Case Report

Sport-Related Structural Brain Injury in High School Soccer: Epidural Hemorrhage After a
“Header”
Nishit Mummareddy1, Andrew D. Legarreta1, Aaron M. Yengo-Kahn1,2, Hansen C. Bow2, Gary S. Solomon1,2,
Robert P. Naftel2, Scott L. Zuckerman1,2

Key words

- BACKGROUND: Sports-related structural brain injury (SRSBI) is a rare, but

- Epidural hematoma

potentially catastrophic, injury. Limited data exist outlining its epidemiology,
pathophysiology, and outcomes. We have presented a case of an epidural hematoma (EDH) that occurred during a high school soccer game.

- Soccer
- Sport-related structural brain injury

Abbreviations and Acronyms
CT: Computed tomography
EDH: Epidural hematoma
SDH: Subdural hemorrhage
SRC: Sports-related concussion
SRSBI: Sports-related structural brain injury
From the 1Vanderbilt Sports Concussion Center, Vanderbilt
University School of Medicine, Nashville; and 2Department
of Neurological Surgery, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
To whom correspondence should be addressed:
Scott L. Zuckerman, M.D., M.P.H.
[E-mail: scott.zuckerman@vumc.org]
Citation: World Neurosurg. (2019) 127:20-23.
https://doi.org/10.1016/j.wneu.2019.03.198
Journal homepage: www.journals.elsevier.com/worldneurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2019 Elsevier Inc. All
rights reserved.

INTRODUCTION
Sports-related structural brain injury
(SRSBI) is a rare, but potentially, catastrophic athletic injury.1,2 Possible SRSBIs
include subarachnoid hemorrhage, subdural hemorrhage (SDH), epidural hemorrhage (EDH), cerebral contusion, shear
injury, and malignant edema.3,4 Unlike
sports-related concussion (SRC), SRSBIs
will have positive neuroimaging findings
on computed tomography (CT) and often
lead to worse clinical outcomes, with the
potential for permanent disability and
death.1-4 At present, a paucity of data exist
outlining the overall epidemiology, pathophysiology, and outcomes of these rare
injuries. Thus, to improve our knowledge,
the neurosurgical community should
closely scrutinize each SRSBI that occurs.
To date, the few reports studying
SRSBIs have focused on SDH in collision
sports, such as American football.3,5-11
Another
often
mentioned—albeit

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- CASE

DESCRIPTION: A 16-year-old boy had experienced a head-to-ball
collision and head-to-head collision with another player. He denied loss of
consciousness, endorsed retrograde amnesia, and complained of a minor
headache. On the sidelines, he subsequently passed brief orientation and
physical exertion tests. However, on returning to play, he experienced blurry
vision, along with headache and nausea/vomiting. At the local hospital, he was
found to have a 2.6-cm right frontal EDH. After transfer to our institution,
increasing somnolence was noted, prompting emergent evacuation of the EDH.
His postoperative course was unremarkable, and he was discharged on postoperative day 2. At the 2-week and 3-month follow-up visits, he did not express
any complaints or residual deficits and was cleared for full sporting activity.

- CONCLUSIONS: The present case highlights one of the few SRSBIs that have

occurred in soccer. Because of their rarity and severity, a concerted effort
should be made to report these cases of SRSBIs regarding the mechanism,
postcollision symptoms, and long-term outcomes.

controversial—entity of SRSBI is “second
impact syndrome,” in which an athlete
experiences consecutive concussive episodes, leading to loss of autoregulation,
vascular engorgement, and uncontrollable
intracranial hypertension.12 EDH as an
SRSBI has not been well reported,
resulting in difficulty identifying any
meaningful trends. To date, EDH in
SRSBIs has been described in golf,
skateboarding, soccer, horse riding, and
basketball.13-16 Specifically to soccer—an
unhelmeted,
noncollision
sport—
although SDHs have been reported,4,8,17
to the best of our knowledge, only a
single case of a soccer-induced EDH has
been reported.13 The case was reported in
2000, and the EDH had occurred in a 19year-old soccer player who had struck
another player’s head during the act of
heading.13 Aside from that report nearly 2
decades ago, no further mention of EDH
occurring during soccer has been
reported.

In the present report, we have described
a 16-year-old boy who developed an EDH
during the act of heading in a high school
soccer game. Our objectives were to 1)
describe the case from the reported information, from the initial impact to his
long-term recovery; 2) draw meaningful
insights regarding the mechanism, immediate signs and symptoms, and longterm outcomes; and 3) encourage the
reporting of cases of SRSBI, especially
from soccer. It is our hope that this information will help with the early recognition of these rare injuries and the
mitigation of the long-term neurologic
consequences.

CASE REPORT
Presentation
A 16-year-old boy (5 ft, 7 in., 140 lb) with
no previous head trauma, who had been in
his usual state of health, had begun

WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.03.198

CASE REPORT
NISHIT MUMMAREDDY ET AL.

playing in a high school soccer game. All
information obtained about the prehospitalization events had been reported by
reliable informants. The informants reported that in the first half of the game, he
had jumped to head a ball and experienced a head-to-head collision with
another player (6 ft, 160 lb), in addition to
a ball-to-head collision. Both players were
sprinting to the ball, both jumped,
collided, and both fell backward. The ball
struck the left side of his head, and the
opposing player struck the right. Immediately after the collision, the patient
remained motionless for seconds but
began conversing shortly thereafter. The
player, teammates, and coaches denied he
had experienced any loss of consciousness. However, the informants reported
that the athlete displayed transient retrograde amnesia, confirmed thereafter by
the athlete. After the collision, he had also
complained of a minor headache and a
“knot” (superficial scalp edema) on his
right frontal head. The player had left the
field under his own power and subsequently passed a brief sideline concussion
screen, consisting of basic orientation
questions and a brief symptom inventory.
He had also engaged in sideline jogging
and denied any return of symptoms. After
passing the sideline concussion test and
light aerobic activity, he had returned to
play. However, minutes later, he began to
experience blurry vision and was simultaneously slide tackled from the behind,
resulting in another fall, although without
any overt head impact. While falling to the
ground, he had braced himself with his
hands to avoid any impact to his head. He
had remained kneeling on the field and
reported headache and nausea. He was
then removed to the sidelines and began
to have multiple episodes of emesis.
When he began to appear pale and
lethargic, he was taken to the local hospital, where a head CT scan was performed. The CT scan showed a large, right
frontal EDH. He was immediately airlifted
to our institution for higher acuity care.
Hospital Course
After the transfer, the CT scan confirmed a
2.6-cm right frontal EDH with a 2-mm
midline shift (Figure 1). He had an initial
Glasgow coma scale score of 15;
however, the neurosurgery team noted
increasing somnolence. He underwent

SPORT-RELATED STRUCTURAL BRAIN INJURY IN HIGH SCHOOL SOCCER

emergent evacuation of the EDH without
complications. His postoperative course
was unremarkable. He was discharged on
postoperative day 2.
Follow-Up
At both the 2-week and 3-month follow-up
visits, he did not express any complaints
or residual deficits. He was cleared for full
activity, including sports, at the 3-month
visit. He did not require any physical,
occupational, or cognitive therapy. After
sitting out 2e3 weeks from school, he did
not require any additional scholastic
accommodations.
DISCUSSION
To the best of our knowledge, the present
case is the second report of an EDH
resulting from an athletic head injury
while playing soccer. Several important
conclusions can be drawn, including the
mechanism of head-to-head contact,
continued emesis as the trigger for hospital evaluation, and the good long-term
outcome. Furthermore, future areas of
potential research can be suggested,
including video evaluation, protective
headgear, and the long-term return to
sports.
Similarities
Important similarities exist between the
present case and that reported by Bruzzone et al.13 First, both players were
injured while attempting to head the
ball. This mechanism is most commonly
implicated in soccer-related concussion
and appears to be similarly implicated in
SRSBIs.18,19 Moreover, both players
endorsed retrograde amnesia, which has
been found to portend a worse prognosis
and, in many cases, a more severe injury
after SRC.20-22 Both athletes also manifested persistent emesis (in addition to
seizure in the case reported by Bruzzone
et al.13), both had had clearly identifiable
triggers for hospital evaluation, both had
presented to a tertiary care hospital with
a Glasgow coma scale score of 15, and
both had made a complete recovery after
surgical evacuation, indicating that if the
EDH is diagnosed and treated early,
athletes with sports-related EDH can do
very well. This is not surprising and no
different than EDH due to general,
nonsports-related traumatic causes, which

WORLD NEUROSURGERY 127: 20-23, JULY 2019

Figure 1. Computed tomography scan
showing a 2.6-cm right, frontal epidural
hematoma after heading resulting in a
head-to-head collision in a soccer game.

have consistently shown positive outcomes compared with traumatic brain
injury from SDH.23
Return to Play
A notable difference between the 2 cases is
that our patient returned to play the same
day and experienced another fall, and the
patient reported by Bruzzone et al.13
immediately went to the hospital. Our
athlete
had
passed
all
sideline
concussion testing, and the retrograde
amnesia had quickly resolved. Although
the athlete was reportedly motionless for
a brief period, no obvious loss of
consciousness was witnessed. One
wonders whether a video review would
have captured an “impact seizure” or
“blank-stare,”
which
would
have
prompted immediate removal from play.
Evaluation of head impacts with video
review at the professional level has been
an increasing area of research, and the
signs of impact seizure, blank-stare, and
lying motionless have been found to be
very specific for an SRC diagnosis.24,25
Therefore, video review could have a role
in high school sports. In addition, the
postcollision slide tackle appeared to have
been irrelevant, indicating that a “second
impact” did not occur, and the EDH had
likely developed from the first, higher
energy head collision. It appears our
athlete experienced the classic “lucid interval” described in patients with EDH and

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CASE REPORT
NISHIT MUMMAREDDY ET AL.

then began to decline.26 This same lucid
interval was reported by Bruzzone
et al.,13 whose patient experienced a
seizure but not until 45 minutes after the
head impact.
Mechanism
Understanding the mechanism of injury
can provide crucial insights into injury
prevention and recognition. Our studentathlete experienced a head-to-head collision on the right and a ball-to-head impact
on the left, which allows us to conclude
that the head-to-head impact almost
certainly resulted in the EDH, rather than
the ball impact. Although ball-to-head
impacts have been shown to lead to SRC
in female soccer players,19 it appears that a
ball-to-head impact was not involved in
the SRSBI of the present patient, as one
would hypothesize owing to the biomechanical properties of the softer ball and
harder skull. The findings from both cases
support the notion that the act of heading
with a simultaneous head-to-head collision is the most dangerous.13 Coaches,
officials, and team medical personnel
should have a heightened sense of
awareness during any act of heading that
specifically involves head-to-head contact. Perhaps more routine sideline evaluations after a head-to-head impact can be
recommended, especially for those that
result in an athlete falling to the ground.
Some youth soccer leagues have banned
heading altogether, although this has
occurred only in youth soccer and would
not have applied to the our high school
athlete.27,28 Healthcare providers should
be aware that patients who, in the act of
heading, experienced a head-to-head
collision should be watched very closely,
and those involving ball-to-head mechanisms are much less risky regarding
SRSBI.
Single Impact
Regarding the mechanism, it appears that
EDHs in sports are due to a single highenergy impact rather than multiple subconcussive blows. Although we could not
be certain that our student-athlete had not
experienced additional subconcussive
blow before the principal impact, no lower
energy impacts were endorsed by the
athlete or observed by informants. EDHs
in sports have been seen in tennis, golf,
and soccer—all noncontact sports—

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SPORT-RELATED STRUCTURAL BRAIN INJURY IN HIGH SCHOOL SOCCER

confirming that a single high impact is the
culprit.13-16 One can hypothesize that the
most common mechanism would be a
single blow, possibly resulting in fracture,
although our patient did not experience a
skull fracture. Translating this to soccer,
although headgear has not been shown to
prevent the functional cerebral injury seen
in SRC, it is possible that protective
headgear could protect prevent against
structural injuries such as fractures and,
possibly, EDH.29 This is purely conjecture,
with no data to support or refute, but
could be an area of potential future study.
Long-Term Return to Sport
Regarding the outcomes, an SRSBI leading to EDH seems to result in a good
prognosis compared with SDH or injuries
to the brain parenchyma.3,30,31 Although
an SRSBI in the form of an EDH can be
seen as prognostically more favorable, an
SRSBI in the form of an SDH will
commonly result in significant mortality
and morbidity. Recently, a case series by
Yengo-Kahn et al.3 described permanent
neurological deficits in 3 consecutive
cases of student-athlete football players
experiencing an SDH. After 3 months, the
present patient—a competitive soccer
player—was allowed to return to soccer. In
contrast, the athlete reported by Bruzzone
et al.13 was allowed only to return to
jogging,
swimming,
and
cycling.
Theoretically, we believed it appropriate
that once the craniotomy had healed, the
athlete would be safe to return to sports.
This brings about an important
question—can the athlete return to a
contact sport after EDH? Also, if the
patient does, would some type of
headgear warranted? No data exist to
answer these questions.
Need for Increased Reporting of Cases
Finally, our case is only the second reported case of an EDH in soccer players.
Thus, it is difficult to fully understand the
pathology and provided appropriate prevention and treatment recommendations
without a larger sample. We encourage
clinicians and researchers worldwide to
study and report their findings on SRSBIs.
CONCLUSIONS
The present case has highlighted the
rareness of an SRSBI that occurred in

soccer and only the second case of EDH
that occurred during the act of heading.
Our student-athlete made a complete,
uncomplicated recovery from his SRSBI,
with a return to soccer at 3 months postoperatively. However, several notable
themes were found, including the mechanism of heading and head-to-head contact and persistent emesis as a trigger for
hospital evaluation. Many unanswered
questions about SRSBIs remain, including
the incidence rate of SRSBIs in general
and specific to each type. Thus, a
continued effort by those who treat and
study this entity should be made to report
their institution’s cases to make progress
in understanding the epidemiology of
these injuries. Furthermore, the pathogenesis of SRSBI should be understood
more thoroughly.
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SPORT-RELATED STRUCTURAL BRAIN INJURY IN HIGH SCHOOL SOCCER

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Conflict of interest statement: Gary S. Solomon is a
consultant for the Nashville Predators, Tennessee Titans, and
the athletic departments of Tennessee Tech University and
the University of Tennessee, with the fees paid to his
institution. He is also a consultant to the National Football
League Department of Health and Safety. The remaining
authors declare that the article content was composed in the
absence of any commercial or financial relationships that
could be construed as a potential conflict of interest.
Received 20 February 2019; accepted 19 March 2019

19. Zuckerman SL, Totten DJ, Rubel KE, Kuhn AW,
Yengo-Kahn AM, Solomon GS. Mechanisms of

27. U.S. Youth Soccer. US youth soccer announces
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usyouthsoccer.org/us_youth_soccer_announces_
relabeling_of_age_groups_and_heading_restriction_

WORLD NEUROSURGERY 127: 20-23, JULY 2019

Citation: World Neurosurg. (2019) 127:20-23.
https://doi.org/10.1016/j.wneu.2019.03.198
Journal homepage: www.journals.elsevier.com/worldneurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2019 Elsevier Inc. All
rights reserved.

www.journals.elsevier.com/world-neurosurgery

23