Although the sport of female boxing has a long history (women’s boxing as a legitimate sport dates back to 1722 when British fighter, Elizabeth Wilkinson, entered the ring), the activity’s current popularity is unprecedented. Demand is increasing for women into the professional ring to take advantage of their drawing power in a previously male-dominated sport that is suffering at the box office. As more women participate in this activity, we can expect them to experience many of the serious neurologic injuries observed in male participants. With the patient’s informed consent and institutional review board approval, this case describes the first reported subdural hematoma in a female secondary to boxing, including a detailed neuropsychological evaluation, and discusses actions that increased this participants’ risk of neurological injury. We also outline strategies to decrease such risks.
A 24-yr-old professional female boxer presented to our facility complaining of headache and nausea of increasing intensity the morning after a bout. She was a 60-kg, right-handed Caucasian, and had begun boxing approximately 1 yr before presentation. Despite having only two sanctioned matches, she was elected “National Boxer of the Year” for her organization and had competed in the women’s division of the state “tough man” competition. She sparred anywhere from 3 to 7 d·wk−1 and had always used full-face headgear, a mouthpiece, and 16-ounce gloves both in competition and in sparring. She had never experienced symptoms of a concussion or lost consciousness during a match or sparring session until this incident per herself, her family, and her trainer.
Two weeks before presentation, the patient was matched with a 120-kg male opponent for sparring, and was knocked down with a right hook when the male boxer became frustrated. There was no loss of consciousness, and she was alert and oriented immediately after the incident. This knockdown ended the sparring session, and minutes after the patient developed a global headache, which increased in intensity over the next week. The patient was allowed to participate in a contest 2 wk after the sparring session while still symptomatic, which she stopped voluntarily during the second round when her headache becoming intolerable. She did not have any significant trauma to the head during that event. She presented to the emergency room the next morning when her pain became intractable (approximately 12 h after the bout).
Computed tomography (CT) scan of the brain revealed a large heterogeneous subdural fluid collection over the left cerebral hemisphere causing a large left-to-right midline shift (Fig. 1). The ipsilateral basilar cistern and lateral ventricle were partially effaced, and multiple densities of blood were noted consistent with an acute on chronic subdural hematoma. On arrival, the patient had a Glasgow Coma Score (GCS) of 15, and her only complaints were a severe headache and nausea. The patient had no speech or motor deficits and coagulation studies were within normal.
A left frontal temporoparietal craniotomy was performed, and approximately 300–400 mL of blood at different stages of evolution was discovered upon opening the dura. This collection was under high pressure and had well-developed membranes. After evacuation of the clot and associated membranes, there was immediate reexpansion of the underlying parenchyma. The patient tolerated the procedure well and awoke immediately after surgery with a GCS of 15 and no gross neurological deficits. The patient was observed in the intensive care unit for 1 d after the procedure and was discharged from the hospital on postoperative day 7.
One month after surgery, the patient reported persistent neuropsychological difficulties. These included subjective memory, concentration, and language problems. She described frequently losing her train of thought, forgetfulness, blurry vision, word-finding difficulties, slurring of speech, and spelling problems. In addition, she reported increasing depression and anxiety. Neuropsychological evaluation was performed and revealed several objective deficits. Confrontation naming was in the low-average range and below expectations given her education level. The patient also performed in the low-average range on tests of memory for verbal information and tasks requiring manipulation of information. Overall, she displayed a pattern of problems with memory, concentration, and speeded processing that would be consistent with acute traumatic brain injury. The patient did not return to the sport of boxing and is currently participating in neuropsychological rehabilitation.
Because the head is the main target for opponent’s blows, athletes that participate in professional boxing are at risk for both acute and long-term neurologic injury. Acute neurological injuries range from mild concussions to cerebral hemorrhage, diffuse axonal injury, and death (8). The most commonly occurring brain injury resulting in boxing deaths is the subdural hematoma. This type of injury can be divided into an acute form (presenting within 48–72 h and hyperdense on CT imaging) and a chronic form (which presents in a later time frame and is isodense or hypodense on CT). The injury results from bleeding within the subdural space from stretched and torn bridging vessels, and can be caused by the rotational acceleration incurred from a blow during boxing (3). The spectrum of clinical presentation of this type of injury varies from minor headache to deep coma. In the former, the initial hemorrhage is small and does not result in significant brain compression. However, bleeding and oozing of blood into the subdural space may continue, and the patient often presents at a later date with clinical symptoms suggestive of increased intracranial pressure. The patient described in this case report likely suffered a small acute subdural hematoma during the sparring session in which she was knocked down. The hemorrhage was not large enough to cause mass effect until exacerbated by her continued participation in the sport.
Several return to competition guidelines exist (Table 1) and should be strictly adhered to in contact sports. The three most commonly utilized are those proposed by the Colorado Medical Society (4), the American Academy of Neurology (7), and Cantu (2). Regardless of which system of guidelines is used, it is commonly accepted that an athlete should not return to competition at least until asymptomatic at rest and during exertion. This basic tenet was not adhered to in the presented case report. In addition to the dangers of participation with an undiagnosed subdural hematoma, the athlete discussed in this report was also placed at a high risk for second impact syndrome (SIS) by being allowed to return to competition while still symptomatic. SIS, which has a mortality approaching 100%, has been described in a number of contact sports including boxing (5). First characterized in 1984, it is believed to result from dysfunction of vascular autoregulation of the brain secondary to trauma (1).
Women participating in the sport are obviously susceptible to the same injuries as their male counterparts. In addition to this inherent danger, there are several issues that could increase their risk of such mishaps. Although the sport of female boxing is centuries old, its current popularity with spectators is increasing pressure on boxing managers and promoters to include female events as undercards. This marketing demand speeds the promotion of novice boxers through the professional ranks. The boxer in this report had only participated in two sanctioned matches and was deemed “National Female Boxer of the Year” by her organization. In the male boxing community, years of amateur training and matches often precede the transition to professional. During this time, the athlete develops defensive skills that are harder to acquire than punching technique and offensive moves. This sacrifice in experience for rapid advancement into the professional arena can result in top female contenders lacking adequate defensive skills.
The pressure to have women meet during events can result in mismatches between fighters of unequal skill and experience paired to fill empty schedule slots. This is especially true in the heavier weight classes, where veteran fighters are few. The scarcity of female fighters also leads to intergender sparring. Although no organization currently sanctions matches between males and females, sparring sessions in many gyms are female versus male. Intergender sparring is acceptable as a training tool, but should be carefully monitored, and sessions that appear to be losing control should be terminated.
The large number of punches landed before a knockout in lighter weight divisions can be just as dangerous to the nervous system as one heavy blow (6). In male boxing, most serious head injuries result from the accumulation of blows throughout the bout versus one powerful knockout punch. This may explain why fatalities seem to be more common in the lighter weight classes. Women boxers are usually smaller and lack the power to deliver the quick knockout.
Several management pearls can be taken home from this case. Most importantly, an athlete that has persistent neurological symptoms should not be allowed to participate. This suspension should remain in effect until the symptoms have resolved with and without exertion. Boxers should be examined before and after sparring and matches. If they exhibit neurologic signs or symptoms, they should be prohibited from participation and referral should be made for diagnostic imaging and observation. Those responsible for the safety of the athlete must remain cognizant that in a small percentage of patients, seemingly trivial concussive symptoms can result in catastrophic outcomes. A detailed history of recent head injury, not necessarily associated with sports (such as from motor vehicle accidents or at work), should be obtained and considered when evaluating an athlete before a competition.
This case report of a female boxer who suffered an acute on chronic subdural hematoma and was left with residual neuropsychological deficits illustrates that this population can be expected to incur many of the injuries long associated with male participation. Although several factors may increase the female participant’s risk for acute neurological injury, the chance of serious sequelae was compounded by several poor decisions regarding this athlete’s management. The most important mistake made was allowing her to compete with persistent neurological symptoms. The fact that she had a persistent worsening headache should have also alerted those looking over her of the possibility of neurological injury and the need for evaluation/diagnostic imaging. This report is timely in that female athletes are more often crossing into previously male dominated sports and should serve as a reminder that these participants are vulnerable to similar injuries. Previous safety guidelines should be utilized in this new population of participants.
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