Forum
Robert C. Cantu, M.A., M.D.
World Cup Soccer; a Major League Soccer Superstar’s Career-Ending Injury,
Concussion; and WORLD NEUROSURGERY: A Common Thread
Robert C. Cantu
F or nearly a month in June and July, 2010, we were treated to
the grandest spectacle in participation sport, played on the
world stage before unbelievable media coverage as well as fan
participation coming from all over the world. International sport’s
largest participation event, soccer, has been played by the best pro-
fessionals at the Fédération Internationale de Football Association
(FIFA) World Cup in South Africa. The final was an epic battle, with
Spain winning in electrifying fashion 1-0 over the understandably
distraught The Netherlands.
FIFA, the governing body for this event, is headquartered in
Zurich, Switzerland, in a surreally beautiful modern building and
setting. I cannot think of FIFA without remembering the three Inter-
national Concussion Conferences that FIFA, along with the Interna-
tional Ice Hockey Federation, International Olympic Committee,
and most recently the International Rugby Union, sponsored. These
meetings, held initially in Vienna in 2001, Prague in 2004, and ap-
propriately at FIFA headquarters in 2008, and the consensus state-
ments from these meetings dramatically advanced concussion
awareness, understanding, and management (1, 4, 5, 11).
We now recognize that a concussion is a traumatic brain injury
induced by an impulsive force transmitted to the head resulting from
a direct or indirect impact to the head, face, neck, or elsewhere (9).
Concussions may present with a wide range of clinical signs and
symptoms, including physical signs (e.g., loss of consciousness,
amnesia), behavioral changes (e.g., irritability), cognitive impair-
ment (e.g., slowed reaction times), sleep disturbances (e.g., drows-
Key words
䡲 Chronic Traumatic Encephalopathy
䡲 Concussion
䡲 Post Concussion Syndrome
䡲 Soccer
䡲 Traumatic Brain Injury
Abbreviations and Acronyms
FIFA: Fédération Internationale de Football Association
From the Center for the Study of Traumatic Encephalopathy and Department of
Neurosurgery, Boston University School of Medicine, Boston, Massachusetts, USA
224 www.SCIENCEDIRECT.com
Clinical Professor, Department of Neurosurgery
Co-Director of the Neurological Sports Injury Center
Brigham & Women’s Hospital
Center for the Study of Traumatic Encephalopathy
Boston University School of Medicine
iness), somatic symptoms (e.g., headaches), cognitive symptoms
(e.g., feeling “in a fog”), and/or emotional symptoms (e.g., emo-
tional lability) (4). Because these impairments in neurologic func-
tion often present with a rapid onset and resolve spontaneously,
many concussions are neither recognized by athletes nor observed
by coaches or athletic trainers (7, 8, 10, 12). As a result, a large
proportion of concussions are simply unreported.
Concussions in male and female soccer players typically occur as a
result of head collisions in the act of heading the ball (40.5%), and
goalies are at highest risk (2). The incidence of reported concussion
in women is higher than in men, and the rate of recovery appears to
be slower at the high school level as compared to college (7).
In soccer, rule changes may be in order because there is a specific
mechanism of injury associated with concussion, especially in
adults. Because concussions typically occur in both men and women
as a result of contact while heading the ball, limiting this type of
contact may be appropriate (4).
There are various types of headgear proposed to limit the effect of
concussion in soccer athletes. Although there have been nonran-
domized studies of the effect of headgear on head injuries in soccer,
there have not been analytic studies specifically looking at the role of
headgear on concussion rate or severity (3, 6). This remains a poten-
tial area of interest.
Although much is currently understood about concussion, we
have barely begun to fully appreciate the pathophysiology and bio-
mechanical forces that produce this condition and possible conse-
To whom correspondence should be addressed: Robert C. Cantu, M.A., M.D.
[E-mail: rcantu@emersonhosp.org]
Citation: World Neurosurg. (2010) 74, 2/3:224-225.
DOI: 10.1016/j.wneu.2010.07.023
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter © 2010 Published by Elsevier Inc.
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.07.023
 FORUM
ROBERT C. CANTU A COMMON THREAD

quences, postconcussion syndrome, and chronic traumatic enceph-
alopathy.
Two years ago, the World Cup was a possible stage for Taylor
Twellman, a superstar Major League Soccer star in the United States.
A lethal scorer, Twellman still is the youngest and fastest player in
league history to reach the 100-goal plateau. At age 28, this former
Major League Soccer Most Valuable Player’s future seemed brilliant.
Yet his ninth concussion (including a grade 1, 3 grade 3, and 3 grade
2 concussions) and perhaps a premature return led to a persistent
postconcussion syndrome that derailed and then terminated his
career. Showing himself to be a bright young man of multiple tal-
ents, Twellman was nonetheless at this summer’s World Cup, un-
fortunately not as a participant but rather as a member of the TV
media broadcasting events back to the United States.
So what is the connection between the World Cup, Taylor
Twellman, concussion, and WORLD NEUROSURGERY? Concus-
sion is experienced in and by all people. Just as WORLD NEURO-
SURGERY takes neurosurgical knowledge global, so does the
World Cup for soccer, reported by Twellman. Neurosurgical ex-
periences are no longer primarily a U.S. experience, as was Twell-
man’s soccer, but is now on an international scale. The journal,
like concussion, is in its infancy, like Twellman’s media career,
but with exploding implications for neurosurgical knowledge
and a worldwide audience.

REFERENCES
1. Aubry M, Cantu R, Devorak J: Summary and agree-
ment statement of the first international conference
on concussion in sport, Vienna 2001. Physician
Sportsmedicine 30:57-63, 2002.
2. Benson BW, Hamilton GM, Meeuwisse WH, Mc-
Crory P, Dvorak J: Is protective equipment useful in
preventing concussion? A systematic review of the
literature. Br J Sports Med 43(Suppl 1):i56-67, 2009.
3. Cantu R: Consensus Statement on Concussion in
Sport—The 3rd International Conference on Con-
cussion, Zurich, November 2008. Neurosurgery 64:
786-787, 2009.
4. Concussion (mild traumatic brain injury) and the
team physician: a consensus statement. Med Sci
Sports Exerc 38:395-399, 2006.
5. Cusimano MD: Canadian minor hockey partici-
pants’ knowledge about concussion. Can J Neurol
Sci 36:315-320, 2009.
6. Delaney JS, Lacroix VJ, Leclerc S, Johnston KM:
Concussions among university football and soccer
players. Clin J Sport Med 12:331-338, 2002.
7. Delaney JS, Al-Kashmiri A, Drummond R, Correa
JA: The effect of protective headgear on head inju-
ries and concussions in adolescent football (soccer)
players. Br J Sports Med 42:110-115, discussion 115,
2008.
8. Field M, Collins MW, Lovell MR, Maroon J: Does age
play a role in recovery from sports-related concus-
sion? A comparison of high school and collegiate
athletes. J Pediatr 142:546-553, 2003.
9. Gessel LM, Fields SK, Collins CL, Dick RW, Com-
stock RD: Concussions among United States high
school and collegiate athletes. J Athl Train 42:495-
503, 2007.
10. McCrory P, Johnston K et al: Summary and agree-
ment statement of the second international confer-
ence on concussion in sport, Prague 2004. Br J
Sports Med 39:196-205, 2005.
11. McCrory P, Meeuwisse W, Johnston K, et al: Con-
sensus statement on concussion in sport—the 3rd
International Conference on concussion in sport,
held in Zurich, November 2008. J Clin Neurosci 16:
755-763, 2009.
12. Valovich McLeod TC, Bay RC, Heil J, McVeigh SD:
Identification of sport and recreational activity con-
cussion history through the preparticipation screen-
ing and a symptom survey in young athletes. Clin J
Sport Med 18:235-240, 2008.
Citation: World Neurosurg. (2010) 74, 2/3:224-225.
DOI: 10.1016/j.wneu.2010.07.023
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter © 2010 Published by Elsevier
Inc.

WORLD NEUROSURGERY 74 [2/3]: 224-225, AUGUST/SEPTEMBER 2010 www.WORLDNEUROSURGERY.org 225