Neurosurgical Panel Determines New Criteria for Concussion Diagnosis

Although it is often very clear when a head injury has occurred, criteria have been needed to assess concussion injury independently of a particular researcher's working definition. As the authors of the study below note, there is in the concussion literature a "pervasive circularity in the relationship between case identification and outcome reporting for individual studies. That is, in most of the published literature, criteria for a definition of a case of concussion were prespecified, and then patients were selected on the basis of those criteria. Thus, data on the prevalence of the criteria as outcomes in those samples are overestimated."

The authors reviewed multiple head injury studies (in sports, hospital, and military settings) in a effort to come up with criteria for concussion that would choose persons who had a concussion from those with potentially concussive events who were not felt to have had concussion.

The guidelines are to be published in September, but were just released in advance online.

The symptoms and signs found to be in common as indicators for concussion, regardless of individual study criteria among reviewed studies, were:

(1) observed and documented disorientation or confusion immediately after the event.

(2) impaired balance within 1 day after injury.

(3) slower reaction time within 2 days after injury.

(4) impaired verbal learning and memory within 2 days after injury.



Neurosurgery September 2014 - Volume 75 - Issue - p S3–S15

doi: 10.1227/NEU.0000000000000433

Concussion Guidelines

Concussion Guidelines Step 1: Systematic Review of Prevalent Indicators

Carney, Nancy PhD; Ghajar, Jamshid MD, PhD; Jagoda, Andy MD; Bedrick, Steven PhD; Davis-O'Reilly, Cynthia BSc; du Coudray, Hugo PhD; Hack, Dallas MD; Helfand, Nora; Huddleston, Amy MPA; Nettleton, Tracie MS; Riggio, Silvana MD

Correspondence: Jamshid Ghajar, MD, PhD, Brain Trauma Foundation, 7 World Trade Center, 34th Floor, 250 Greenwich St, New York, NY 10007. E-mail:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

BACKGROUND: Currently, there is no evidence-based definition for concussion that is being uniformly applied in clinical and research settings.

OBJECTIVE: To conduct a systematic review of the highest-quality literature about concussion and to assemble evidence about the prevalence and associations of key indicators of concussion. The goal was to establish an evidence-based foundation from which to derive, in future work, a definition, diagnostic criteria, and prognostic indicators for concussion.

METHODS: Key questions were developed, and an electronic literature search from 1980 to 2012 was conducted to acquire evidence about the prevalence of and associations among signs, symptoms, and neurologic and cognitive deficits in samples of individuals exposed to potential concussive events. Included studies were assessed for potential for bias and confound and rated as high, medium, or low potential for bias and confound. Those rated as high were excluded from the analysis. Studies were further triaged on the basis of whether the definition of a case of concussion was exclusive or inclusive; only those with wide, inclusive case definitions were used in the analysis. Finally, only studies reporting data collected at fixed time points were used. For a study to be included in the conclusions, it was required that the presence of any particular sign, symptom, or deficit be reported in at least 2 independent samples.

RESULTS: From 5437 abstracts, 1362 full-text publications were reviewed, of which 231 studies were included in the final library. Twenty-six met all criteria required to be used in the analysis, and of those, 11 independent samples from 8 publications directly contributed data to conclusions. Prevalent and consistent indicators of concussion are (1) observed and documented disorientation or confusion immediately after the event, (2) impaired balance within 1 day after injury, (3) slower reaction time within 2 days after injury, and/or (4) impaired verbal learning and memory within 2 days after injury.

CONCLUSION: The results of this systematic review identify the consistent and prevalent indicators of concussion and their associations, derived from the strongest evidence in the published literature. The product is an evidence-based foundation from which to develop diagnostic criteria and prognostic indicators.

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