Military Acute Concussion Evaluation 2 (MACE 2) — Questions and Answers

Question 1: What aspect of neurological function is assessed with balance tests in the MACE?

Cognitive ability
Hearing ability
Visual acuity
Coordination and equilibrium (Correct answer)

Correct answer: Coordination and equilibrium

Balance tests, such as tandem gait or standing on one leg, are included in the MACE to assess an individual's coordination and equilibrium. Concussions can disrupt the brain's ability to process sensory information and control motor movements, leading to impaired balance and an increased risk of falls.

Question 2: What should be done if a patient shows significant cognitive impairment during the MACE?

They should rest and re-test after 24 hours
They should be sent for immediate advanced medical evaluation (Correct answer)
They should be given painkillers and monitored
They should continue with normal activities

Correct answer: They should be sent for immediate advanced medical evaluation

Significant cognitive impairment identified during the MACE, especially if severe or worsening, indicates a potentially more serious brain injury or complication. In such cases, the protocol mandates immediate referral for advanced medical evaluation (e.g., neuroimaging, specialist consultation) to rule out conditions like intracranial bleeding.

Question 3: In the MACE, what is the significance of asking patients to recall a list of words?

To measure problem-solving ability
To test language skills
To assess short-term memory and attention (Correct answer)
To evaluate long-term memory

Correct answer: To assess short-term memory and attention

Asking patients to recall a list of words is a standard component of the MACE cognitive assessment. This task specifically evaluates immediate and short-term verbal memory, as well as the patient's ability to pay attention and encode new information, which are often impaired following a concussion.

Question 4: What is the 'blast overpressure' and how is it measured?

The temperature of the blast
The pressure wave exceeding normal atmospheric pressure created by an explosion, measured in pounds per square inch (PSI) (Correct answer)
The speed of shrapnel
The volume of the explosion sound

Correct answer: The pressure wave exceeding normal atmospheric pressure created by an explosion, measured in pounds per square inch (PSI)

Blast overpressure is the positive pressure phase of the blast wave. Even relatively low overpressure (5-15 PSI) can cause TBI. Higher pressures cause progressively more severe injuries to multiple organ systems.

Question 5: What is the MACE 2 (Military Acute Concussion Evaluation 2)?

A standardized screening tool used by military medical personnel to assess cognitive function and identify potential mild traumatic brain injury in service members (Correct answer)
A military fitness test
A combat readiness evaluation
A weapon qualification assessment

Correct answer: A standardized screening tool used by military medical personnel to assess cognitive function and identify potential mild traumatic brain injury in service members

The MACE 2 is a validated, field-deployable screening instrument that evaluates cognitive domains affected by concussion, including orientation, immediate memory, neurological screening, concentration, and delayed recall.

Question 6: What are the four categories of concussion symptoms?

Physical (headache, dizziness), cognitive (confusion, memory problems), emotional (irritability, anxiety), and sleep-related (insomnia, drowsiness) (Correct answer)
Only headache
Only dizziness and nausea
Only memory loss

Correct answer: Physical (headache, dizziness), cognitive (confusion, memory problems), emotional (irritability, anxiety), and sleep-related (insomnia, drowsiness)

Concussion symptoms span four domains: physical (headache, nausea, balance problems, light/noise sensitivity), cognitive (confusion, slowed thinking, poor concentration), emotional (irritability, sadness, anxiety), and sleep (too much/too little).

Question 7: What cognitive rehabilitation strategies are used for concussion recovery?

No cognitive rehabilitation exists for concussion
Graduated cognitive loading, compensatory strategy training, attention and memory exercises, and psychoeducation about expected recovery (Correct answer)
Only medication is used
Cognitive rehabilitation is only for severe TBI

Correct answer: Graduated cognitive loading, compensatory strategy training, attention and memory exercises, and psychoeducation about expected recovery

Cognitive rehabilitation may include progressive cognitive loading (reading, problem-solving), compensatory strategies (note-taking, checklists), targeted attention/memory training, and education about normal recovery expectations.

Question 8: What are the visual symptoms of concussion?

Only complete vision loss
Only color blindness occurs
Blurred vision, double vision (diplopia), light sensitivity (photophobia), difficulty tracking moving objects, and visual field deficits (Correct answer)
Concussion never affects vision

Correct answer: Blurred vision, double vision (diplopia), light sensitivity (photophobia), difficulty tracking moving objects, and visual field deficits

Visual disturbances are common after concussion because multiple brain areas involved in visual processing are vulnerable to injury. Convergence insufficiency, accommodation dysfunction, and saccadic eye movement abnormalities are frequently observed.

Question 9: Which component is NOT part of the MACE neurological examination?

Cognitive screening
Neurological screening
Symptom evaluation
Physical endurance test (Correct answer)

Correct answer: Physical endurance test

The MACE focuses on neurological and cognitive assessments relevant to concussion, such as symptom evaluation, cognitive screening (memory, orientation), and neurological screening (balance, coordination). A physical endurance test, which measures stamina and physical exertion, is not a component of the MACE neurological examination as it does not directly assess concussion-related brain function.

Question 10: How does body armor affect blast-related brain injury?

Armor has no effect on blast injuries
Helmets eliminate all concussion risk
Body armor protects the torso but does not prevent blast wave transmission to the brain; helmet protection against blast overpressure is limited (Correct answer)
Body armor completely prevents blast TBI

Correct answer: Body armor protects the torso but does not prevent blast wave transmission to the brain; helmet protection against blast overpressure is limited

While helmets protect against secondary (fragment) and tertiary (impact) blast injuries, they provide limited protection against the primary blast wave, which can still cause brain injury through pressure transmission.

Question 11: What is the TBI screening process at post-deployment health assessments?

Only physical injuries are screened
A standardized questionnaire asking about potential concussive events, symptoms, and functional impairment during deployment, triggering referral for positive screens (Correct answer)
No TBI screening occurs post-deployment
Screening only occurs if requested

Correct answer: A standardized questionnaire asking about potential concussive events, symptoms, and functional impairment during deployment, triggering referral for positive screens

Post-Deployment Health Assessment (PDHA) and Post-Deployment Health Reassessment (PDHRA) include validated TBI screening questions. Positive screens trigger referral for comprehensive evaluation, capturing TBIs that may have been missed during deployment.

Question 12: What is chronic traumatic encephalopathy (CTE)?

An acute condition occurring immediately after head trauma
A progressive neurodegenerative disease associated with repeated head trauma, diagnosed definitively only at autopsy (Correct answer)
A condition caused by a single concussion
A curable form of brain injury

Correct answer: A progressive neurodegenerative disease associated with repeated head trauma, diagnosed definitively only at autopsy

CTE is associated with repeated head impacts over years, causing tau protein accumulation in the brain. Symptoms include cognitive decline, behavioral changes, and depression. Currently, definitive diagnosis requires post-mortem brain examination.

Question 13: What emotional and behavioral changes should be monitored after concussion?

Only anger is an emotional symptom
No emotional changes occur with concussion
Irritability, mood swings, anxiety, depression, decreased frustration tolerance, and personality changes (Correct answer)
Emotional changes only occur with severe TBI

Correct answer: Irritability, mood swings, anxiety, depression, decreased frustration tolerance, and personality changes

Concussion commonly affects emotional regulation through disruption of prefrontal cortex function and limbic system connections. Irritability, anxiety, depression, and reduced emotional control are common and often distressing symptoms.

Question 14: What is the primary purpose of cognitive testing in the MACE?

To measure physical endurance
To assess cognitive impairment (Correct answer)
To diagnose chronic mental health disorders
To evaluate respiratory function

Correct answer: To assess cognitive impairment

The primary purpose of cognitive testing within the MACE is to systematically evaluate for any deficits in cognitive functions such as memory, attention, concentration, and orientation. These impairments are hallmark signs of a concussion and help guide diagnosis and management decisions.

Question 15: Which of the following tests is typically included in the MACE neurological examination?

Lung capacity test
MRI scan
Verbal memory test (Correct answer)
Blood glucose level

Correct answer: Verbal memory test

The MACE neurological examination includes a cognitive screening component, and a verbal memory test is a standard part of this. This typically involves asking the individual to recall a list of words, which helps assess their immediate and delayed verbal memory, a key indicator of cognitive function post-concussion.

Question 16: What does the History section of the MACE specifically document regarding amnesia?

Whether any amnesia is present and whether it is retrograde, anterograde, or both (Correct answer)
The specific memories lost since birth
Whether the patient remembers their name and unit
Duration of amnesia only

Correct answer: Whether any amnesia is present and whether it is retrograde, anterograde, or both

The History section documents the presence and type of amnesia (retrograde — before the event, anterograde — after the event) as both are clinically significant for concussion diagnosis.

Question 17: What documentation is required throughout the concussion recovery process?

Only the initial assessment needs documentation
Documentation is optional during recovery
Initial MACE scores, serial symptom checklists, follow-up MACE scores, activity progression notes, and final return-to-duty clearance documentation (Correct answer)
Only the final clearance needs to be documented

Correct answer: Initial MACE scores, serial symptom checklists, follow-up MACE scores, activity progression notes, and final return-to-duty clearance documentation

Comprehensive documentation tracks the entire recovery: initial assessment, serial symptom monitoring, repeat cognitive testing, progressive activity tolerance, and final clearance. This record supports medical decisions and disability claims if needed.

Question 18: When should the Delayed Recall portion of the MACE be administered relative to Immediate Memory?

The following day
Immediately after the third Immediate Memory trial
At least 5 minutes after the Immediate Memory trials (Correct answer)
Exactly 30 minutes after the last memory trial

Correct answer: At least 5 minutes after the Immediate Memory trials

Delayed Recall is administered after a delay of at least 5 minutes following the Immediate Memory trials, typically after the neurological exam.

Question 19: What balance and vestibular symptoms are associated with concussion?

Dizziness, vertigo, balance problems, motion sensitivity, and difficulty with rapid head movements (Correct answer)
Concussion does not affect balance
Balance problems only occur in elderly patients
Only severe TBI causes dizziness

Correct answer: Dizziness, vertigo, balance problems, motion sensitivity, and difficulty with rapid head movements

The vestibular system is commonly disrupted by concussion, causing dizziness, balance impairment, and motion sensitivity. These symptoms are assessed through balance testing (BESS) and may require vestibular rehabilitation.

Question 20: What distinguishes combat-related TBI from sports concussion?

Sports concussion is never serious
Combat TBI is always more severe
There is no difference
Combat TBI often involves blast mechanisms, polytrauma, comorbid PTSD, delayed presentation, and austere treatment environments (Correct answer)

Correct answer: Combat TBI often involves blast mechanisms, polytrauma, comorbid PTSD, delayed presentation, and austere treatment environments

Combat TBI differs from sports concussion in mechanism (blast vs. impact), comorbidities (PTSD, pain, polytrauma), diagnostic challenges (delayed presentation, overlapping symptoms), and treatment context (operational environment vs. clinic).

Military Acute Concussion Evaluation 2 (MACE 2)

The MACE 2 is a standardized, multimodal tool used by military healthcare providers to evaluate concussion in service members, covering history and screening, symptom reporting, neurological examination, cognitive assessment, and vestibular/ocular-motor screening.

Questions

30 min

Time Limit

80%

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