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DrRussMD
DrRussMD, Board Certified MD
Category: Medical
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Experience:  Board certified Internal medicine and Integrative medicine. Many years of experience all areas.
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Below is a long winded and (I am guessing) pretty challenging

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Below is a long winded and (I am guessing) pretty challenging set of questions, even for an expert. Apologies for that and rest assured that I will definitely pay the maximum fee if I receive an answer (even if it is an incomplete one). The reason I am asking is that I have basically developed a serious phobia/possible delusion about having suffered a concussion since walking into a low hanging doorway (sort of clipped it really) a while ago and, although I did not suffer any noticeable symptoms I know the only possible way I can get over the problem is to try and fully understand what happened to me. I have numbered the questions to make it clearer.
It is now commonly accepted by various experts in the field, that concussions (or mild traumatic brain injuries) rarely cause any structural/physical damage to the brain -- i.e do not shear axons or dendrites (at least in most cases) -- I believe finite element modelling simulations of brain injuries have shown this most conclusively. Rather, in the case of concussions the axons are stretched and this leads to a (generally) reversible chemical imbalance in the brain.
(1) Is it likely the case that concussion symptom severity and/or duration is correlated with the degree of the injury to the brain, even at the mildest end of the continuum? That is, as you move along the continuum, from the very mildest to the moderately mild, the immediate symptoms (i.e. ones that occur straightaway after the impact) and/or the later residual symptoms (the one's that last for days or weeks) increase in duration and severity? I looked at a study which suggested that this was the case: http://www.ncbi.nlm.nih.gov/pubmed/25154550
(2) Would it be right that the severity and duration of the residual symptoms is probably a better indication than the acute symptoms? If concussions initiate a chemical imbalance in the brain which temporarily impairs neuronal signalling on a large-scale and evolves over time, the residual symptoms literally are the damage, so to speak, rather than the immediate/acute symptoms, which are more like the starting conditions for the chain of events that lead to the chemical imbalance, I suppose?
Related to this: (3) is it the case that the acute symptoms of a concussion are sometimes delayed -- i.e. is it sometimes the case that there are no symptoms immediately following a head impact until hours or maybe a day later? And if this is sometimes the case, is this only the case when there is an extradural bleed or when there is a focal (rather than diffuse) impact to the brain that only affects a small area of the brain and only becomes a problem when the swelling develops or when some type of chemical imbalance escalates?
The reason I ask is because I saw footage of a major league baseball player who was struck on the head by a baseball. He winced in pain and looked a tiny bit dazed for about 5 seconds but then seemed fine and carried on playing with no problems. The next day he suffered really severe sensitivity to light and sound and felt completely disorientated and went on to miss 16 games, so his symptoms mast have lasted a long time. Most boxing knockouts -- ones were the acute symptoms happen at the point of impact and completely incapacitate the boxer -- don't seem to cause symptoms that last that long, so I was confused about what might be going on. Was he playing through his symptoms, did he suffer a minor extradural bleed, or was it something to do with the focal nature of the impact. Perhaps this isn't very well understood by anyone?
(4) I am guessing that an absence of residual symptoms (or very minimal ones) indicates a very minor chemical disruption of the brain's functioning -- or (5) perhaps it indicates no chemical imbalance whatsoever, because such a chemical imbalance is a large scale all-or-nothing thing; that is, perhaps neuronal strain exists on a continuum, but there is a definite threshold for the level of strain that leads to a chemical imbalance -- which may possible reconcile the all-or-nothing view of concussions with the continuum view of concussions?
Thanks for your time,
Paddy
Submitted: 2 years ago.
Category: Medical
Expert:  DrRussMD replied 2 years ago.
Hello
This sounds like anxiety.
Let me ask you, what actual injury occurred, was there tissue damage, a scan?
What medical diagnoses do you have?
On any medications?
Customer: replied 2 years ago.

I walked into the corner of a low-hanging, plaster-on-brick doorway at a slow-to-medium walking speed -- which is about 1.0 to 1.5 m/s. The corner made contact with the top-front of my head, about 2 inches back from my hairline -- the middle of the frontal bone. Despite a shooting pain that resonated in my teeth there were no noticeable immediate symptoms, and the fact that I stayed on my feet and experienced the full arch of the pain means I didn't lose consciousness. No amnesia either (pre or post) Despite being quite sharp, the edge didn't split my scalp but did produce a raised welt.

The problem is that I had only had about 2 hours sleep that evening, and therefore felt understandable tired throughout the day, but being prone to anxiety -- as you accurately judged -- I am worried that my mental slowness wasn't entirely the result of a lack of sleep.

As I mentioned, I have heard cases were people suffer an impact and then only develop symptoms hours or days later. Is this just something medical professionals say to make sure people are not complacent, or might it result from the fact that many sports people do not take the immediate symptoms seriously, because they often resolve quickly without any long term problems, or hide them to stay in the game -- and it is in these cases that the symptoms can come back later?

I don't have any diagnoses per say, but I am prone to episodes of profound and long lasting anxiety. I can be fine for years (even show slightly reckless and fearless behaviour) and then some type of negative thought process gets going and I become a nervous wreck. I have an obsessive mind. I talk about the same subjects again and again, and have done well academically because of this. (Do not register very highly on the autistic spectrum though).

No medications.

I had an SWI scan and it came back perfectly normal.

Expert:  DrRussMD replied 2 years ago.
I think this is all anxiety, you have no current symptoms related to concussion.
1. you can not predict this.
2. if symptoms do not continue, the fact is that there is generally no problem, not from the injury you describe.
3. There can be a delay in symptoms, but generally we are talking minutes to a few hours.
4. I don't think you have any problem related to this injury from your story.
I do think there is a psychological problem, reading your post....why, if you have normal exams, and no residual symptoms, would you obsess over this, which is what it sounds like?
I think the treatment needed is along these lines.
OK, so that is an initial answer….
Please use reply to expert if you have further questions. When you are ready, please click a positive rating [hopefully excellent]. If you forgot something, come back. I am here daily.
Customer: replied 2 years ago.

Why is it the case that if symptoms do not continue there is generally not a problem -- and what is meant by a "problem"? Also, I was under the impression that there currently exists no scan that can pick-up a concussion/mtbi?

As for why I obsess about it? Probably a fear of losing something that my happiness depends upon -- i.e. my functioning brain, which I have built my confidence upon. I am trying to write a book at the moment and have invested everything in it. It is like a dancer who breaks their leg or ruptures their achilles tendon. The average person -- including myself -- could get over that, but for the dancer it threatens to destroy his or her world.

Expert:  DrRussMD replied 2 years ago.
For actual brain injury, it generally takes multiple concussions.
A concussion is a blow to the head with symptoms.
You did not even have symptoms.
I think that getting help with the anxiety about this will help your brain the most.
A functional MRI or a SPECT can give some idea about how your brain works, but any relationship to the blow to your head would be a guess.
Please use reply to expert if you have further questions. When you are ready, please click a positive rating [hopefully excellent]. If you forgot something, come back. I am here daily.
Customer: replied 2 years ago.

I appreciate your mild annoyance. I am not as narcissistic and self-indulgent and this exchange may make me appear.

Last two questions: when symptoms are delayed do they manifest in an obvious and forceful way -- i.e. in a way that would be very noticeable? Like blurred vision, losing balance, being really confused about everything?

I can imagine that someone might be so out-of-it that they might not even register that there was a problem, but if someone was coherent enough to hold a reasonable challenging conversation, order a cab and navigate their way around an un-familiar city (all things I did that day) that person would (in all probability) be coherent enough to recognise the symptoms of a concussion -- and they would be more obvious than just feeling a bit tired, as I did?

Also once, the symptoms manifest, they are probably going to be hanging around for a few days at the minimum. I ask because after sleeping on a train for about 4 hours on my way home, I woke up and felt almost completely recovered from the period of tiredness. Would it be right to say that was not consistent with a concussion?

Expert:  DrRussMD replied 2 years ago.
Not at all. To answer the final questions:
Yes
When symptoms are delayed they manifest as a clear concussion.
Or post concussion syndrome, which is a clear set of symptoms.
Yes, if you were out of it , you, and others, would know.
Yes, your symptoms were not consistent with a concussion.
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