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Changes in pupils after asymptomatic high-acceleration head impacts indicate changes in brain function

November 26, 2019

CHARLOTTESVILLE, VA (NOVEMBER 26, 2019). Researchers from the University of Michigan found significant pupillary changes in high-school football athletes after they had sustained a high-acceleration head impact. The changes were detected using a noninvasive, hand-held, quantitative pupillometry device, which potentially could be used in a nonclinical setting for a quick assessment of possible brain injury. Detailed findings on this subject are found in the article, "Pupillary changes after clinically asymptomatic high-acceleration head impacts in high school football athletes," by Jacob R. Joseph, M.D., and colleagues, published today in the Journal of Neurosurgery.


During American football practices and games, athletes are regularly subjected to head impacts of varying intensities--hits that may or may not produce the clinical signs and symptoms of a concussion.

Previous studies have found associations between high-acceleration head impacts and neuronal and axonal injury, even in the absence of symptoms and diagnosis of concussion. These studies have relied on the results of invasive tests, such as biomarker analysis and advanced neuroimaging, which are expensive, time-consuming, and not always readily available.

The authors of this study looked at the potential of quantitative pupillometry (QP) as an objective, fast, and noninvasive method to assess the neurological effects of high-acceleration head impacts when no symptoms are apparent. QP provides objective, quantifiable data on changes in pupil size and reactivity to light. Such changes can reflect changes in brain function.

Present Study

Thirteen high-school football players completed the entire study. Sensors were placed in these athletes' football helmets to measure and record the frequency and intensity of head impacts during all practices and games in a football season. Data on all head impacts were collected for each athlete. The focus of this study was on high-acceleration head impact, which was defined as an impact that simultaneously exceeds 95-gravity linear acceleration and 3760-radian/second2 rotational acceleration.

QP was performed to measure each athlete's pupil size and reactivity to light (in all, eight parameters of the pupil) at various time points throughout the playing season and to compare these measurements with normative data. The authors state that testing only took two minutes per session, and in each instance the ambient lighting was similar. Testing was performed 1) before the playing season began; 2) at the middle of the season, following a game; 3) after the season had ended; and 4) in athletes who sustained a high-acceleration head impact, following the practice session or game in which the impact occurred.

At the time of pupillometry testing, the athletes also underwent neurocognitive testing to determine whether the impacts produced concussive injuries. This was performed using the Sport Concussion Assessment Tool, 5th Edition. The authors focused on evaluations of symptoms, cognitive screening, balance assessment, and delayed recall.

Seven athletes experienced high-acceleration head impacts without a related concussion diagnosis during the playing season, six of them before the midseason evaluation. In a comparison of QP measurements obtained following high-acceleration head impacts with those obtained at the midseason evaluation (control), the authors found significant decreases in three of the eight QP parameters, specifically pupil dilation velocity, percent change in pupil diameter, and maximum pupil constriction velocity.

In a comparison of QP measurements across the playing season (measurements obtained at the preseason [baseline], midseason, and end-of-season evaluations), the authors found significant changes in two QP parameters, namely average pupil constriction velocity and maximum pupil constriction velocity.

The authors found no significant changes in neurocognitive test values when they compared values obtained following a high-acceleration head impact with values obtained at the midseason evaluation. They also found no significant changes when they compared neurocognitive test values across the playing season.

The results of this study show that measurable changes in pupillary parameters occurred following asymptomatic (non-concussion-related) high-acceleration head impacts. The authors state these results suggest that "nonconcussive [high-acceleration head impacts] may affect intrinsic brain reflex pathways and may reflect biological injuries that previously were found using more invasive methods" such as biomarker analysis and advanced neuroimaging.

QP may prove to be an inexpensive, rapid, objective, noninvasive method of determining brain injury following sports-related head impacts.

The authors point out that the sample of athletes evaluated in this study is small and the study is preliminary. The authors stress the importance of conducting a larger study to confirm their findings.

When asked about the study, Dr. Joseph said, "In this study, we found more evidence that extremely severe head impacts seem to have an effect on these high school athletes. We had previously found that these severe hits (high-acceleration head impacts) caused increases in traumatic brain injury biomarkers, and now we are seeing changes in the pupil's response to light, all despite the athlete being completely asymptomatic otherwise. This suggests that high-acceleration head impacts may be the most important aspect of football and other contact sports to reduce in frequency and eventually eliminate from the game."
Joseph JR, Swallow JS, Willsey K, Almeida AA, Lorincz MT, Fraumann RK, Oppenlander ME, Szerlip NJ, Broglio SP. Pupillary changes after clinically asymptomatic high-acceleration head impacts in high school football athletes. Journal of Neurosurgery, published online, ahead of print, November 26, 2019; DOI: 10.3171/2019.7.JNS191272.

Disclosure: Dr. Joseph reports having received support for the study from NeurOptics, Inc. and the Blue Cross Blue Shield Foundation of Michigan. Dr. Oppenlander is a consultant for Globus Medical, DePuy Synthes, and LifeNet Health.

For additional information, please contact: Ms. Jo Ann M. Eliason, Communications Manager, Journal of Neurosurgery Publishing Group, One Morton Drive, Suite 200, Charlottesville, VA 22903. Email:; Phone: 434-982-1209.

For 75 years, the Journal of Neurosurgery has been recognized by neurosurgeons and other medical specialists the world over for its authoritative clinical articles, cutting-edge laboratory research papers, informative case reports, expert technical notes, and more. Each article is rigorously peer reviewed. The Journal of Neurosurgery is published monthly by the JNS Publishing Group, the scholarly journal division of the American Association of Neurological Surgeons. Other peer-reviewed journals published by the JNS Publishing Group include Neurosurgical Focus, Neurosurgical Focus: Video, the Journal of Neurosurgery: Spine, and the Journal of Neurosurgery: Pediatrics. All five journals can be accessed at

Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with more than 10,000 members worldwide. The AANS is dedicated to advancing the specialty of neurological surgery in order to provide the highest quality of neurosurgical care to the public. All active members of the AANS are certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons (Neurosurgery) of Canada or the Mexican Council of Neurological Surgery, AC. Neurological surgery is the medical specialty concerned with the prevention, diagnosis, treatment, and rehabilitation of disorders that affect the entire nervous system including the brain, spinal column, spinal cord, and peripheral nerves. For more information, visit

Journal of Neurosurgery Publishing Group

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