Reflections on 40 Years as a Sideline Physician

G. Robert Nugent, M.D.


Neurosurg Focus. 2006;21(4):1-5. 

In This Article

The Second-Impact Syndrome

In 1984 Saunders and Harbaugh[10] described a football player who after a head injury remained symptomatic for 1 week but still returned to play, only to suffer a second injury with edema, which was fatal. It was postulated that the cause of the fatal cerebral hemorrhage was a failure of autoregulation. This was the birth of the so-called second-impact syndrome, about which much concern and fear has been expressed ever since. Although I have not seen the syndrome, I have had a long-standing interest in the matter and have had some reservations about its validity. If it is a real problem, why don't we see it regularly in boxers? And what is the evidence that this phenomenon is due to a failure of autoregulation?

In 1998, McCrory and Berkovic[8] re viewed the reported cases of this syndrome and found only 17 that met their criteria for the entity. Their criteria consisted of the following: 1) medical review after a witnessed first impact; 2) documentation of ongoing symptoms following the initial impact up to the time of the second impact; 3) witnessed second head impact with a subsequent rapid cerebral deterioration; and 4) neuro path ological or neuroimaging evidence of cerebral swelling without a significant intracranial hematoma or another cause of cerebral edema (for example, encephalitis). They found that none of the reported cases met these criteria and in 12 of them there was no documented second impact; many of the players merely collapsed during the second play. There were only five probable cases of the syndrome, and the athletes involved in cluded three boxers, one ice hockey player, and one high school football player. It was of interest that all of these probable cases, and most of the ones in the series, in volved teenagers. McCrory and Berkovic raise the question whether the second-impact syndrome really exists or whether it is more related to the severe and often fatal cerebral edema seen in association with head trauma in children, which has been described previously.[2,3,9] Is this problem then unrelated to a second impact, and is it one that is more of a first-impact syndrome that is unique to injury in the young brain?


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