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post concussion syndrome
A constellation of findings following head injury, generally mild head injury (initial Glasgow coma scale 13-15). Loss of consciousness does not have to occur for postconcussion syndrome to develop.
Etiology:
1) coup injury
2) contrecoup injury
3) cerebral contusion
4) diffuse axonal injury
5) release of excitatory neurotransmitters
a) glutamate
b) acetylcholine
Epidemiology:
- 5% of military personelle returning from combat deployment [2]
Clinical manifestations:
1) common manifestations
a) headache 30-90%
- tension headache
- migraine headache
- intracranial hypotension
- greater occipital neuralgia (cervicogenic headache)
- headaches resolve in 3 months in 50% of patients
b) dizziness 50%
c) fatigue
d) psychological symptoms 50%
- irritability
- anxiety
- depression
- frustration
- insomnia or hypersomnia
- decreased libido
- diminished appetite
e) cognitive impairment
- memory impairment 20%
- difficulty concentrating 20%
- resolution in 3-6 months
f) slower reaction time [4]
2) less common manifestations
- benign positional vertigo
- hearing loss
- anosmia
- photophobia
- visual impairment
- difficulty focusing vision
- blurry vision
- diplopia
- sleep disturbance
- hyperacusis
- tinnitus
- dysgeusia
- anosmia
3) rare manifestations
- delayed subdural hematoma
- delayed epidural hematoma
- seizure disorder
- transient global amnesia
- movement disorder
- tremor
- parkinsonism
- torticollis
Diagnosis:
- ICD-10 requires:
- cognitive impairment
- somatic complaint
- emotional disorder
- sleep disorder
Laboratory:
1) X-ray if skull fracture suspected
2) computed tomography (CT)
a) Glasgow coma scale < 15
b) focal neurologic deficits
3) magnetic resonance imaging (MRI)
4) electroencephalography (EEG): post-traumatic seizure
5) electronystagmography (ENG)
6) audiogram if indicated
7) visual testing
6) neuropsychiatric testing
Radiology:
- neuroimaging with MRI may show diminished hippocampal volume [4]
Differential diagnosis:
1) chronic subdural hematoma
2) chronic epidural hematoma
3) psychiatric disturbance
a) depression
b) anxiety
c) hysteria
d) somatoform disorder
e) compensation neurosis
4) malingering
5) symptoms are common after concussion & not necessarily new or related to traumatic brain injury [5]
Management:
1) recognition of symptoms
- treatment is supportive [2]
- rehabilitation
2) pharmacologic agents aimed at specific symptoms [2]
a) amitriptyline
b) non-steroidal anti-inflammatory agents (NSAIDs)
c) muscle relaxants
d) propranolol
e) calcium channel blockers
3) transcutaneous electrical nerve stimulation (TENS)
4) biofeedback
5) physical therapy
6) awareness of sequelae
a) learning difficulties
b) concentration difficulties
c) emotional lability
7) counseling
General
cerebral concussion
syndrome
References
- Saunders Manual of Medical Practice, Rakel (ed),
WB Saunders, Philadelphia, 1996, pg 1076-79
- Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17.
American College of Physicians, Philadelphia 2009, 2012, 2015
- Evans RW.
Persistent post-traumatic headache, postconcussion syndrome,
and whiplash injuries: the evidence for a non-traumatic basis
with an historical review.
Headache. 2010 Apr;50(4):716-24.
PMID: 20456159
- Singh R et al.
Relationship of collegiate football experience and concussion
with hippocampal volume and cognitive outcomes.
JAMA 2014 May 14; 311:1883
PMID: 24825643
http://jama.jamanetwork.com/article.aspx?articleid=1869211
- Iverson GL, Silverberg ND, Mannix R et al
Factors Associated With Concussion-like Symptom Reporting in
High School Athletes.
JAMA Pediatr. 2015 Oct 12:1-9
PMID: 26457403
- Zemek R, Barrowman N, Freedman SB et al
Clinical Risk Score for Persistent Postconcussion Symptoms
Among Children With Acute Concussion in the ED.
JAMA. 2016;315(10):1014-1025
PMID: 26954410
http://jama.jamanetwork.com/article.aspx?articleid=2499274