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Although concussion is the most common type of brain injury seen in athletes, there is always the possibility that head impact may cause a more severe structural brain injury. This is a complication that is feared by all sports physicians and others involved in athletic care.
Acute subdural haematoma (ASDH) results from traumatic laceration to the brain, from bleeding from the cortical vessels into the subdural space or from acceleration–deceleration injury to the head that causes tearing of the bridging veins, resulting in clot formation in the subdural space between the arachnoid and dural meningeal layers. A subdural haematoma is often associated with some underlying parenchymal (brain) injury, including diffuse axonal injury. In contrast, extradural haematoma usually results from a skull fracture causing damage to a meningeal artery, which is situated between the dura and the skull. Classically, there is no significant parenchymal injury in extradural haematoma.
Subdural and extradural haematomas are distinct clinical entities that share some common elements in sports medicine yet also have certain individual peculiarities that are important in return-to-sports decision making.
Case 1: subdural haematoma
A 31-year-old professional boxer has won all 26 fights he has contested. He sustained a small subdural haematoma in a fight he won (fig 1). There was mild mass effect from the subdural haematoma, and it was observed with serial CT scans, without the requirement for surgical drainage. Spontaneous resolution of the subdural collection was noted on a repeat CT scan at 6 weeks. It is now 1 year later, and he has a normal neurological examination and formal neuropsychological testing is normal. The result of his brain MRI scan is also normal (including magnetic resonance venogram (MRV) and magnetic resonance angiogram (MRA) sequences).
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