Emergency Medicine Book


Second Impact Syndrome

Aka: Second Impact Syndrome, Malignant Brain Edema
  1. See Also
    1. Concussion
    2. Postconcussion Syndrome
    3. Return to Play after Concussion
    4. Head Trauma
    5. Mild Traumatic Brain Injury
    6. Concussion Grading
    7. Cognitive Deficit following Concussion
  2. Definitions
    1. Second Impact Syndrome
      1. Following a first Minor Head Injury, a second significant Head Injury results in severe neurologic injury
  3. Epidemiology
    1. Uncommon to rare, but with devastating consequences
    2. Appears limited to children and adolescents
      1. Although adults with multiple Concussions may develop chronic Traumatic encephalopathy (CTE)
      2. CTE, by contrast, results in a chronic neurodegenerative disorder with Dementia and Parkinsonism features
  4. Pathophysiology
    1. Results from repeated Concussions over a short period of time
      1. Initial Traumatic Brain Injury initiates an inflammatory response and altered cerebral autoregulation
    2. Subsequent head injuries result in cerebral edema without physiologic compensatory mechanisms
      1. Rapid and diffuse cerebral edema with no effective treatment (does not respond to manitol)
      2. Reduced cerebral Blood Flow or fluctuating cerebral flow, varying with systemic perfusion
  5. Signs
    1. Rapid neurologic decline following repeated Head Injury
  6. Imaging
    1. CT Head
      1. Cerebral edema
      2. Small Cerebral Ventricles
      3. Loss of cerebral sulci
      4. Loss of subarachnoid space
  7. Management
    1. See Increased Intracranial Pressure in Closed Head Injury
    2. See Severe Head Injury Management
    3. See Status Epilepticus
  8. Prevention
    1. Helmets should not offer a false sense of security against Second Impact Syndrome
      1. Helmets do not prevent Second Impact Syndrome in those with unresolved prior Concussion-related symptoms
    2. Prevention of Second Impact Syndrome is the primary focus of post-Concussion guidelines in sports
      1. See Return to Play after Concussion
  9. Course
    1. Mortality approaches 50% with severe neurologic sequelae in the other 50%
  10. References
    1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
    2. McCrory (2012) Br J Sports Med 47(5): 250-8 [PubMed]

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