical management strategies

• Acknowledge & reassure
• Diagnose & treat identifiable conditions
• Emphasize importance of active recovery
• Refer to multidisciplinary specialists as needed
• Exercise as ‘dose’ of medication

Our patient

• Acknowledged symptom burden
• Framework for recovery & plan
• Discussed sleep hygiene
• Referred to Physical Therapy:

– Vestibular rehabilitation – Exercise program (e.g., Buffalo protocol)

• Initiated migraine treatment
• Therapy (Plan A) and/or consideration of pharmacologic tx

(Plan A or B) PRN clinical course

• Agreed on short interval follow-up to assess recovery and

need to shift to next strategy. (He did well over the next 1-2 months)

Select references for reading

1. Blennow K, Brody DL, Kochanek PM, et al. Traumatic brain injuries. Nat Rev Dis Primers. 2016; 2:16084. 2. Gardner RC, Yaffe K. Epidemiology of mild traumatic brain injury and neurodegenerative

• disease. Mol Cell Neurosci. 2015; 66:75-80.

3. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is medicine for concussion. Curr Sports Med Rep. 2018;17:262-270. 4. Reams N, Eckner JT, Almeida AA, et al. A clinical approach to the diagnosis of traumatic encephalopathy syndrome: A review. JAMA Neurol. 2016; 73:743-749. 5. Scholten J, Vasterling JJ, Grimes JB. Traumatic brain injury clinical practice guidelines and best practices from the VA state of the art conference. Brain Injury. 2017; 31:1246-1251. 6. Sharp DJ, Jenkins PO. Concussion is confusing us all. Pract Neurol. 2015; 15:172-186. 7. Ventura RE, Balcer LJ, Galetta SL, Rucker JC. Ocular motor assessment in concussion: Current status and future directions. J Neurol Sci. 2016; 361:79-86. 8.

• 5. Guideline for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms. Third

Edition, 2018. https://braininjuryguidelines.org/concussion/index.php?id=155 (Ontario Neurotrauma Foundation) 9. https://www.healthquality.va.gov/guidelines/Rehab/mtbi/mTBICPGFullCPG50821816.pdf (VA/DoD)

• 10. 12. Brody DL. Concussion Care Manual. Second Ed., Oxford Press, 2019.

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Thank You

Cathra Halabi, MD

Assistant Clinical Professor of Neurology Founder & Director, Neurorecovery Clinic Neurovascular Division, Department of Neurology Weill Institute for Neurosciences

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