In which subset of patients with concussion do you recommend further brain imaging?

I recommend further imaging of a concussion patient in a subset of patients. If the patient had a seizure with the head injury or any sign of declining mentation within the first few hours, they should have a CT head emergently. If it is within 1 week from injury and they report steadily worsening every day or if any focal findings on neurologic exam, then I would order STAT CT head without contrast in an outpatient setting. If they have not improved and stayed about the same after weeks to months from the injury despite treatment interventions (NSAIDs, physical therapy, lifestyle modifications, etc.), then I order an MRI brain with and without contrast with SWI sequences. If the patient has persistent headaches, the contrast will rule out ...

Initial management of a concussion with confusion and memory difficulty consists of brief (24–48 hours) relative physical and cognitive rest, followed by a gradual, individualized return to normal activities as tolerated, but avoiding strict prolonged rest (“cocooning”). After the initial rest period, patients should progressively resume cognitive and physical activities, provided these do not significantly worsen symptoms.

Nonpharmacological interventions are important, especially for cognitive symptoms such as confusion and memory difficulty. These include psychoeducation, cognitive rehabilitation, and cognitive-behavioral therapy, with accommodations (such as reduced workload with written instructions. For persistent symptoms, aerobic e...