AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Background

Postconcussive syndrome (PCS), a sequela of minor head injury (MHI), has been a much-debated topic of recent years. Muddled by conflicting findings regarding symptom duration, an absence of objective neurologic findings, inconsistencies in presentation, poorly understood etiology, and significant methodologic problems in the literature, PCS remains controversial. Depending on the definition and the population examined, 29-90% of patients experience postconcussive symptoms shortly after the traumatic insult.

While no universally accepted definition exists, most of the literature defines the syndrome as the continuation of at least 3 of the following symptoms: headache, dizziness, fatigue, irritability, impaired memory and concentration, insomnia, and lowered tolerance for noise and light. Confusion exists in the literature, with some authors defining it as symptoms of at least 3 months duration, while others define it as symptoms appearing within the first week. In this article, the syndrome is loosely defined as symptom occurrence and persistence within several weeks after the initial insult. PCS can be divided into early and late or persistent PCS, with symptoms occurring for more than 6 months in duration.

Now, an ICD-10 diagnostic criteria as well as an investigatory Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) in appendix form are available. The ICD-10 criteria include a history of traumatic brain injury (TBI) and the presence of 3 or more of the following 8 symptoms: (1) headache, (2) dizziness, (3) fatigue, (4) irritability, (5) insomnia, (6) concentration or (7) memory difficulty, and (8) intolerance of stress, emotion, or alcohol.The DSM-IV criteria are (A) history of TBI causing "significant cerebral concussion;" (B) cognitive deficit in attention and/or memory; (C) presence of at least 3 of 8 symptoms (eg, fatigue, sleep disturbance, headache, dizziness, irritability, affective disturbance, personality change, apathy) that appear after injury and persist for 3 months; (D) symptoms that begin or worsen after injury; (E) interference with social role functioning; and (F) exclusion of dementia due to head trauma and other disorders that better account

for the symptoms. Criteria C and D require symptom onset or worsening to be contiguous to the head injury, distinguishable from preexisting symptoms, and have a minimum duration of 3 months.

Pathophysiology

An MHI typically indicates a blow to the head with a brief period of loss of consciousness (LOC) and/or posttraumatic amnesia or disorientation. At presentation, the Glasgow Coma Scale (GCS) score is 13-15, although more recent literature has suggested, and many clinicians concur, that a GCS score of 15 and possibly 14 denotes a minor injury, as a GCS score of 13 is associated with a much greater chance of significant intracranial findings on cranial CT scan. LOC is thought to result from trauma to the brain stem or from diffuse cerebral injury. MHI can cause cortical contusion from a coup and contre-coup mechanism. Findings at initial neurologic examination may be completely normal, and the patient usually has a normal CT scan of the brain.

An absence of LOC and/or a normal CT scan, however, do not confirm the absence of damage to the brain. Shear strain on the neurons that leads to diffuse axonal injury can occur without CT abnormalities. The soft tissues of the neck may be strained while protecting the brainstem and inhibiting LOC.

Neuropsychological assessments and scanning (eg, CT scanning, MRI, PET, SPECT) used to detect organic causes may reveal impairments associated with PCS. Findings from neuropsychological evaluations demonstrate that symptom severity is not necessarily dependent on neurologic status immediately following injury. However, in some series, the length of LOC or posttraumatic amnesia may be correlated with the probability of developing PCS.

Discrepancies between organic evidence and symptom presentation bring symptom origination into question. Manifestations most commonly occur during the initial weeks and resolve within 3 months after injury, yet symptom persistence in approximately one third of patients with an MHI, often with objective cognitive deficits that have resolved, may make assessment and treatment difficult.

It is not entirely discernible which symptoms are organic and which have a psychological basis. However, some researchers have hypothesized that early PCS symptoms are more likely to be organic, and PCS symptoms that persist beyond 3 months have a nonorganic, psychological basis. Physical-emotional comorbidity precipitates the development and continuation of symptoms associated with PCS, because recovery is based on injury severity, age, education, vocational abilities, physical well being, psychosocial skills, cognitive functioning, and personality factors.

Frequency

United States

More than 2 million instances of MHI occur in the United States each year. The overall incidence rate of MHI for persons not hospitalized, with data compiled by the National Hospital Ambulatory Medical Care Survey (1995-1996), was 392 per 100,000 population or 1,027,000 visits per year to hospital EDs in the US. Depending on the definitions used and population examined, approximately 20-90% of patients develop at least 1 symptom of PCS within the first month, and about 40% have at least 3 symptoms at 3 months.

One survey of high school sports revealed that 20% of football players sustained some form of minor head trauma in 1 year. The incidence of PCS in these players is unknown.

Mortality/Morbidity

Morbidity is mainly due to the persistence of symptoms, which make it difficult for patients to resume premorbid functions.

Sex

Men suffer MHI more frequently than women, but the incidence of PCS is greater in females than in males.

Age

Fifty percent of MHI sufferers are aged 15-34 years. However, PCS has no predilection for any specific age group.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

History

Most patients present shortly after an MHI. Often, patients return after a previous evaluation in the ED because of persistent postconcussive symptoms. Findings may include the following:

• Headache - Tension type, migraine, occipital neuralgia, cluster, supraorbital or infraorbital neuralgia, cephalgia
• Cranial nerve symptoms and signs - Dizziness, vertigo, nausea, tinnitus, blurry vision, hearing loss, diplopia, diminished sense of taste and smell, light and noise sensitivity
• Psychological and neurovegetative problems - Anxiety, irritability, depression, sleep disturbance, change in appetite, decreased libido, fatigue, personality change
• Cognitive impairment - Memory impairment, diminished concentration and attention, delayed information processing and reaction time

Physical

In general, the findings at physical examination are normal. The patient may exhibit subtle neurologic findings, but objective focal motor deficits should raise a concern about an undiagnosed intracranial bleed. Other findings may include the following:

• Depressed affect
• Decreased ability to smell and taste
• Neurasthenia or hyperesthesia (but not in a dermatomal distribution)
• Cognitive deficits
• • Neuropsychological testing has revealed that defects can persist 6 months or longer when other symptoms are present.
  • These defects include difficulties with vocabulary, short-term and intermediate-term memory, attention, cognitive flexibility, information processing, object recall, drawing, and mathematics.
  • Patients without other subjective symptoms usually perform normally on these tests.
  • However, testing also has revealed that these defects resolve when other somatic and neurologic symptoms do not.

Causes

Risk factors for the development of PCS include nonsporting mechanisms, loss of consciousness, amnesia for the event, female sex, and abnormal neurobehavioral testing results after the incident.

• Although a common perception is that people develop PCS from head injury who perceive a source of blame for the injury desire to pursue litigation, one study did not demonstrate a correlation between blame and litigation. In fact, PCS symptoms persisted after settlement.
• Some authors have concluded that persons with a history of depressive and anxiety disorders, certain premorbid personality types, or poor coping skills may be predisposed to PCS, but the data are conflicting.
• Neck pain after a head injury has not been correlated with the development of PCS.
• Although the numbers of patients tend to be relatively small, more recent studies suggest that postconcussive syndrome is more likely to develop in patients presenting with nausea, headache, and dizziness.
• An increased serum level of S-100 and neuron-specific enolase is found in patients with minor head injury. These proteins are released with brain damage and can be found in the peripheral blood serum. They have poor specificity since they may also be elevated in noncerebral injuries. However, in one study, elevated levels of S-100 in addition to specific symptoms of dizziness, headache, and nausea was associated with long-term persistence of PCS symptoms. How useful this will be in clinical practice is unclear.

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Lab Studies

• No specific laboratory studies are needed, unless concomitant illness is suspected or unless the diagnosis is unclear and believed to be of toxic or metabolic origin.

Imaging Studies

• CT scanning is used to determine the presence of intracranial abnormalities and skull fractures. In young patients with no loss of consciousness and a normal neurologic examination, CT scanning is of very low yield and is unlikely to be positive. Patients with PCS usually do not present immediately after the trauma.
• • If a CT scan has already been obtained, the utility of a repeat scan is minimal in the absence of focal neurologic signs or unless the patient is at risk for delayed hemorrhage.
  • If a CT scan has not been obtained and if the patient had a loss of consciousness and a GCS of 15, the likelihood of finding an operable lesion is extremely limited. Unfortunately, these patients with symptoms and a normal examination may still harbor an injury that requires intervention. A more detailed discussion on head trauma and CT scan can be found in the eMedicine article Emergency Neuroradiology.
  • In general, a single head CT still a reasonable, fast, and effective screening test in the significantly symptomatic patient.
• MRI is more sensitive than CT scanning in depicting lesions associated with MHI and PCS.
• • Most commonly, frontotemporal lesions are demonstrated; these seem to correlate with areas of deficit at neuropsychological testing.
  • An MRI obtained 4-24 months after trauma reveals old contusions, loss of discrimination between gray and white matter, and irregular brain contours.
  • An MRI obtained in the acute period has little clinical significance. If one is obtained, it should be obtained on an outpatient basis in conjunction with follow-up. While traumatic lesions may be depicted on MRIs in patients with MHI and a normal nonenhanced CT scan, they rarely influence the acute clinical course.

Other Tests

• Neuropsychological testing
• • This testing rarely is performed in the acute setting, although it may have some value in predicting the development of symptoms.
  • A series of standardized tests and questionnaires are used to measure attention, language, memory, emotional functioning, and other neurobehavioral parameters.
  • The Rivermead Postconcussion Symptoms Questionnaire is used to quantify PCS symptoms.
  • Neuropsychological assessments may be used. These include the Wechsler Adult Intelligence Scale and specific subtests (digit span and vocabulary), Trail Making Test, complex figure drawings (eg, Rey Osterreith), copy trials and memory trials, category tests, controlled oral word association (Hopkins Verbal Learning Test), Wisconsin Card Sorting Test, and the Paced Auditory Serial Addition Task.
  • The objective personality measure, Minnesota Multiphasic Personality Inventory, Second Edition (MMPI2), may be used.
  • The Hospital Anxiety and Depression Scale, Impact of Even Scale, Galveston Orientation and Amnesia Test, and assessments of posttraumatic amnesia are used together as prognostic screening instruments for predicting PCS persistence.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Emergency Department Care

No specific care is required in the ED. Patients with the symptom constellation consistent with PCS require thorough physical and neurological examinations. A CT scan should be obtained if significant concern about intracranial hemorrhage exists, although this injury is rare in the patient presenting late with a nonfocal findings at examination.

• Supportive care may include the use of nonnarcotic analgesics and antiemetics.
• Although some patients may be admitted if symptoms are severe, most can be discharged.
• • Several studies have revealed that patients admitted acutely after an MHI may have a lower incidence of PCS and its attendant social and psychological morbidity.
  • This finding is probably due to active interventions at follow-up.
  • There does not seem to be any medications at discharge that can prevent or hasten the resolution of PCS. While several are investigatory, none have been found useful clinically as yet.
  • Several studies have shown that providing patients with an explanation of symptoms as well as expectations may decrease the amount and time of postconcussive symptoms.
• Prompt follow-up care and reassurance may hasten resolution of symptoms.

Consultations

Rarely is consultation warranted in the ED once the diagnosis is made. Outpatient referral is the cornerstone of treatment. One study suggests that findings of early neuropsychological assessment may determine the prognosis; however, this assessment rarely is performed in the ED.

FOLLOW-UP

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Outpatient care is the cornerstone of treatment and involves multidisciplinary teams that provide testing and treatment, including cognitive rehabilitation, psychotherapy, stress management, vocational counseling, and pain management.
• • No treatments have been proven effective; however, the multidisciplinary approach is believed to be worthwhile.
  • A neurologist, physical medicine specialist, primary care physician, or psychologist specializing in these disorders usually coordinates treatment.
• Neurotherapy or quantitative EEG biofeedback is a modality that has been shown in recent studies to improve symptoms of PCS. However, more controlled studies are needed at this point.

Deterrence/Prevention

• The emergency physician should encourage the use of interventions to decrease the incidence of traumatic brain injury.
• • This approach is particularly important in young adults, who have a higher incidence of head injury than do others.
  • Encourage patients to wear a seatbelt and bicycle and/or motorcycle helmets, as appropriate.

Prognosis

• True prognosis is difficult to define given that many patients with minor symptoms may not enter the healthcare system and those that participate in research appear to have more significant symptoms at baseline. In addition, a wide heterogeneity exists in patients enrolled in studies.
• Most patients recover fully in less than 3 months, although some small studies suggest persistence of minor cognitive defects for asymptomatic minor traumatic brain injury patients.
• Approximately 15% of patients complain of problems more than 12 months after injury. This group will experience persistent and intrusive symptoms that may be refractory to treatment and impose a lifelong disability.
• At least one study found the persistence of dizziness as a symptom seemed to portend a longer and more significant symptom complex. Other studies found the depression, pain, and symptom invalidity were correlated with longer and worse symptoms.

Patient Education

• Educate the patient about the usual self-limited nature of PCS.
• Education about the usual symptoms may be helpful.
• Discussions concerning preparation for the graded resumption of vocational and academic routines may lessen PCS persistence.
• For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Concussion.

MISCELLANEOUS

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to recognize the benefits of reassurance and providing follow-up care.
• • Patients are likely to experience difficulty with symptoms when neurologic examinations, psychological assessments, and physical examinations reveal limited evidence of or explanation for the persistence of the symptoms.
  • Patients' veracity may be questioned; they may be treated as if they are neurotic or merely seeking compensation.
  • Practitioners may be confused about complaints when objective evidence is not present.
  • Follow-up during recovery may aid in preventing symptom persistence.
• Failure to provide patients with information regarding the sequelae of MHI.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Sep 6, 2006