Concussion management in combat sports: consensus statement from the Association of Ringside Physicians.

Various organisations and experts have published numerous statements and recommendations regarding different aspects of sports-related concussion including definition, presentation, treatment, management and return to play guidelines. 1-7 To date, there have been no written consensus statements specific for combat sports regarding management of combatants who have suffered a concussion or for return to competition after a concussion. In combat sports, head contact is an objective of the sport itself. Accordingly, management and treatment of concussion in combat sports should, and must, be more stringent than for non-combat sports counterparts.The Association of Ringside Physicians (an international, non-profit organisation dedicated to the health and safety of the combat sports athlete) sets forth this consensus statement to establish management guidelines that ringside physicians, fighters, referees, trainers, promoters, sanctioning bodies and other healthcare professionals can use in the ringside setting. We also provide guidelines for the return of a combat sports athlete to competition after sustaining a concussion. This consensus statement does not address the management of moderate to severe forms of traumatic brain injury, such as intracranial bleeds, nor does it address the return to competition for combat sports athletes who have suffered such an injury. These more severe forms of brain injuries are beyond the scope of this statement. This consensus statement does not address neuroimaging guidelines in combat sports.

Care of The Older Fighter: Position Statement of the Association of Ringside Physicians.

Older Fighters are defined as combat sports athletes older than 35 years, based on heightened medical risks and historical classification. Age-related changes to the neurological, cardiopulmonary, endocrinological, thermoregulatory, osmoregulatory, and musculoskeletal systems increase these athletes' risks for injury and may prolong their recovery. These age-related risks warrant special considerations for competition, licensure, prefight medical clearance, in-fight supervision, post-fight examination, and counseling regarding training practices and retirement from combat sports. Neurological considerations include increased risk of intracranial lesions, intracranial hemorrhage, and sequelae from traumatic brain injury (TBI), warranting more comprehensive neurological evaluation and neuroimaging. Increased risk of myocardial ischemia and infarction warrant careful assessment of cardiac risk factors and scrutiny of cardiovascular fitness. Older fighters may take longer time to recover from musculoskeletal injury; post-injury clearance should be individualized.

Asymptomatic elevation of liver enzymes due to levetiracetam: a case report.

Levetiracetam is a commonly used broad-spectrum anticonvulsant efficacious in both partial and generalized seizures. It has an extremely favorable side effect profile with few drug-drug interactions, low potential for hematological and hepatic toxicity, and thus has rapidly become the preferred drug in patients with traumatic brain injuries who need seizure prophylaxis. We report, here, a patient who was started on levetiracetam for seizure prophylaxis after developing large bifrontal-parietal traumatic subdural hematomas (SDH) following a fall from a horse necessitating bifrontal craniotomies for evacuation. The patient developed an asymptomatic elevation of the liver enzymes. The liver enzymes trended back to normal after levetiracetam was stopped, and topiramate was initiated in its place.

Curriculum Innovations: Developing an EEG Workshop for Hands-on Training in Electroencephalography During Resident Rotation in Clinical Neurophysiology.

A 3-hour hands-on EEG workshop was conducted as a part of resident rotation in clinical neurophysiology to determine its feasibility and educational value for neurology residents, medical students, and EEG technologists, with the learning objectives of motivating interest in clinical electroencephalography, enhancing ability to recognize a normal EEG and identify physiological and non-physiological artifacts, and enhancing teaching, organizational and communication skills of EEG technologists. The workshop included a demonstration of EEG electrode placement according to the 10-20 System on a resident volunteer by the EEG technologist. Activation procedures (photic stimulation and hyperventilation) were demonstrated to the residents during the 25-minute recording. A board-certified epileptologist later reviewed the record with the residents. Resident and EEG technologist feedback on the workshop was obtained via non-formal e-mail request. All residents rated the workshop highly and found it more engaging and motivating than the didactic EEG lecture in which basics of EEG recording are reviewed. The residents gained improved awareness and appreciation of the role of the technologist and the skill and time involved in obtaining an EEG record. The EEG technologist appreciated the face-to-face interaction with the residents and felt part of the patient care team. A hands-on EEG workshop as a part of resident clinical neurophysiology rotation is feasible, effective, and motivating in teaching residents and medical students the basis of EEG recording and recognition of common physiological and non-physiological artifacts in a normal record.

Neuroimaging in professional combat sports: consensus statement from the association of ringside physicians.

Professional boxing, kickboxing, and mixed martial arts (MMA) are popular sports with substantial risk for both acute and chronic traumatic brain injury (TBI). Although rare, combat sports athletes have died in the ring or soon after the completion of a bout. Deaths in these instances are usually the result of an acute catastrophic neurological event such as an acute subdural hematoma (SDH). Other causes may include acute epidural hematoma (EDH), subarachnoid hemorrhage (SAH), intraparenchymal hemorrhage (IPH), or a controversial, rare, and still disputed clinical entity called second-impact syndrome (SIS). Neuroimaging or brain imaging is currently included in the process of registering for a license to compete in combat sports in some jurisdictions of the United States of America and around the world. However, the required imaging specifics and frequency vary with no consensus guidelines. The Association of Ringside Physicians (an international, nonprofit organization dedicated to the health and safety of the combat sports athlete) sets forth this consensus statement to establish neuroimaging guidelines in combat sports. Commissions, ringside physicians, combat sports athletes, trainers, promoters, sanctioning bodies, and other healthcare professionals can use this statement for risk stratification of a professional combat sports athlete prior to licensure, identifying high-risk athletes and for prognostication of the brain health of these athletes over the course of their career. Guidelines are also put forth regarding neuroimaging requirements in the immediate aftermath of a bout.

Transgender competition in combat sports: Position statement of the Association of ringside physicians.

The Association of Ringside Physicians (ARP) is committed to the concept of fair competition. It advocates for two equally skilled and matched athletes to keep bouts fair, competitive, entertaining, and, most importantly, safe for all combatants. Numerous studies have proven that transgender women may have a competitive athletic advantage against otherwise matched cis-gender women. Likewise, transgender men may suffer a competitive disadvantage against cis-gender men. These differences - both anatomic and physiologic - persist despite normalization of sex hormone levels and create disparities in competitive abilities that are not compatible with the spirit of fair competition. More importantly, allowing transgender athletes to compete against cisgender athletes in combat sports, which already involve significant risk of serious injury, unnecessarily raises the risk of injury due to these differences. Hence the ARP does not support transgender athlete competition against cisgender athletes in combat sports.

Delayed left anterior and middle cerebral artery hemorrhagic infarctions after attempted strangulation: a case report.

The 2 common carotid arteries bifurcate in the neck into the internal and external carotid arteries. The internal carotid artery enters the skull and further divides into the anterior and middle cerebral artery. During its short course in the neck, the carotid artery travels encased in the carotid sheath along with the vagus nerve and the internal jugular vein. During its course in the neck, the carotid artery is quite superficial, making it vulnerable to both penetrating and blunt traumatic injuries. We report here a case of a 40-year-old man who presented to the emergency department after sudden collapse and loss of consciousness a day after an attempted strangulation. Imaging revealed large hemorrhagic infarcts in the left anterior cerebral artery and middle cerebral artery territories as well as a smaller infarcts in the right anterior cerebral artery territory necessitating emergency decompressive hemicraniectomy. Our case report adds to the existing literature on nervous system injury due to strangulation. Physicians should be aware of the possibility of delayed presentation of neurological deficit after attempted strangulation.

The Relationship Between Epilepsy, Obstructive Sleep Apnea, and Treatment Outcome.

Both epilepsy and obstructive sleep apnea are common conditions and hence frequently coexist in a given patient. A complex bidirectional relationship exists between the 2 conditions where the presence of one affects the other. Treatment of obstructive sleep apnea with continuous positive airway pressure may improve seizure control in medically refractory epilepsy patients, leading to improved quality of life. Understanding of this complex relationship between epilepsy, sleep, and sleep disorders such as obstructive sleep apnea continues to evolve.

Central nervous system tuberculosis masquerading as primary dementia: a case report.

Primary dementias are the most common cause of memory impairment in patients above the age of 60. Hypothyroidism, depression, vitamin B12 deficiency and infectious diseases such as syphilis at times may present with memory impairment mimicking primary dementias in their clinical presentation. We present here a 64-year-old female who presented with complaints of forgetfulness, confusion, memory loss and impaired concentration for the past 3 months. Neuroimaging and computed tomography of the chest were suggestive of active tuberculosis. Anti-tubercular therapy led to resolution of enhancing lesions in the brain and abatement of memory deficits.