Revista de Medicina Desportiva (English) September 2018 | Page 23
described in athletes, in the third
decade of life, victims of minor CET,
without severe brain hemorrhagic
lesions. The autopsies revealed CM1,
no signs of syringomyelia, but with
herniation of the cerebellar tonsils
down to the 7 th cervical vertebra
(about 110mm in relation to fora-
men magnum). 9,10 In 2014, Wang H
describes the case of a 23-year-old
athlete, a victim of CET after a fall
of his own height. He started with
occipital headaches, ataxia, dyspha-
gia and tetraparesis. The neuroradio-
logical exams revealed CM1 without
syringomyelia, signs of obstruction
of the 4 th ventricle and a hernia-
tion of 18mm. A craniectomy of the
posterior fossa was performed,
associated with the removal of the
posterior arc of C1 as an emergency
procedure, with complete resolu-
tion of the neurological problrms in
thirty days. 11
Strahle and Meehan conducted
retrospectives studies in 650 young
athletes with diagnosis of CM1 not
subjected to surgery. No case of
sudden death or focal neurological
injury has been recorded. 66 cases
of cerebral concussion were identi-
fied. 12,13 According to Clay’s study
of the epidemiology of the cerebral
concussion in sporting practice,
the number registered corresponds
to twice the cases normally refer-
enced. 14
The sports-medical examination
applied in Portugal does not value
in a detailed way the existence of
neurological signs and symptoms. In
the medical evaluation of the ath-
letes of CS it is important to value
the existence of headaches, cervical
pain and different changes of the
sensitivity, both in the trunk and in
the limbs.
The risk for the athlete with CM1
to suffer a severe neurological injury
during the CS is low. However, it is
higher than in the general popula-
tion. 12 The asymptomatic athletes,
whose CM1 was incidentally diag-
nosed, should be evaluated on a
case-by-case basis. The oblitera-
tion of the space subarachnoid,
the presence of syringomyelia, the
indentation of the anterior portion
of the marrow and the presence of
symptoms related to changes in the
flow dynamics of cerebrospinal fluid
are elements that can predispose
the athlete to serious neurological
deficits and they are usually strong
restriction criteria. There is not
enough data in the literature to indi-
cate the degree of cerebellar hernia-
tion that contraindicate CS practice.
The presence of two or more brain
concussions should not allow the CS
practice. 15 The symptomatic athletes
with CM1, without any imaging
characteristics described before, are
not usually prevented from practic-
ing CS. However, both the athlete
and the family should be aware of
the risk and of the injuries they may
be subjected to. 12,13
The posterior craniectomy decom-
pression and the removal of the
posterior arc of C1 is not generally
recommended on the asympto-
matic athletes involved on contact
sports as prophylaxis for neurologi-
cal lesions. The surgery is usually
reserved for symptomatic athletes,
being controversial in the asympto-
matic patients with signs of syringo-
myelia. 15,16
Conclusion
The diagnosis of CM1 is an impor-
tant factor for protection of the
health of the athlete, particularly on
DS. The sports medical examination
should identify symptoms and signs
that may raise the clinical suspicion
that could lead to the appropri-
ate imaging exams. The adequacy
of sports practice and the advice
of athletes and families should be
considered. The return to sports of
the athletes with neurological injury
or athletes subjected to surgery
should be much more restricted,
being generally considered absolute
counterindication to the practice
of CS. On the athletes with greater
risk of getting neurological injury, it
is important to adapt the sporting
activity with alternative modalities.
A more systematic clinical follow-
up in the neurosurgery department
should be carried out.
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The authors declare a lack of conflict of
interest
Correspondence to
João P Pinheiro
jpá[email protected]
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