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Loss of Consciousness: Pathophysiology and Implications in Grading and Safe Return To Play
Loss of Consciousness: Pathophysiology and Implications in Grading and Safe Return To Play
James P. Kelly, MD, provided conception and design; analysis and interpretation of the data; and drafting, critical revision, and
final approval of the article.
Address correspondence to James P. Kelly, MD, Chicago Neurological Institute, 233 East Erie Street, Suite 704, Chicago, IL
60611. Address e-mail to jpk070@northwestern.edu.
Objective: To provide historical background and current con- Conclusions/Recommendations: The observation of LOC
cepts regarding the importance of loss of consciousness (LOC) at the time of concussion must be viewed as reflecting a po-
in the evaluation of concussion and athletes. tentially worrisome traumatic brain injury. LOC is followed by
Data Sources: A MEDLINE search identified scientific and more severe acute mental status abnormalities and carries a
clinical articles on sport concussion management published greater risk of intracranial pathology than concussion without
from 1966 to present. Discussions were held with authors of LOC. Prolonged LOC represents a neurologic emergency,
selected reports. Recent research findings reported at national
which may require neurosurgical intervention. Lingering symp-
meetings were reviewed.
Data Synthesis: The relative importance of LOC in the eval- toms of concussion, even without LOC, should be monitored
uation of concussion was reviewed in light of scientific and clin- closely and managed according to established guidelines for
ical evidence in the literature. Comments made by authors of safe return to play.
concussion grading scales were considered in the development Key Words: concussion, mild traumatic brain injury, sport
of expert consensus statements. concussion guidelines
D
oes an athlete’s loss of consciousness (LOC) affect the and also for some span of time thereafter, before an awareness
management of sport-related concussion? Increasing of the surroundings and events returns (Figure). A brief period
attention surrounds the issue of concussion in sports of memory loss or retrograde amnesia is common following
and recreation in the medical literature,1 as evidenced by the LOC and sometimes occurs even without LOC.4
devotion of this entire issue of the Journal of Athletic Training Concussion is diagnosed by determining what actually hap-
to the topic. I will attempt to address the question, ‘‘In mild pened to the individual’s brain function at the time of the in-
traumatic brain injury (MTBI), or more specifically, sport-re- jury.2 This diagnosis is not made by neuroimaging studies,
lated cerebral concussion, what is the importance of LOC?’’ such as computed tomography (CT) scanning or magnetic res-
It is important to correct a common misconception that con- onance imaging (MRI) scanning, nor is it made by neuropsy-
cussion only occurs if an individual is rendered unconscious. chological testing performed days or weeks later. The exami-
Health care professionals know that concussions often occur nation of the athlete at the time of the injury or detailed
without LOC—especially in the world of athletics.2 Tempo- accounts of the signs and symptoms at the time of the injury
rary confusion or even a permanent gap in memory (posttrau- are much more valuable in formulating a diagnosis of con-
matic amnesia or PTA) can occur without LOC.3 This is true cussion. In the sport setting, eyewitness reports or videotape
for concussion that occurs in any setting, not only in sports evidence of the injury are often available and helpful in the
and recreation. While the focus of this article is concussion neurologic assessment of the athlete.
during athletic activity, any past medical history of concussion
outside the sports arena must be considered when health care
Pathophysiology of Loss of Consciousness
professionals make decisions regarding return to participation
in sports. It is important to distinguish between unconsciousness from
When an individual sustains a concussion with amnesia, he a neurologic cause and other uses of the term ‘‘unconscious-
or she often later assumes that there was a LOC; however, it ness’’ in psychology or philosophy. Whereas psychological
is important for the health care professional to determine unconsciousness refers to a state of unawareness or repressed
whether LOC actually occurred. An individual who has am- ideas,5 neurologic unconsciousness is paralytic coma.6 This
nesia associated with the injury cannot observe himself or her- neurologic state represents a form of brain dysfunction in-
self and is, by definition, an unreliable historian regarding the volving either the hemispheres or the deep structures of the
event itself. Anyone rendered unconscious also has an asso- brain (including the reticular activating system, which governs
ciated amnesia, both for the period of time while unconscious sleep and wake cycles7), or both. In the neurologic uncon-
Cantu (1986)40 No loss of consciousness, post- Loss of consciousness ,5 min- Loss of consciousness .5 min-
traumatic amnesia ,30 min- utes or posttraumatic amnesia utes or posttraumatic amnesia
utes of 30 minutes to 24 hours .24 hours
Colorado (1991)38,39 Confusion without amnesia, no Confusion with amnesia, no loss Loss of consciousness
loss of consciousness of consciousness
American Academy of Neurology Transient confusion, no loss of Transient confusion, no loss of Any loss of consciousness (brief
(1997)41 consciousness, concussion consciousness, concussion or prolonged)
symptoms ,15 minutes symptoms .15 minutes
*Reprinted with permission.