Second Impact Syndrome: A Rare But Usually Fatal Condition

An athlete who is recovering from a concussion but who has not yet fully recovered is at risk for a rare, but usually fatal, condition called second impact syndrome (SIS).

Typically, the athlete suffers post-concussion symptoms after the first head injury, such as headache, visual, motor or sensory changes or mental difficulty, especially with the thought and memory process. Before these symptoms have cleared, which may take minutes, hours, days or weeks, the athlete returns to competition and receives a second blow to the head, which can cause massive swelling in the brain.  Since the brain is contained inside the rigid bone of the skull, this swelling causes compression of the brain.  In severe cases, the brain is squeezed through small holes within the skull.  This squeezing of the brain through these small holes is known as “herniation.”  Herniation can lead to decreased blood flow to the brain, and ultimately, to the athlete’s death.

Sudden onset

The second blow may be unremarkable, perhaps only involving a blow to the chest that jerks the athlete’s head and indirectly sends accelerating forces to the brain. Affected athletes may appear stunned, but do not suffer loss of consciousness (LOC) and often complete the play. They usually remain alert on their feet for 15 seconds to 1 minute or so but seem dazed. Often, affected athletes remain on the playing field or walk off under their own power. Usually within seconds to minutes of the second impact, the athlete – conscious but stunned – suddenly collapses to the ground, semi-conscious with rapidly dilating (widening) pupils and loss of eye movement, and stops breathing.

Every year during football season, it seems, there is an article in the newspaper about an athlete who returned to football before he had recovered completely from a concussion. Often, the athlete told his doctor, athletic trainer, and coach that he was better but confided to friends and teammates that he still had lingering symptoms, such as headaches or nausea.  And, although no one remembers any major blows to the head or collisions, the athlete develops massive brain swelling and dies.

As Dr. William P. Meehan III,  Director of the Micheli Center for Sports Injury Prevention at Children’s Hospital Boston writes in his 2011 book, Kids, Sports, and Concussion, “[a]though second impact is rare, it has a devastating effect on those involved.  Those who do survive second impact syndrome are neurologically devastated. They often spend many weeks to months in a coma.  Many times they have a hole cut in their neck through which a permanent breathing tube is inserted. They are hooked up to a machine to help them breathe. They receive all of their nutrition intravenously as they are not awake enough or alert enough to eat or drink.”

Effect on medical personnel

He notes that the effect on the athletic trainer, team physician, primary care physician, and other medical personnel involved in the athlete’s care can also be devastating, with many:

• left wondering about their relationship with the athlete;
• confused as to why the athlete would not have spoken of his symptoms (the reluctance of athletes to honestly report concussion symptoms is an ongoing and serious problem);
• questioning whether or not there were other steps they could have taken in order to prevent the injury;
• starting to fear that other athletes on the team are perhaps downplaying their symptoms in order to return to play and are therefore at risk for second impact syndrome;
• often reluctant to allow future athletes to return after sustaining a sport-related concussion
• left wondering whether their coaching had something to do with the athlete downplaying his symptoms;
• wondering whether there was anything they cold have done to prevent the injury; and
• worrying about the remainder of athletes under their supervision.

Hardest on teammates

As Dr. Meehan notes, “second impact syndrome is perhaps hardest on the teammates of the injured player”:

• While some of them may have been aware that the athlete was still experiencing symptoms from his concussion, most were unaware that returning to play prior to complete recovery from a concussion could lead to such a devastating outcome.
• They often feel a sense of guilt about not informing the athletic trainer, parents, or coaching staff that the athlete was still experiencing symptoms (this is why SmartTeams strongly encourages implementation of a “buddy system” in which athletes watch for signs of concussion in a fellow teammate).
• They are devastated by the loss of their friend.
• They are haunted by thoughts that perhaps they could have prevented the injury.
• They fear for their own safety on the playing field.

All young athletes – male and female – at risk

Concussion experts agree that, in general, the younger the athlete, the longer it takes for the symptoms of a concussive event to clear. (2)   The brains of young athletes are still developing (2) making them particularly susceptible to catastrophic injury if the brain has not healed before a second blow to the head.  Indeed, the vast majority of the victims of Second Impact Syndrome (95% by some estimates) are under the age of eighteen, almost all of them males. Second impact syndrome (or what some see as a form of malignant cerebral oedema, or swelling) is known to occur only in young children and adolescents, and does not occur in the adult population. (3)

Dr. Meehan suspects, however, that “girls, women and older men are equally susceptible and cases [of second impact syndrome in these populations] may be seen in the future. Since the majority of athletes playing contact and collision sports are young men and boys, and since second impact syndrome is rare, it is statistically more likely to occur in young male athletes.”  But with the number of female athletes participating in contact and collision sports increasing every year, Dr. Meehan says that it “is possible that a case of second impact syndrome will occur in a female athlete in the future.”

Indeed, Dr. Meehan’s prediction came true in 2014,  when a 17-year-old female rugby player in Canada, Rowan Stringer, was found to have died as a result of  second impact syndrome, after returning to play days after she suffered a severe concussion after being tackled hard during a game four days before, hitting her head and neck on the ground, after failing a driving test, and after admitting to friends, but not to her coach or medical personnel, that she was still experiencing concussion symptoms.  

Keeping SIS in perspective

In an editorial in the September 2012 Clinical Journal of Sports Medicine (1), Loyola Chicago neuropsychologist Christopher Randolph reminds parents that “the risk of catastrophic outcome after sport-related concussion is very low.  Each year, tens of millions of young people participate in organized sports, and death from sport-related head trauma, although devastating in every case, occurs less than death by a host of other causes, including sport-related cardiovascular events and lighting strikes.”  

As a result, Randolph says, “all athletes and parents need to be counseled that catastrophic outcomes from head injuries are an extremely rare, but inherent, risk of contact sports, and he argues that to suggest “that such an outcome would be eliminated by simply preventing repeat concussions or ‘second impact syndrome’ is grossly misleading.”

1. Kirkwood MW, Randolph C, Yeates KO. Sport-Related Concussion: A Call for Evidence and Perspective Amidst the Alarms. Clin J Sports Med 2012;22(5):383-384.  

2. Davis GA, Purcell LK. The evaluation and management of acute concussion in young children. Br J Sports Med. 2014;48:98-101. doi:10.1136/bjsports-2012-092132.

3. McCrory P, Davis G, Makdissi M. Second impact or cerebral swelling after sporting head injury.  Curr Sports Med Rep. 2012;11:21-23.