Ringside Doctors Publish Consensus Statement on Fighter Brain Imaging

Combat Sports have no consistent standards of what brain imaging is needed from jurisdiction to jurisdiction. From national federations, to State and Tribal Commission to Provincial and even Municipal Commissions and in some cases to no commissions at all there is profound inconsistency in health and safety standards in combat sports.

Hoping to improve this reality today the Association of Ringside Physicians (a non profit international organization of doctors practicing ringside medicine) published a consensus statement setting out what brain imaging should take place before a fighter is allowed to compete and what imaging should take place after a bout.

The following consensus was published for pre bout imaging:

  • A brain MRI (1.5 Tesla minimum or 3 Tesla magnet strength) is the recommended imaging modality of choice to assess for any structural pathology and to establish a baseline at the time of initial licensure.
  • When a brain MRI is not feasible, either due to its non-availability, or a combat sports athlete has an absolute contraindication to an MRI scan, a CT of the brain with and without intravenous contrast may suffice with the knowledge of the limitations of CT scan technology. It is recommended that such combat sports athletes also undergo a comprehensive neurological exam at the time of initial licensure.
  • Any combatant with an aneurysm or arteriovenous malformation (AVM) should be denied professional licensure in combat sports. Cavernous malformations range in size from less than one-quarter inch to 3–4 inches and have a lower risk of bleeding as compared to aneurysms and AVMs. At present there is no consensus on an acceptable size of cavernous malformation with respect to combat sports. Combatants with cavernous malformations in the brain MRI need further evaluation and clearance from a neurologist or a neurosurgeon prior to licensure. Preferably this clearance should be obtained from a physician with experience in management of cerebral vascular malformations.
  • Combatants with venous anomalies on brain MRI may be allowed licensure on a case-by-case basis after clearance from a neurologist or neurosurgeon. Preferably this clearance should be obtained from a physician with experience in management of cerebral vascular malformations.
  • At present there is no consensus on acceptable size of other structural lesions such as arachnoid cysts. Combatants with large arachnoid cysts should be denied licensure. Combatants with small-sized arachnoid cysts may be granted licensure after clearance from a neurologist or neurosurgeon. Preferably this clearance should be obtained from a physician with experience in management of these cysts.
  • Repeat brain MRI should be considered if there is neurological/neurocognitive decline from baseline.
  • Repeat brain MRI should also be performed prior to the next bout if a combat sports athlete sustained a significant head impact exposure (in competition/training) that poses a risk for TBI. When repeat brain MRI is not feasible, either due to its non-availability, or a combat sports athlete has an absolute contraindication to an MRI scan, a CT of the brain with and without contrast may suffice with the knowledge of limitations of CT technology and balancing cumulative radiation exposure against clinical utility.
  • Regardless of suspected neurological decline or history of significant injury, repeat brain MRI should be performed at a minimum every 3 years provided initial/previous imaging had no abnormalities. If previous brain MRI has shown an abnormality, more frequent repeat imaging is indicated. All repeat imaging should be compared to baseline/previous imaging. When repeat brain MRI is not feasible, either due to its non-availability, or a combat sports athlete has an absolute contraindication to an MRI scan, a CT of the brain with and without contrast may suffice with the knowledge of limitations of CT technology and balancing cumulative radiation exposure against clinical utility.
  • A CTA or MRA of the brain is recommended in addition to an MRI of the brain at the time of initial licensure for all combat sports athletes 40 years or older.
  • The decision to medically clear a combat sports athlete to compete when imaging suggests evidence of an abnormality, prior/chronic TBI, or change from baseline, should be made on a case-by-case basis after careful consideration and review of the combat sports athlete’s medical and family history, age, fight record, neurological examination, and neurocognitive assessment.
  • The role of more advanced neuroimaging techniques such as DTI, ASL, fMRI, MTI, MSI, and MEG in risk stratification and prognostication needs further study and should be considered on a case-by-case basis.

For post bout imaging the ARP’s consensus statement is as follows:

  • An urgent CT scan of the head without contrast is recommended if the combat sports athlete demonstrates any of the ‘red flag’ during the bout or in the immediate aftermath of the bout
  • A combat sports athlete who demonstrates any of the ‘red flag’ signs and symptoms should be transported immediately via on-site ambulance to a designated trauma center for evaluation. Transport to a Level I trauma center with 24 h in-house coverage by neurosurgery and neurology is recommended.
  • Clinical decision regarding the need for cervical spine imaging should be made on a case-by-case basis determined by the mechanism of injury, presence or absence of numbness and tingling in the extremities, neck pain, midline tenderness, and neurological deficit.
  • These are the ‘red flags; mentioned above –
‘Red Flag’ Signs and Symptoms of Serious Brain Injury
Glasgow Coma Scale (GCS) <15
Suspected open, depressed or basal skull fracture
Cerebrospinal fluid (CSF) coming out of nose or ears
Post-traumatic seizure
Focal neurological deficit
>1 episode of vomiting since the head injury
Pupillary abnormality
Progressive increase of headache, nausea/vomiting, light/ noise sensitivity and vision problems
Deterioration of mental status/overall condition

The full article, titled Neuroimaging in professional combat sports: consensus statement from the association of ringside physicians, can be accessed for free here.

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