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CRM: Neurologic Assessment
Concussion Recognition & Management
Module 4 Assessment

Neurologic Assessment

boy being tested on ophthalmoscope
It is also important to do a thorough neurologic exam. Most of the time, neurologic testing is used to rule out worse issues, rather than to rule in concussion.

Neurologic assessment typically involves a head-to-toe exam with components such as:
  • Visual examinations, including pupil size and reactivity (PEARL), nystagmus, smooth pursuit, and funduscopic examination.
  • Manual muscle test from head to toe, noting whether it exacerbates symptoms.
  • Balance, including heel-to-toe and gait.
Focal neurologic findings will point to other diagnoses.

To Scan or Not to Scan

Neuroimaging will not provide a solid "This is a concussion" diagnosis, but is useful in ruling out structural abnormalities when indicated. Along with concerns about structural abnormalities in an acute exam, other red flags for neuroimaging include focal neurologic deficits and/or an atypical course - for example, a sudden increase in symptoms for no reason.
CT & MRI scans

This statement from the American Society for Sports Medicine can equip you with facts to counter any arguments from concerned family members or other lay people who may question the decision to forego neuroimaging.
From the 2013 American Medical Society for Sports Medicine Position Statement:
Concussion in Sport
"The vast majority of athletes with sports-related concussion do not require neuroimaging. Standard neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is negative in concussion, but is used to evaluate for more serious brain injury."

CT Computed Tomography scan
MRI Magnetic Resonance Imaging scan
Best used acutely for evaluating for:
  • Bony fracture.
  • Intracranial bleeding, contusion, mass effects.
  • Brain stem herniation.
CTs expose the brain to radiation and should be used judiciously.
More sensitive for:
  • Evaluating persistent or worsening symptoms.
  • Concern for underlying pathology (e.g., headache or seizure disorder, arteriovenous malformation, Chiari malformation, etc.).
MRIs have improved with stronger magnets and different techniques that can detect minor abnormalities after concussion. The clinical relevance of the findings are unclear.

Module 4 Assessment

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