EDITORIAL

Warm up

"Tomber dans les pommes" – can head injury cause brain damage?

P McCrory

Those readers looking for some amusing leisure time reading need look no further than the December issue of the Canadian Medical Association Journal. The enterprising authors—Antoine Cyr (age 5 years) and his brother Louise-Oliver (age 7 years) in conjunction with their father—analysed the adventures of Tintin in an attempt to discover why the Tintin grew no taller from 1929 to 1975, never had a girlfriend, and never needed to shave.¹

After an exhaustive review of the published literature, episodes of head injury were identified by the authors and the injury severity determined by the duration of loss of consciousness (as measured by the number of frames before Tintin returned to normal activity) and the number of stars revolving above Tintin’s head following injury.

Rather surprisingly a total of 50 episodes of head injury were identified (43 were AAN grade 3 concussion injuries) in Tintin’s career. The mean length of LOC was 7.5 frames. The number of concussive events per adventure ranged from two to six, and most were blunt object impacts. Despite the absence of formal neuroimaging or neuro-endocrine assessment, the authors postulated that the repeated head trauma resulted in hypogonadotrophic hypogonadism and growth hormone deficiency, which in turn would explain his delayed statural growth, delayed onset of puberty, and lack of libido.

This is the first report of such a syndrome occurring following concussion. Pituitary and hypothalamic dysfunction is seen not uncommonly following severe head trauma or in the setting of raised intracranial pressure after head injury but to date such a phenomenon has not been reported with concussive injury. As a result one would have to speculate that Tintin was in fact suffering from primary hypothalamic dysfunction and his clumsiness and repeated head trauma was incidental. The occurrence of repeated concussive injuries in athletes has been documented previously and thought to reflect the individuals risk taking behaviour rather than an intrinsic potential for injury². In Tintin’s case, annual neuropsychological screening may be advisable to detect and hopefully prevent any long term cognitive deterioration.

It has been suggested by some authors^3,4 that repeated concussive injuries may be a risk factor for "second impact syndrome"; however, this has been questioned due to the limited evidence for its existence.⁵ In Tintin’s case, fear of this putative complication seems to have not been a management concern in his return to normal activity.

Some anecdotal return to play guidelines^6,7 would recommend immediate retirement or termination of the current adventure given that Tintin often experiences more than three concussive episodes in a short space of time. However, the Vienna guidelines⁸ recommend no mandatory exclusion period but individualised assessment of recovery—a strategy that Tintin appears to have followed in preference. If these guidelines were strictly adhered to, however, then he would have to terminate the adventure following the initial injury and Snowy the dog or Captain Haddock may have to play a more central role in the story outcome.

I can only suggest that Tintin play close attention to the forthcoming Prague guidelines in view of his propensity of concussive injury in order to avoid long term problems.

1. Cyr A, Cyr L, Cyr C. Acquired growth hormone deficiency and hypogonadotrophic hypogonadism in a subject with repeated head trauma. Can Med Assoc J 2004;171:1433–4.[Free Full Text]
2. Gerberich SG, Priest JD, Boen JR, Straub CP, Maxwell RE. Concussion incidences and severity in secondary school varsity football players. Am J Public Health 1983;73:1370–5.[Abstract/Free Full Text]
3. Cantu RC. Second-impact syndrome. Clin Sports Med 1998;17 (1) :37–44.[CrossRef][Medline]
4. Kelly JP, Nichols JS, Filley CM, et al. Concussion in sports. Guidelines for the prevention of catastrophic outcome. JAMA 1991;266:2867–9.[Abstract/Free Full Text]
5. McCrory PR, Berkovic SF. Second impact syndrome. Neurology 1998;50:677–83.[Abstract/Free Full Text]
6. Cantu RC. Guidelines for return to contact sports after cerebral concussion. Phys Sportsmed 1986;14:75–83.
7. Kelly J, Rosenberg J. Diagnosis and management of concussion in sports. Neurology 1997;48:575–80.[Free Full Text]
8. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the first International Conference on Concussion in Sport, Vienna 2001. Physician and Sports Medicine 2002;30:57–62.

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