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In the Indian subcontinent, traumatic brain injury stands as the leading cause of pediatric stroke, whereas in Europe, it is considered a rare or potentially underdiagnosed factor. The etiology of post-traumatic stroke is unknown, although it has been associated with the presence of calcification in the lenticulostriate arteries, a condition known as "mineralizing angiopathy." The theory suggests that calcified lenticulostriate vessels in a brain with inadequate myelination could have an increased vulnerability to mechanical injuries, which may result in their obstruction. This ischemic stroke associated with mineralizing angiopathy usually occurs after mild traumatic brain injury, with an asymptomatic interval following the trauma. The typical age of presentation is between 6 and 24 months. Children with mineralizing lenticulostriate vasculopathy generally experience a favorable outcome after stroke, with the majority achieving complete or nearly complete recovery of their motor functions. Despite aspirin treatment, a small proportion of children may still face stroke recurrence following repeat head trauma. We present the cases of two male patients with clinical features compatible with childhood stroke after a mild traumatic brain injury.

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Sub-acute subdural hematoma (SASDH) in the elderly is a challenging diagnosis given its insidious onset and nonspecific presentation, particularly following minor head trauma. This case report highlights the clinical features, diagnostic challenges, and management of SASDH in an elderly patient. A 72-year-old male presented with a five-day history of giddiness, headache, and balance issues, which began suddenly without a significant triggering event. His medical history was notable only for a minor fall approximately one month before presentation, after which he experienced no immediate or significant symptoms. An MRI at an outside hospital revealed bilateral frontoparietotemporal SASDHs with diffuse cerebral edema. The patient underwent a bilateral mini craniotomy for hematoma evacuation and was managed postoperatively with anti-seizure medications and supportive care, resulting in a satisfactory outcome. The diagnosis of SASDH requires a high index of suspicion, especially in the elderly, who may present with vague and progressive symptoms following minor head trauma. Early and accurate diagnosis via imaging, particularly MRI, is crucial for effective management. Surgical intervention, typically involving hematoma evacuation, significantly improves outcomes in patients with SASDH, underscoring the importance of timely surgical referral and treatment. Elderly patients presenting with unexplained neurological symptoms following even minor trauma should be evaluated for SASDH. Early recognition and intervention are crucial to prevent long-term morbidity and mortality in this vulnerable population.

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Chronic subdural hematoma (cSDH) is a common disease in the neurological and neurosurgical world. The recommended treatment for cSDH patients with moderate or severe neurological symptoms is surgical evacuation, but cSDH frequently recurs. The patient's ABO blood type may influence the outcome. This study aims to evaluate the correlation between cSDH recurrence and blood type O. We performed a retrospective analysis of the data of patients with cSDH who were surgically treated. Recurrence was defined as the need for re-operation within the first 12 weeks after the initial surgery. We analyzed standard demographic data, duration and type of surgery, ABO blood types, and the re-operation rate. Univariate and multivariate analyses were conducted. A total of 229 patients were included. The recurrence of hematoma was identified in 20.5% of patients. Blood type O was found to be significantly associated with cSDH recurrence leading to re-operation within 12 weeks (p = 0.02, OR 1.9, 95% CI 1.1-3.5). Thrombocyte aggregation inhibition and oral anticoagulants were not predictors of cSDH recurrence. Patients with blood type O in our cohort were identified to be at higher risk of cSDH recurrence and may, therefore, be a more vulnerable patient group. This finding needs further evaluation in larger cohorts.

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Minor head trauma (MHT) is very frequent in children and post-traumatic headache (PTH) is one of its most common complications; however, its management is still a challenge. We aimed to assess the incidence and clinical characteristics of, and risk factors for, PTH among children referred to our pediatric emergency department (PED) for MHT. A total of 193 patients aged 3-14 years evaluated for MTH were enrolled and followed up for 6 months through phone calls and/or visits. PTH occurred in 25/193 patients (13%). PTH prevalence was significantly higher in school-aged (≥6 years) than in pre-school-aged children (21.6% vs. 4.9%, respectively, p < 0.009). Females were found to be more affected. The median time of onset was 4.6 days after MHT; resolution occurred in a median of 7 weeks. In 83.3% of patients, PTH subsided in <3 months, while in 16.7% it persisted longer. A total of 25% of children exhibited the migraine and 75% the tension-type variant. Our analysis indicates the presence of headache upon arrival in PED, isolated or associated with nausea and dizziness, as a factor predisposing the patient to the development of PTH. Our findings could be useful to identify children at risk for PTH for specific follow-up, family counseling, and treatment.

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AIM: Validated clinical decision rules on neuroimaging are not available for children who are evaluated more than 24 h after a minor head trauma. We compared clinically important traumatic brain injuries in children who presented with a minor head trauma within or after 24 h. METHODS: This was a retrospective analysis of patients aged 0-17 years, who were evaluated for minor head traumas by five paediatric emergency departments in Northern Italy between January 2019 and June 2020. Children with clinically important traumatic brain injuries were divided into those who had presented within and after 24 h. RESULTS: The study comprised 5981 children (59.9% boys), with a median age of 2 years, including 243 (4.1%) who had presented more than 24 h after their minor head trauma. Neuroimaging was performed on 448 (7.5%) patients and the time of presentation had no impact on the rates of clinically important traumatic brain injuries. Multiple logistic regression did not show any association between clinically important traumatic brain injuries and late presentation. CONCLUSION: Delayed presentation to a paediatric emergency department after a minor head trauma did not alter the risk of clinically important traumatic brain injuries and the same neuroimaging rules could apply.

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Minor blunt head trauma (MHT) represents a common reason for presentation to the pediatric emergency department (ED). Despite the low incidence of clinically important traumatic brain injuries (ciTBIs) following MHT, many children undergo computed tomography (CT), exposing them to the risk associated with ionizing radiation. The clinical predictions rules developed by the Pediatric Emergency Care Applied Research Network (PECARN) for MHT are validated accurate tools to support decision-making about neuroimaging for these children to safely reduce CT scans. However, a few non-ionizing imaging modalities have the potential to contribute to further decrease CT use. This narrative review provides an overview of the evidence on the available non-ionizing imaging modalities that could be used in the management of children with MHT, including point of care ultrasound (POCUS) of the skull, near-infrared spectroscopy (NIRS) technology and rapid magnetic resonance imaging (MRI). Skull ultrasound has proven an accurate bedside tool to identify the presence and characteristics of skull fractures. Portable handheld NIRS devices seem to be accurate screening tools to identify intracranial hematomas also in pediatric MHT, in selected scenarios. Both imaging modalities may have a role as adjuncts to the PECARN rule to help refine clinicians' decision making for children at high or intermediate PECARN risk of ciTBI. Lastly, rapid MRI is emerging as a feasible and accurate alternative to CT scan both in the ED setting and when repeat imaging is needed. Advantages and downsides of each modality are discussed in detail in the review.

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BACKGROUND: The presence of oral anticoagulant therapy (OAT) alone, regardless of patient condition, is an indication for CT imaging in patients with mild traumatic brain injury (MTBI). Currently, no specific clinical decision rules are available for OAT patients. The aim of the study was to identify which clinical risk factors easily identifiable at first ED evaluation may be associated with an increased risk of post-traumatic intracranial haemorrhage (ICH) in OAT patients who suffered an MTBI. METHODS: Three thousand fifty-four patients in OAT with MTBI from four Italian centers were retrospectively considered. A decision tree analysis using the classification and regression tree (CART) method was conducted to evaluate both the pre- and post-traumatic clinical risk factors most associated with the presence of post-traumatic ICH after MTBI and their possible role in determining the patient's risk. The decision tree analysis used all clinical risk factors identified at the first ED evaluation as input predictor variables. RESULTS: ICH following MTBI was present in 9.5% of patients (290/3054). The CART model created a decision tree using 5 risk factors, post-traumatic amnesia, post-traumatic transitory loss of consciousness, greater trauma dynamic, GCS less than 15, evidence of trauma above the clavicles, capable of stratifying patients into different increasing levels of ICH risk (from 2.5 to 61.4%). The absence of concussion and neurological alteration at admission appears to significantly reduce the possible presence of ICH. CONCLUSIONS: The machine-learning-based CART model identified distinct prognostic groups of patients with distinct outcomes according to on clinical risk factors. Decision trees can be useful as guidance in patient selection and risk stratification of patients in OAT with MTBI.

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BACKGROUND: The most common cause of death or severe impairment in children older than one-year-old is traumatic brain injury (TBI). Assessing TBI in children with minor head trauma (MHT) using clinical findings from history-taking and a physical exam is crucial to minimizing unnecessary brain CTs and more accurately predicting TBI. We aimed to evaluate the findings of brain CT scans in children with mild head trauma and their relationship with clinical signs and symptoms to avoid unnecessary interventions in many children with MHT. METHODS: This cross-sectional-analytical study was performed to evaluate the findings of brain CT scans in children with MHT and their relationship with clinical signs and symptoms that were referred to Poursina Hospital in Rasht in the first half of 2021. Children were divided into two age groups: under two years and 2-12 years, and analyzed separately. Initially, a list containing all demographic information, patients' clinical signs, and symptoms were prepared. The collected data were then analyzed using SPSS software version 26. RESULTS: According to the results, the mean age of patients was 66.01 months and 88 were boys (56.4%). The most common mechanism of injury was falling from a height. Most patients had isolated head injuries. Among the accompanying injuries, facial injuries were the most common. Among the clinical factors studied, cranial fracture on CT scan and GCS less than 15 were significantly associated with the occurrence of traumatic brain injury on CT scan. In addition, cranial fracture on CT scan, injury severity, and history of vomiting had the highest positive predictive value, respectively. CONCLUSION: Standard history and clinical examination are sufficient to identify high-risk cases of pediatric head injuries. GCS is the most important risk factor for pediatric MHT. Requesting a CT scan is not recommended without these risk factors.

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PURPOSE: Due to the increase in accessibility of computed tomography (CT), repeat head CT scans are routinely ordered for patients with minor head injuries. The aim of this study is to evaluate the necessity and outcomes of routine repeat head CT in patients with GCS score of 13-15 who presented to the emergency department (ED) of Antalya University Hospital in Turkey with blunt head trauma. METHODS: We retrospectively reviewed the charts of patients with minor head trauma that received initial and repeat head CT results from July 1, 2013 to June 30, 2015. Clinical characteristics of patients were compared for two groups of patients: those with neurological deterioration, and those who had routine head CT not required by change in neurological status. Repeat head CT results were analyzed for radiological worsening and the necessity of a surgical or medical intervention such as craniotomy, ICP monitoring, VP shunt and mannitol or hypertonic saline administration. RESULTS: Of 3578 patients with blunt head trauma, 656 (18.3%) patients had repeat head CT; 449 of these (68.4%) had a GCS score of 13-15. We analyzed 441 patients for CT and clinical changes. Eight patients were excluded because of poor image quality and/or penetrating injury. Neurological deterioration was the reason for repeat head CT in 73 (16.5%) patients Rates of medical (mannitol treatment) or surgical (craniotomy) intervention in this group were 26% (95% Confidence Interval [95% CI], 15.7-36.3%) in contrast to 0.8% (95% CI 0.1-1.7%) in the group of patients with routinely ordered head CT but without clinical deterioration. The following factors were statistically associated with need for intervention: use of anticoagulant or antithrombotic medication, fracture in middle meningeal artery territory, even a single point decrease in GCS score, increased headache, recurrent vomiting, neurological deficit, and finally, changes in repeat head CT. CONCLUSIONS: In patients with minor head injuries, those without neurological deterioration have a very low risk of need for medical or surgical intervention. Routinely ordering repeat head CT scans in this group may not be routinely indicated.

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BACKGROUND: Deciding whether a cranial Computed Tomography (CT) scan in a patient with minor head trauma (MHT) is necessary or not has always been challenging. Diagnosing Traumatic Brain Injury (TBI) is a fundamental part of MHT managing especially in children who are more vulnerable in terms of brain CT radiation consequences and TBI. Defining some indications to timely and efficiently predict the likelihood of TBI is necessary. Thus, we aimed to determine the impact of clinical findings to predict the need for brain CT in children with MHT. METHODS: In a prospective cohort study, 200 children (2 to 14 years) with MHT were included from 2019 to 2020. The data of MHT-related clinical findings were gathered. The primary and secondary outcomes were defined as a positive brain CT and any TBI requiring neurosurgery intervention, respectively. In statistical analysis, we performed Binary Logistic regression analysis, Fisher's exact test and independent samples t-test using SPSS V.26. RESULTS: The mean age of participants was 6.5 ± 3.06 years. Ninety patients underwent brain CT. The most common clinical finding and injury mechanism were headache and falling from height, respectively. The results of brain CTs were positive in seven patients (3.5%). We identified three predicting factors for an abnormal brain CT including headache, decreased level of consciousness, and vomiting. CONCLUSION: We showed that repetitive vomiting (≥2), headache, and decreased level of consciousness are predicting factors for an abnormal brain CT in children with MHT.

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BACKGROUND: In pediatric patients with minor head trauma, computed tomography (CT) is often performed beyond the scope of recommendations that are based on existing algorithms. Herein, we evaluated pediatric patients with minor head trauma who underwent CT examinations, quantified its frequency, and determined how often traumatic findings were observed in the intracranial region or skull. METHODS: We retrospectively reviewed the medical records and neuroimages of pediatric patients (0-5 years) who presented at our hospital with minor head trauma within 24 h after injury. RESULTS: Of 2405 eligible patients, 1592 (66.2%) underwent CT examinations and 45 (1.9%) had traumatic intracranial hemorrhage or skull fracture on CT. No patient underwent surgery or intensive treatment. Multivariate analyses revealed that an age of 1-5 years (vs. <1 year; P < 0.001), Glasgow Coma Scale (GCS) score of 14 (vs. a score of 15; P = 0.008), sustaining a high-altitude fall (P < 0.001), using an ambulance (P < 0.001), and vomiting (P < 0.001) were significantly associated with the performance of CT examination. In addition, traumatic abnormalities on CT were significantly associated with the combination of an age of under 1 year (P = 0.042), GCS score of 14 (P < 0.001), and sustaining a high-altitude fall (P = 0.004). CONCLUSION: Although slightly broader indications for CT use, compared to the previous algorithms, could detect and evaluate minor traumatic changes in pediatric patients with minor head trauma, over-indications for CT examinations to detect only approximately 2% of abnormalities should be avoided and the indications should be determined based on the patient's age, condition, and cause of injury.

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INTRODUCTION: Minor head trauma in the child, whether accidental or inflicted, is a frequent reason for seeking medical attention. Our aim is to describe the characteristics of minor head trauma in children aged 0-3 years and the resulting injuries. This in order to help the clinician to suspect and thelegal expert to confirm intentional abuse. STUDY DESIGN: Children aged from 0 to 3 years with minor head trauma and attending the pediatric emergency department were included in the study between January 2013 and June 2014. The correlation between the characteristics of trauma and the resulting injuries was analyzed using a prospective data collection questionnaire completed by the physicians who cared for the child. RESULTS: A total of 709 children with minor head trauma were included in the study. In nearly 90% of cases, fall height was less than 1 m. Only one-third of children aged less than 6 months had external head injury. Low-intensity trauma, such as a low-velocity fall from a height of less than 1.5 m does not cause intracranial injury. External injuries were more frequent in children who had a fall with an anterior impact, while internal injuries were found only in posterior and lateral impacts. CONCLUSION: In the context of minor head trauma, the physician must be vigilant and must ask for a full and clear description of the trauma, its mechanisms and other characteristics, when external or internal head injuries are observed in children aged less than 6 months.

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INTRODUCTION: Traumatic oculomotor nerve injury is usually caused by severe head trauma and is generally associated with other neurological deficits such as basilar skull fracture, orbital injury, or subarachnoid hemorrhage. Isolated traumatic oculomotor nerve injury after minor head trauma and its MRI findings are rarely reported. CASE PRESENTATION: We report a case of a 13-year-old girl with mydriasis, limited inferior and medial movement of the left eyeball, and left ptosis after a mild bump of the left forehead and eye into an electricity pole. The symptoms suggested left oculomotor nerve palsy, but initial facial computed tomography and brain MRI did not reveal any intracranial lesions or fractures in the skull and orbit. Cranial nerve MRI showed segmental hyperintensities and mild thickening of the left oculomotor nerve from the cavernous segment to the proximal orbital segment on T2 short tau inversion recovery and 3D fluid-attenuated inversion recovery volume isotropic turbo spin-echo acquisition sequences. The patient received treatment with oral pyridostigmine for 7 days and was fully recovered at 14 months after injury. DISCUSSION: As traumatic oculomotor nerve palsy can occur without intracranial hematomas or skull base fractures, routine brain MRI may not always reveal abnormalities; thus, MRI dedicated to imaging of the oculomotor nerve using FS T2WI and high-resolution 3D sequences can be helpful for the diagnosis and management of patients suspected of isolated oculomotor nerve injury.

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PURPOSE: The PECARN head trauma (HT) prediction rules have been developed to guide computed tomography-related decision-making for children with minor HT (mHT). There are currently limited data on the rate of unscheduled revisits to emergency departments (EDs), and initially missed intracranial injuries, in children with mHT initially assessed using the PECARN rules. This study aimed to fill this gap in knowledge. METHODS: Clinical charts of children assessed for mHT over a 5-year period at two EDs that implemented the PECARN rules in Italy and France were reviewed retrospectively. Children who returned to EDs for mHT-related, or potentially related complaints, within 1 month of initial assessment were included. RESULTS: The total number of children with mHT presenting for the first time to the EDs of both sites was 11,749. Overall, 180 (1.5%) unscheduled revisits to the EDs occurred for mHT-related or potentially related complaints. Twenty-three of these 180 patients underwent neuroimaging, and seven had an intracranial injury (including one ischemic stroke). Of these, three were hospitalized and none needed neurosurgery or intensive care. CONCLUSION: Unscheduled revisits for mHT in EDs using the PECARN rules were very uncommon. Initially missed intracranial injuries were rare, and none needed neurosurgery or intensive care.

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BACKGROUND: Managing children with minor head trauma remains challenging for physicians who evaluate for the need for computed tomography (CT) imaging for clinically important traumatic brain injury (ciTBI) identification. The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules were adopted in our pediatric emergency department (PED) in December 2013 to identify children at low risk for ciTBI. This study aimed to evaluate this implementation's impact on CT rates and clinical outcomes. METHODS: Retrospective cohort study on pediatric patients with head trauma presenting to the PED of the American University of Beirut Medical Center in Lebanon. Participants were divided into pre- (December 2012 to December 2013) and post-PECARN (January 2014 to December 2016) groups. Patients were further divided into < 2 and ≥ 2 years and stratified into groups of low, intermediate and high risk for ciTBI. Bivariate analysis was conducted to determine differences between both groups. RESULTS: We included 1362 children of which 425 (31.2%) presented pre- and 937 (68.8%) presented post-PECARN rules implementation with 1090 (80.0%) of low, 214 (15.7%) of intermediate and 58 (4.3%) of high risk for ciTBI. CTs were ordered on 92 (21.6%) pre- versus 174 (18.6%) patients post-PECARN (p = 0.18). Among patients < 2 years, CT rates significantly decreased from 25.2% (34/135) to 16.5% (51/309) post-PECARN (p = 0.03), and dropped in all risk groups but only significantly for low risk patients from 20.7% (24/116) to 11.4% (30/264) (p = 0.02). There was no significant decrease in CT rates in patients ≥2 years (20% pre (58/290) vs 19.6% post (123/628), p = 0.88). There was no increase in bounce back numbers, nor in admission rates or positive CT findings among bounce backs. CONCLUSIONS: PECARN rules implementation did not significantly change the overall CT scan rate but reduced the CT scan rate in patients aged < 2 years at low risk of ciTBI. The implementation did not increase the number of missed ciTBI.

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Background and objectives: Anticoagulants are thought to increase the risks of traumatic intracranial injury and poor clinical outcomes after blunt head trauma. The safety of using direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) after intracranial hemorrhage (ICH) is unclear. This study aims to compare the incidence of post-traumatic ICH following mild head injury (MHI) and to assess the need for surgery, mortality rates, emergency department (ED) revisit rates, and the volume of ICH. Materials and Methods: This is a retrospective, single-center observational study on all patients admitted to our emergency department for mild head trauma from 1 January 2016, to 31 December 2018. We enrolled 234 anticoagulated patients, of which 156 were on VKAs and 78 on DOACs. Patients underwent computed tomography (CT) scans on arrival (T0) and after 24 h (T24). The control group consisted of patients not taking anticoagulants, had no clotting disorders, and who reported an MHI in the same period. About 54% in the control group had CTs performed. Results: The anticoagulated groups were comparable in baseline parameters. Patients on VKA developed ICH more frequently than patients on DOACs and the control group at 17%, 5.13%, and 7.5%, respectively. No significant difference between the two groups was noted in terms of surgery, intrahospital mortality rates, ED revisit rates, and the volume of ICH. Conclusions: Patients with mild head trauma on DOAC therapy had a similar prevalence of ICH to that of the control group. Meanwhile, patients on VKA therapy had about twice the ICH prevalence than that on the control group or patients on DOAC, which remained after correcting for age. No significant difference in the need for surgery was determined; however, this result must take into account the very small number of patients needing surgery.

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PURPOSE: We report five rare cases of programmable valve breakage (Codman Hakim-Medos valve) in shunt systems of children with posthemorrhagic hydrocephalus. Only four similar studies have been published in the current literature. METHODS: Between 2013 and 2018, five children with posthemorrhagic hydrocephalus were admitted to the pediatric department. All patients had a history of slight blows to the head in a minor trauma and follow up MRI scans. After initial clinical examination, cranial computed tomography (CT) and X-ray were conducted. RESULTS: In all cases, pumping the reservoir resulted in very slow refilling. The cranial CT in one patient showed slit ventricles confirming the suspicion of overdrainage, the other cases a slight enhancement of the hydrocephalus. In lateral X-rays of the skull in comparison to the first X-ray control of the shunt valve, the pressure control chamber could be seen dislocated in the inferior part of the reservoir in all cases. Surgery revealed that the shunt valve was broken. The pressure control chamber had dropped to the bottom of the reservoir. After implantation of a new shunt valve, the symptoms resolved completely in all five children. Overall this complication occurred in 4.3% (5 of 85 implanted Codman Hakim-Medos valve) of all children necessitating ventriculoperitoneal shunt implantation between January 2013 and December 2018. CONCLUSION: The well-accepted Codman Hakim-Medos programmable valve is part of a tube-system, which is designed to offer the possibility of a reliable and precise treatment of hydrocephalus. Various mechanical and non-mechanical complications of shunt systems have been reported. Valve breakage is a very rare condition, often missed, and must be kept in mind when trauma and prior MRI scan are reported.

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BACKGROUND: Head trauma in children is one of the most common causes for emergency department visits. Although most trauma cases are minor, identifying those patients who have clinically important traumatic brain injury (ciTBI) is challenging. The Pediatric Emergency Care Applied Research Network (PECARN) head trauma prediction rules identifying children who do not require cranial computed tomography (CT) were validated and are used all over the world. However, these rules have not been validated with large cohort multicenter studies in Asia. OBJECTIVES: To investigate whether the PECARN rules can be safely applied to Japanese children. METHODS: We conducted a multicenter, prospective, observational cohort study. We included children younger than 16 with minor head trauma (Glasgow Coma Scale ≥14) who presented to the six participating centers within 24 h of their injuries between June 2016 and September 2017. The primary analysis was set to calculate the negative predictive value of the patients with very low risk by the PECARN rules, compared with a preset threshold of 99.85%. RESULTS: We included 6585 children of which 463 (7.0%) had head CT scans performed and 23 (0.35%) had ciTBI. There were two patients with ciTBI who were classified as very low risk. The negative predictive value, calculated as 99.96% (95%CI: 99.86-100.00; P = .019), was significantly superior compared with the preset threshold of 99.85%. CONCLUSIONS: The PECARN head trauma prediction rules seemed to be safely applicable to Japanese children. Further studies are needed to determine safety in hospitals where physicians do not have expertise in managing children.

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We report a case of QTc prolongation associated with mild concussion in a pediatric patient. An 11-year-old male presented to the emergency department after sustaining a head injury during football practice. He complained of headache and blurry vision. Physical examination was within normal apart from an irregular heart rhythm. Electrocardiogram (ECG) showed normal sinus rhythm with QTc (Bazett formula) 460 ms. The patient was diagnosed with concussion and referred for cardiology follow-up of the QTc. ECG the next day showed QTc 462 ms (heart rate 105 bpm) supine and 494 ms after suddenly standing up (heart rate 120 bpm). Family history was negative for sudden cardiac events. Exercise stress testing 1 week later showed a baseline QTc 462 ms and 488 ms at 4 min into recovery. Holter monitoring showed evidence of increased parasympathetic activity manifested by marked sinus arrhythmia. Repeated ECG, exercise stress testing, and Holter monitoring 3 months later showed normalized QTc values. His concussion symptoms were resolved at the time of repeat testing. Mild head trauma/concussion could be associated with prolonged QTc and abnormal cardiac repolarization. While these changes seem to be self-limiting, they remain a possible substrate for malignant arrhythmias. Recognition of these changes would lead to appropriate reassurance and/or precautions in the acute setting, especially in at-risk populations such as long QT syndrome patients.

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