ILLUSTRATIVE CASE

Acute Subdural Hematoma
Potential Soccer Injury in an Otherwise Healthy Child
Riad Lutfi, MD, Charles J. Mullett, MD, PhD, and Linda S. Nield, MD

Abstract: A 16-year-old adolescent boy presented with headache,
dizziness, loss of consciousness, and a tonic-clonic seizure after heading
a soccer ball in a competitive match. A computed tomographic scan of
the head revealed an acute subdural hematoma with a mass effect. The
patient was emergently referred to a tertiary care facility where he eventually recovered completely with conservative care. No predisposing
medical conditions were found. To the best of our knowledge, this is
the first report of an intracranial hemorrhage secondary to the heading
of a soccer ball alone in an otherwise healthy child without any underlying predisposing central nervous system abnormalities.
Key Words: soccer, sports injuries, subdural hematoma
(Pediatr Emer Care 2009;25: 582Y583)

CASE
A 16-year-old male high school student was transferred to
the emergency department after passing out on the soccer field
after heading a soccer ball in a high school soccer match. During
a goal kick, the patient blocked the ball with the front of his
head. He denied any contact with other players during the match,
and he continued to play until moments later when he felt dizzy
and developed a headache. He left the field, and while resting
at the bench, he lost consciousness for about 30 seconds. Upon
arrival of medical personnel, the boy was awake and responsive,
with normal vital signs. During ambulance transport to the local
emergency department, he developed a tonic-clonic seizure that
resolved spontaneously within a minute. Computed tomographic
(CT) images of the head (Fig. 1) revealed an acute subdural
hemorrhage with a 3- to 4-mm midline shift without sign of skull
fracture. A CT scan of the cervical spine was normal. The patient
was referred to our tertiary care facility for pediatric neurosurgical and neurological consultations. In the pediatric intensive
care unit, the patient was treated prophylactically with anticonvulsants. Serial CT scans over the next 2 days after injury
revealed a stable and then resolving mass effect of the hemorrhage. A magnetic resonance imaging study showed a 3-mm
midline shift and no congenital or other potentially explanatory
lesion that would predispose to a bleed. The patient’s nausea,
vomiting, headaches, and right leg parathesias improved, and he
was discharged home on levetiracetam and activity restrictions
on posttrauma day 3.
A follow-up CT scan 2 weeks later showed a resolved
subdural hemorrhage. An electroencephalogram was normal,
and the levetiracetam was discontinued a month later. Magnetic
resonance angiography and venography done after 4 months

From the Department of Pediatrics, West Virginia University School of
Medicine, Morgantown, WV.
Reprints: Linda S. Nield, MD, West Virginia University School of Medicine,
Morgantown, WV 26505 (e-mail: lnield@hsc.wvu.edu).
Financial Disclosures: None.
Copyright * 2009 by Lippincott Williams & Wilkins
ISSN: 0749-5161

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identified no abnormalities. A magnetic resonance imaging at
that time displayed a miniscule signal abnormality in the right
frontal lobe (opposite the hemorrhage) that most likely represented a small capillary telangiectasia or cavernous angioma,
conditions highly unlikely to be associated with the subdural
bleed. The patient was encouraged to resume full activities but
was cautioned that participating in any sports places him at risk
of further traumatic brain injury with the potential for permanent neurologic sequelae.

DISCUSSION
Soccer is an increasingly popular sport among children in
the United States. Worldwide, there are more than 200 million
Federation International Football AssociationYregistered players,
with more than 16 million participants in the United States.1
Casual observers might conclude that soccer is a noncontact
sport, particularly when compared to American football; however, soccer is a frequent precipitant to an emergency department
visit. Common types of injuries reported include strains, sprains,
fractures, and contusions. Commonly injured body regions vary
by age.2
A unique feature of a soccer play is the purposeful use of
the head for controlling, passing, blocking, and shooting the
soccer ball. Using the head for these purposes places the players
at risk of head injury, which can result from contact to the head
from another player’s head (or other body parts), the ground,
the goalpost, or the ball. Young players are taught that the safe
and proper method of heading the ball is to thrust the head
forward and contact the ball with the upper part of the forehead. This is the method used by the player in our case, but
the ball was arriving with greater than usual force because of
the relative proximity of our patient to the goal kick from the
keeper. This case demonstrates a rare potential danger to the
use of the head in the game of soccer. Studies are available that
detail other reported head injuries associated with soccer play. In
a retrospective Canadian study, 1714 cases of soccer-related
injuries were identified over a 5-year period, with 14% of these
injuries occurring to the head.3 Very few of these could be attributed to the purposeful heading of the ball, and no serious
injuries, such as the subdural hematoma in this case, were identified. Player contact injuries appeared to be a more important
injury control concern. The authors concluded that injuries due
solely to contact to the head by the ball were rare and of minor
significance. A study from Iowa reviewed 1219 cases of traumatic brain injury in high-school athletes.4 Sixty-three percent
of the injuries were related to participation in football, whereas
11% were from soccer. No cases of subdural or other intracranial
hemorrhages were soccer related, but 6 of the cases were identified in football players. While the data from these populationbased studies suggest that the rate of life-threatening intracranial
hemorrhage in soccer is low, other reports, in addition to the
present, also link heading the ball with intracranial hematomas.
One case involved a player whose head was injured secondary
to contact with another player’s head.5 Multiple cases are available involving athletes with intracranial bleeds secondary to
Pediatric Emergency Care

& Volume 25, Number 9, September 2009

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Pediatric Emergency Care

& Volume 25, Number 9, September 2009

Acute Subdural Hematoma in a Healthy Child

to transient cognitive impairment based upon their study of 16to 36-year-old soccer players.
In conclusion, we report the first case of serious intracranial
hemorrhage and traumatic brain injury from contact with a soccer ball alone. This case demonstrates that a subdural hematoma
can occur in an otherwise healthy child without any underlying
predisposing central nervous system abnormality.
REFERENCES
1. Federation International Football Association. FIFA Big Count
2006: 270 Million People Active In Football. Available at:
http://www.fifa.com/aboutfifa/media/newsid=529882.html.
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emergency departments. Acad Emerg Med. 2006;13(5):571Y574.
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FIGURE 1. Computed tomographic scan of the patient’s brain
revealing the subdural hematoma (arrows).

heading the soccer ball, but the subjects were found to have
congenital arachnoid cysts as a predisposing condition.6Y8
Again, no such predisposing condition was found in this case
presentation. The long-term sequelae, if any, of heading the
soccer ball are unknown at this time.9,10
The risk of an intracranial bleed secondary to a soccer injury appears to be extremely low, but the true impact of head
injury on cognitive function is not fully elucidated. In the recent
past, the American Academy of Pediatrics Committee on Sports
Medicine and Fitness recommended that adults who supervise
youth soccer should deemphasize the heading technique until
the potential risk of permanent cognitive impairment is better
defined.11 Since then, multiple studies have been published with
varied results concerning soccer play and its association with
impaired cognition. For example, estimations derived from selfreports in the study by Stephens et al12 of soccer players aged 13
to 16 years indicate the absence of neuropsychological impairment arising secondary to either the cumulative effect of mild
head injuries or of heading the ball. However, Webb and Ochs13
concluded that heading behavior is likely a contributing factor

* 2009 Lippincott Williams & Wilkins

6. Demetriades AK, McEvoy AW, Kitchen ND. Subdural haematoma
associated with an arachnoid cyst after repetitive minor heading injury
in ball games. Br J Sports Med. 2004;38(4):E8.
7. Kawanishi A, Nakayama M, Kadota K. Heading injury precipitating
subdural hematoma associated with arachnoid cystsVtwo case reports.
Neurol Med Chir. 1999;39(3):231Y233.
8. Prabhu VC, Bailes JE. Chronic subdural hematoma complicating
arachnoid cyst secondary to soccer-related head injury: case report.
Neurosurgery. 2002;50(1):195Y197. Discussion 7Y8.
9. Zetterberg H, Jonsson M, Rasulzada A, et al. No neurochemical
evidence for brain injury caused by heading in soccer. Br J Sports Med.
2007;41(9):574Y577.
10. Webbe FM, Ochs SR. Recency and frequency of soccer heading interact
to decrease neurocognitive performance. Appl Neuropsychol. 2003;
10(1):31Y41.
11. American Academy of Pediatrics. Committee on Sports Medicine and
Fitness. Injuries in youth soccer: a subject review. Pediatrics. 2000;
105(3 pt 1):659Y661.
12. Stephens R, Rutherford A, Potter D, et al. Neuropsychological
impairment as a consequence of football (soccer) play and football
heading: a preliminary analysis and report on school students
(13Y16 years). Child Neuropsychol. 2005;11(6):513Y526.
13. Webbe FM, Ochs SR. Recency and frequency of soccer heading interact
to decrease neurocognitive function. Appl Neuropsychol. 2003;
10(1):31Y41.

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