A concussion is a traumatic brain injury caused by a bump, blow or jolt that causes the head and brain to move rapidly back and forth.1 This sudden movement can make the brain bounce or twist within the skull, creating chemical changes and damaging brain cells.1 Concussion signs and symptoms include loss of consciousness, amnesia, clumsiness, nausea or vomiting, light or noise sensitivity, headache and confusion.2 Concussions are common sports injuries; according to estimates by the Centers for Disease Control and Prevention (CDC), an estimated 1.6 to 3.8 million sports- and recreation-related concussions occur in the United States each year.3 Lack of proper diagnosis or poor management of a concussion can result in long-term consequences, including coma or death.4 Some patients may need urgent or elective surgery immediately after a concussion, which can be complicated given the stress associated with any procedure.5 Anesthesia providers should be especially cautious with patients who have had a recent concussion diagnosis, as a concussed brain may be particularly vulnerable.6 In order to give the best care to their patients, anesthesiology practitioners need to understand the complexities of concussion, the problems surgery might pose to a concussed patient and the anesthesia provider’s role.
Concussion refers to the functional issues of a mild traumatic brain injury (mTBI).6 The diagnosis of a concussion can be difficult, as brain imaging after mTBI is usually nondiagnostic, nonpredictive and nonspecific for concussion.6 Though the majority of concussion symptoms, such as headache, resolve within one week, patients who have suffered a previous concussion may not show such a quick recovery.7 Additionally, post-concussive symptoms such as dizziness, fatigue, anxiety and cognitive deficits can result in functional impairment and societal costs extending months after the initial injury.7 These extended symptoms may be due to profound brain changes after concussion.6 Immediately after the head injury, the brain’s metabolic rate increases.6 Then, in the hours, days and weeks following a concussion, the brain enters a state of increased blood flow, reduced metabolism, altered vascular responsiveness and dysfunctional neuronal axon activity.6 Evidence suggests that even after signs and symptoms of a concussion subside, cerebral physiology may remain altered for months.6
Because the brain is vulnerable right after a concussion, clinicians recommend cognitive and physical rest as part of the treatment regimen.6 This includes minimized physical activity; reduction of reading, social visits and video games; and avoidance of significant decision making.6 The need for surgery after a concussion may interfere with these requirements.5 After all, the perioperative period involves a variety of physical and cognitive demands, including exposure to foreign environments, meeting multiple new people, answering questions, making important decisions, bright lights, physical transfers, pain, medications and altered sleep.6 Thus, clinicians may need to balance the time sensitivity of a surgery with the potential dangers of overstimulation after a concussion.5,8
Anesthesiology practitioners in particular should be cautious when administering anesthesia soon after a patient’s concussion.9 A review by Tasker states that the effects of anesthetic agents on the autonomic nervous system and on cerebrovascular reactivity to carbon dioxide could further alter the brain’s post-concussive state.9 Abcejo et al. found that anesthesia use is common in patients after a concussion, and clinicians may need to alter their anesthesia practice to avoid potential injury in these patients.10 Though the data are limited on proper anesthetic practices in patients with altered cerebral physiology,7,11 a review by King and Collins-Yoder shows that anesthesia providers should pay special attention to mean arterial pressures and partial CO2 pressure in concussed patients.11 Furthermore, while D’Souza et al. found no differences in intraoperative and postoperative outcomes between patients with recent concussion and control patients,12 Ferrari et al. and Sheshadri et al. emphasize the lack of literature on long-term outcomes of anesthesia after concussion.8,13 Until the evidence base is better established, Vavilala et al. recommend deferring anesthesia use in post-concussive patients until physical restrictions are lifted.7
Concussion is a serious condition resulting in long-term physiological brain changes. Because surgery can be physically and cognitively stressful, it poses challenges to a patient who was recently concussed. Anesthesia providers need to be especially careful when caring for post-concussive patients, as the cerebral changes from anesthesia may cause further injury to the patient’s vulnerable brain. More research is needed on best practices in anesthesia for concussed patients and the long-term outcomes of anesthesia after concussion.
1. Centers for Disease Control and Prevention. What Is a Concussion? Heads Up February 12, 2019; https://www.cdc.gov/headsup/basics/concussion_whatis.html.
2. Centers for Disease Control and Prevention. Concussion Signs and Symptoms. Heads Up February 12, 2019; https://www.cdc.gov/headsup/basics/concussion_symptoms.html.
3. Daneshvar DH, Nowinski CJ, McKee AC, Cantu RC. The Epidemiology of Sport-Related Concussion. Clinics in Sports Medicine. 2011;30(1):1–17.
4. Brain Injury Research Institute. What is a Concussion? Information and Research 2020; http://www.protectthebrain.org/Brain-Injury-Research/What-is-a-Concussion-.aspx.
5. Rasouli MR, Kavin M, Stache S, Mahla ME, Schwenk ES. Anesthesia for the patient with recently diagnosed concussion: Think about the brain! Korean Journal of Anesthesiology. July 1, 2019.
6. Abcejo AS, Pasternak JJ. Is a Concussed Brain a Vulnerable Brain? Anesthesia after Concussion. Anesthesia Patient Safety Foundation. October 2018;33(2).
7. Vavilala MS, Ferrari LR, Herring SA. Perioperative Care of the Concussed Patient: Making the Case for Defining Best Anesthesia Care. Anesthesia & Analgesia. 2017;125(3):1053–1055.
8. Ferrari LR, O’Brien MJ, Taylor AM, et al. Concussion in pediatric surgical patients scheduled for time-sensitive surgical procedures. Journal of Concussion. 2017;1:1–8.
9. Tasker RC. Anesthesia and concussion. Current Opinion in Anesthesiology. 2017;30(3):343–348.
10. Abcejo AS, Savica R, Lanier WL, Pasternak JJ. Exposure to Surgery and Anesthesia After Concussion Due to Mild Traumatic Brain Injury. Mayo Clinic Proceedings. 2017;92(7):1042–1052.
11. King D, Collins-Yoder A. Perioperative Considerations in Patients With Concussion. AANA Journal. 2019;87(2):97–104.
12. D’Souza RS, Sexton MA, Schulte PJ, Pasternak JJ, Abcejo AS. Recent Preoperative Concussion and Postoperative Complications: A Retrospective Matched-cohort Study. Journal of Neurosurgical Anesthesiology. October 23, 2019.
13. Sheshadri V, Manninen P, Venkatraghavan L. Anesthesia in Patients With Postconcussion Syndrome: Is There Evidence? Journal of Neurosurgical Anesthesiology. April 2017;29(2):185.