CHAPTER 34 • NEUROLOGY 203resolution of symptoms within 3–6 months is a vital
component of any therapeutic regimen.EPILEPSY
- Epileptic syndromes are typically classified into one
of three categories:- Generalized epileptic syndromes that are often
idiopathic, have a genetic predisposition, have
bilateral electrical discharges on electroencephalo-
gram(EEG), and have a good prognosis. - Localization-related epileptic syndromes that are
further divided into three subcategories: (a) idio-
pathic; (b) age-related onset; and (c) symptomatic. - The idiopathicsubtype is usually hereditary and is
notable for negative diagnostic studies. The most
common age-related subtype is benign rolandic
epilepsy. It is a self-limited childhood condition
that is hereditary and typically outgrown before
puberty. The symptomatic category comprises
epileptic syndromes caused by focal brain abnor-
malities, such as cortical malformations and those
secondary to trauma or tumors. The seizures of this
category tend to have a poorer prognosis for either
complete control or cure. Resective epileptic sur-
gery can be the only treatment option and may
reduce the seizure burden.
- Generalized epileptic syndromes that are often
- Unfortunately, because of misconceptions by parents,
school administrators, coaches, physicians, and many
youth are never allowed to participate in sports,
thereby isolating them from their peers and increasing
their risk of comorbid behavior. The most current and
standard recommendations are from the International
League Against Epilepsy and restrict only scuba
diving and sky diving (Commission of Pediatrics of
the International League Against Epilepsy, 1997).- By age 20, approximately 1% of the U.S. population
will have developed some form of epilepsy. Of those
affected, 75% experience their first seizure before
their third decade of life (Daniel, 2002). The chance of
a recurrent seizure after a first seizure is 30–40%.
Once a child has experienced a second seizure, the
chance of recurrence approaches 90%. - Although team sports involving collision or contact
must be pursued cautiously, many athletes with epilepsy
can complete successfully in these sports. Additionally,
the reports of epilepsy developing after participation in
contact sports including boxing, football,and hockey
are extremely rare. The decision regarding participa-
tion by any athlete with epilepsy must be made only
after a careful risk/benefit analysis. - In a patient-by-patient approach, all aspects of an ath-
lete’s seizure history must be considered. This
includes type, frequency, loss of consciousness, pro-
dromes, duration, and postictal symptoms. Also, any
medications used and their physiologic and psycho-
logic effects must be fully evaluated during the
preparticipation examination. - The preparticipation evaluation of an athlete with
epilepsy or other seizure history can be considered a
fearevaluation:
TABLE 34-5 Guidelines for the Management of Concussion in Sports
GRADE FEATURES MANAGEMENT RETURN TO PLAY
1Transient confusion Remove from contest Return if clear within 15 min
No loss of consciousness Examine immediately and at 5-min Second grade-1 in same contest: disqualify
Concussion symptoms resolve in intervals for development of mental athlete, return in 1 week if asymptomatic
less than 15 min status abnormalities or postconcussive at rest and with exercise
symptoms at rest and with exertion
2Transient confusion Remove from contest and disallow return May return after 1 full asymptomatic week
that day with exertion
No loss of consciousness Examine on site frequently for signs of
evolving intracranial pathology
Concussion symptoms last more CT scan or MR imaging if symptoms Second grade-2 concussion: return to play
than 15 min worsen or persist for longer than 1 week after 2 weeks symptom free at rest and
with exertion
3Any loss of consciousness, either Transport athlete to nearest emergency Brief (seconds) grade 3 concussion:
brief (seconds) or prolonged department by ambulance with cervical withhold from play until asymptomatic
(minutes) spine precautions, if necessary for 2 weeks at rest and with exertion
Second grade-3 concussion withhold from
play for a minimum of 1 asymptomatic
monthSOURCE: Kelly JP, Rosenburg JH: Practice parameter: The management of concussion in sports. Neurology48:575–580, 1997. (With permission)