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Postconcussive Syndrome

Brain Syndrome Posttraumatic

Postconcussive syndrome is roughly defined as the persistence of symptoms after a concussion. Headaches, dizziness, fatigue, emotional instability, anxiety, sleep disturbances and an overall decreased quality of life are described as the most important complaints. A comprehensive diagnostic and therapeutic approach, primarily based on the ability to conduct a complete physical workup, is necessary in order to prevent long-term impairment.


Presentation

Traumatic brain injury (TBI) might lead to severely debilitating long-term sequelae in the absence of an early diagnosis and adequate treatment, one of the most important forms being a concussion, defined as a traumatic event during which various pathophysiological processes (primarily mechanical forces exerted on brain tissue) lead to brain injury, but without evidence on imaging studies [1]. Various symptoms appear shortly after the initial injury, including headaches, amnesia, and loss of consciousness, whereas emotional instability, sleep disturbances, and cognitive impairment (reduced reaction time is a key finding) can be present as well [1]. Postconcussive syndrome (PCS) is still an incompletely defined disorder that several authors describe as prolongation of symptoms after a concussion [2] [3]. The majority of patients recover from a concussion within a period of days to weeks, but PCS is estimated to occur in approximately 10% of cases [4]. Notable findings in PCS include persistent emotional instability, difficulty sleeping, anxiety, dizziness, irritability, visual disturbances, sensitivity to noise, and inability to maintain concentration, in addition to complaints mentioned previously [2] [3] [5] [6]. Depression may also be a long-term adverse effect of concussion and is an important constituent of PCS [1] [7].

Fatigue
  • Headaches, dizziness, fatigue, emotional instability, anxiety, sleep disturbances and an overall decreased quality of life are described as the most important complaints.[symptoma.com]
  • The most commonly reported post concussion symptoms are headache, dizziness, decreased concentration, memory problems, irritability, fatigue, visual disturbances, sensitivity to noise, judgment problems, depression, and anxiety.[doi.org]
  • Symptoms In general, the most commonly accepted definition is that postconcussive syndrome consists of someone having suffered from mild TBI and then goes on to suffer from the following: Headache, dizziness, malaise, fatigue, or decreased tolerance to[verywell.com]
  • CLINICAL FINDINGS: Post-concussion syndrome lies within the confines of somatic symptoms (headaches, dizziness, and fatigue), cognitive symptoms (memory and concentration problems) and affective symptoms (irritability, emotional lability, depression,[noninvasiveicp.com]
Chronic Fatigue Syndrome
  • Keywords Traumatic Brain Injury Chronic Fatigue Syndrome Mild Traumatic Brain Injury Mild Head Injury Minor Head Trauma These keywords were added by machine and not by the authors.[doi.org]
  • PCS also shares symptoms with chronic fatigue syndrome, fibromyalgia, and exposure to certain toxins.[en.wikipedia.org]
Intravenous Drugs
  • SH: Negative for tobacco, alcohol, or intravenous drug use. Meds: Advil PRN. Allergies: NKDA. Physical Exam: VITALS: BP 99/64 HR 53 RR 12 Temp 98.8 GENERAL: Healthy-appearing athletic female in no acute distress. HEENT: EOMI, PERRLA.[amssm.org]
Sighing
  • Unfortunately, the referral of a patient with the possibility of post concussion syndrome to a busy neurology outpatient clinic can precipitate an inward sigh of reluctant resignation in even the most diligent neurologist or neurosurgeon.[doi.org]
Nausea
  • Three days later, she presented to the athletic training room clinic with complaints of frontotemporal headache, nausea, dizziness, photosensitivity, and phonosensitivity. She also endorsed feeling slowed down, irritability, and drowsiness.[amssm.org]
  • She had a brief convulsion immediately after the fall, was unresponsive for less than 1 minute, and awakened with a severe generalized headache and nausea but no vomiting.[doi.org]
  • Your Doctor may prescribe certain medications to help ease your symptoms, such as painkillers (for headaches), anti-depressants or anti-nausea medication.[sportsinjuryclinic.net]
  • Repeated vomiting or nausea. Slurred speech. The people checking on you should take you to an emergency department right away if you: Look very drowsy or cannot be awakened.[braininjspecialists.com]
Vomiting
  • She denied nausea, vomiting, vision changes, weakness, or new trauma. History: PMH: 8 concussions and right orbital fracture, per above. PSH: None. FH: No significant hx. SH: Negative for tobacco, alcohol, or intravenous drug use. Meds: Advil PRN.[amssm.org]
  • She had a brief convulsion immediately after the fall, was unresponsive for less than 1 minute, and awakened with a severe generalized headache and nausea but no vomiting.[doi.org]
  • Repeated vomiting or nausea. Slurred speech. The people checking on you should take you to an emergency department right away if you: Look very drowsy or cannot be awakened.[braininjspecialists.com]
  • Immediate symptoms of a concussion can include confusion, amnesia, nausea, vomiting, headache or dizziness. Post-concussion syndrome (PCS) is a condition in which the symptoms of a concussion persist for weeks, months or years.[livestrong.com]
Benign Paroxysmal Positional Vertigo
  • In patients with Visual Motion Sensitivity (VMS), BNO can improve both subjective visual perception and objective performance with sensorimotor tasks. [19] Considerations: [11] It is important to clear patients of Benign Paroxysmal Positional Vertigo[physio-pedia.com]
  • BPPV (Benign Paroxysmal Positional Vertigo) is always screened for and promptly treated when found. If gaze stability is impaired, a peripheral source such as labyrinthine concussion without fracture may be to blame.[jlgh.org]
Emotional Lability
  • Irritability, depression, anxiety, or emotional lability Subjective concentration, memory, or intellectual difficulties Insomnia Reduced alcohol tolerance Most experts agree that symptoms should begin no later than 4 weeks after the head injury.[verywell.com]
  • CLINICAL FINDINGS: Post-concussion syndrome lies within the confines of somatic symptoms (headaches, dizziness, and fatigue), cognitive symptoms (memory and concentration problems) and affective symptoms (irritability, emotional lability, depression,[noninvasiveicp.com]
  • lability Subjective concentration, memory, or intellectual difficulties without neuropsychological evidence of marked impairment Insomnia Reduced alcohol intolerance Preoccupation with above symptoms and fear of brain damage with hypochondriacal concern[momsteam.com]
  • People who are with a person who has PCS will notice either a lack of emotional displays or emotional lability. Some experience a lack of motivation or apathy, which may be a direct result of the illness or secondary to the depression seen in PCS.[autoaccident.com]
  • Symptoms in 3 or more of the following symptom categories: Headache, dizziness, malaise, fatigue, altered noise tolerance Irritability, depression, anxiety, emotional lability Subjective concentration, memory, or intellectual difficulties without neuropsychological[physio-pedia.com]
Headache
  • Headaches, dizziness, fatigue, emotional instability, anxiety, sleep disturbances and an overall decreased quality of life are described as the most important complaints.[symptoma.com]
  • She complained of 2 months of constant throbbing bilateral frontotemporal headaches – worse with exercise – and difficulty concentrating in class. Her headaches would occasionally wake her from sleep and were usually relieved by Advil.[amssm.org]
  • We recorded middle latency auditory evoked potentials (MLR) and slow vertex responses (SVR) in 20 individuals with prolonged cognitive difficulties, behavior changes, dizziness, and headache after concussion.[ncbi.nlm.nih.gov]
  • Headache is one of the most common complaints in patients with traumatic brain injury. By definition, headache that develops within 1 wk after head trauma (or within 1 wk after regaining consciousness) is referred to as posttraumatic headache (PTH).[doi.org]
  • Headaches can be treated with pain medication, and anti-emetics may be useful for dizziness. A combination of medication and therapy can be beneficial for symptoms of depression.[verywell.com]
Dizziness
  • Headaches, dizziness, fatigue, emotional instability, anxiety, sleep disturbances and an overall decreased quality of life are described as the most important complaints.[symptoma.com]
  • We recorded middle latency auditory evoked potentials (MLR) and slow vertex responses (SVR) in 20 individuals with prolonged cognitive difficulties, behavior changes, dizziness, and headache after concussion.[ncbi.nlm.nih.gov]
  • On exam, she was tender to palpation over the right inferior orbit and had worsening headache and dizziness with vestibular testing.[amssm.org]
  • The literature was reviewed to attempt to delineate prevalence of dizziness as a symptom, impairments causing dizziness, the functional limitations it causes and its measurement.[doi.org]
  • Headaches can be treated with pain medication, and anti-emetics may be useful for dizziness. A combination of medication and therapy can be beneficial for symptoms of depression.[verywell.com]
Irritability
  • Notable findings in PCS include persistent emotional instability, difficulty sleeping, anxiety, dizziness, irritability, visual disturbances, sensitivity to noise, and inability to maintain concentration, in addition to complaints mentioned previously[symptoma.com]
  • The prevalence of headache, irritability, fears, sleep disorders, learning difficulties, as well as concentration and memory problems did not differ significantly between children with mild traumatic brain injury and the control group when the results[ncbi.nlm.nih.gov]
  • She also endorsed feeling slowed down, irritability, and drowsiness. On exam, she was tender to palpation over the right inferior orbit and had worsening headache and dizziness with vestibular testing.[amssm.org]
  • The most commonly reported post concussion symptoms are headache, dizziness, decreased concentration, memory problems, irritability, fatigue, visual disturbances, sensitivity to noise, judgment problems, depression, and anxiety.[doi.org]
  • Postconcussive symptoms such as headache, dizziness, irritability, and difficulties with memory and attention are reported frequently after traumatic brain injuries (TBI) of all severities.[ncbi.nlm.nih.gov]
Insomnia
  • Irritability, depression, anxiety, or emotional lability Subjective concentration, memory, or intellectual difficulties Insomnia Reduced alcohol tolerance Most experts agree that symptoms should begin no later than 4 weeks after the head injury.[verywell.com]
  • The most common complaints are headaches, dizziness, fatigue, irritability, anxiety, insomnia, loss of consciousness and memory, and noise sensitivity.[ncbi.nlm.nih.gov]
  • Some common symptoms, such as apathy, insomnia, irritability, or lack of motivation, may result from other co-occurring conditions, such as depression.[en.wikipedia.org]
  • There are many different ways of defining PCS, but it is usually considered present if three or more symptoms (such as insomnia, headache, and dizziness) are present for at least three months.[healthofchildren.com]
  • Common symptoms seen in patients with this condition include: Dizziness Headache Slurred speech Nausea Other symptoms may include: Anxiety Sound and light sensitivity Insomnia In order to confirm the diagnosis, a physician will often perform a brain scan[tsrinjurylaw.com]
Vertigo
  • Symptoms of a central source may include nausea with nonpositional vertigo and imbalance.[doi.org]
  • Visual Vertigo Scale (VVS) [15] Condition-specific, 15-item questionnaire which assesses a patient’s perceived severity of vertigo symptoms over the past month.[physio-pedia.com]
  • Symptoms of headache, dizziness/vertigo, and brain fog are often major associations. Patients often become very plastic, or efficient in brain pathways that should not be utilized.[portchiro.com]
  • She also complained of positional vertigo (dizziness when moving the head) that came on only after the concussion.[uppercervicalawareness.com]
  • The symptoms most often associated with postconcussion syndrome are headache, dizziness, vertigo, anxiety, fatigue, difficulty in concentrating, depression, heart palpitations, tinnitus, and apathy.[aapc.com]

Workup

Physicians must bear in mind the importance of an early diagnosis of concussion and proper initiation of therapy, particularly in younger athletes. For this reason, a meticulous clinical workup is recommended. Firstly, a detailed patient history must cover all the details regarding the event that led to brain injury (time, description of the mechanism of injury, and severity of impact) and evaluate the presence of associated symptoms [1]. The Sport Concussion Assessment Tool 2 (SCAT2), comprising of a series of self-evaluating questions, a Glasgow coma scale grading (GCS), cognitive assessment, as well as examination of balance and coordination, is a comprehensive tool that can be of significant benefit in assessing individuals in whom a concussion is suspected [1]. The subjective nature of this test, however, is a major limitation [2]. In addition to findings obtained during the interview with the patient, a complete physical and neurological examination is also important. Clinical criteria should be supported by various tests, the most important being the treadmill test that determines whether symptoms appear or become exacerbated with exercise [2] [8]. If patients are unable to perform strenuous activities after TBI due to the reappearance of symptoms, the diagnosis of PCS is highly likely [2] [8]. The role of imaging studies in identifying additional injuries to other structures (eg. the cranium) is quite important but is of little benefit for PCS due to the absence of macroscopic changes in the brain after a concussion.

Treatment

  • Treatment of PCS is significantly different from that of SRC alone. Primary care physicians often are the first to evaluate these patients, but some are unfamiliar with the available therapeutic approaches.[ncbi.nlm.nih.gov]
  • "Evaluation and treatment of postconcussive symptoms". NeuroRehabilitation 17 (4): 265–83. MA McCrea. Mild Traumatic Brain Injury and Postconcussion Syndrome: The New Evidence Base for Diagnosis and Treatment.[verywell.com]
  • Traumatic brain injury (TBI) might lead to severely debilitating long-term sequelae in the absence of an early diagnosis and adequate treatment, one of the most important forms being a concussion, defined as a traumatic event during which various pathophysiological[symptoma.com]
  • Several standardized, empirically supported treatment manuals are available.[ncbi.nlm.nih.gov]

Prognosis

  • The prognosis for minor cranial traumas is benign at vital level but a number of patients will develop long-term complaints, which contrast with the negativity of the clinical examination and complementary explorations.[noninvasiveicp.com]
  • The prognosis of mild CET is still uncertain and not all who have suffered a mild CET are going to develop a post-concussional syndrome.[elsevier.es]
  • Written by over 100 acknowledged leaders in the field, and containing hundreds of tables, graphs, and photographic images, the text deals with issues of neuroimaging and neurodiagnostic testing, prognosis and outcome, acute care, rehabilitative care,[books.google.com]
  • Treatment typically involves: normalising post-concussion symptoms and emphasising their non-malignant nature; providing an optimistic prognosis and estimate of likely recovery time; explaining the nature of, and how to cope with, impairments of speed[web.archive.org]
  • Prognosis The overall outcome is difficult to assess. Most individuals who have PCS recover fully, although if recovery has not occurred in one year it is less likely that it will ever occur.[healthofchildren.com]

Etiology

  • The etiology of these symptoms is often controversial. Neuropsychological, neurophysiological, and neuropathological evidence that brain damage can occur in the absence of gross neurological deficits after mild injuries is reviewed.[ncbi.nlm.nih.gov]
  • Mood disorders occurring after TBI are clearly an area of neuropsychiatry in which further research in etiology as well as treatment is needed.[doi.org]
  • Both physiological and psychological etiologies have been suggested as causes for persistent post concussion symptoms and this has led to much controversy and debate in the literature.[doi.org]
  • The etiology of these symptoms in individuals with mild TBI has been a subject of some controversy with theories ranging from neural damage to malingering.[ncbi.nlm.nih.gov]

Epidemiology

  • Recent findings We have now a more consistent view of the epidemiology of post-traumatic brain injury psychiatric disorders both in adult and pediatric populations.[doi.org]
  • Epidemiology/Pathophysiology First published: 26 October 2011 Cited by: 1 Abstract Abstract Concussion is defined as a biomechanically induced brain injury characterized by the absence of gross anatomic lesions.[doi.org]
  • EPIDEMIOLOGY AND NATURAL RECOVERY The number of people who sustain a mild head injury and experience subsequent post-concussion symptoms is very high.[web.archive.org]
  • Thurman DJ, Branche CM, Sniezek JE: The epidemiology of sports-related brain injuries in the United States: recent developments. J Head Trauma Rehabil 1998, 13 :1–8. PubMed Google Scholar 7.[doi.org]
  • […] features include: Emphasis on a disease state management approach to patient assessment and treatment Promotion of a holistic, biopsychosocial model of patient assessment and care Review of current expert consensus on practice guidelines Exploration of epidemiologic[books.google.com]
Sex distribution
Age distribution

Pathophysiology

  • This review provides an overview of the pathophysiology of SRC and descriptions of both pharmacologic and nonpharmacologic treatment options to allow primary care physicians to provide evidence-based care to patients experiencing postconcussive syndrome[ncbi.nlm.nih.gov]
  • Traumatic brain injury (TBI) might lead to severely debilitating long-term sequelae in the absence of an early diagnosis and adequate treatment, one of the most important forms being a concussion, defined as a traumatic event during which various pathophysiological[symptoma.com]
  • Recent literature relating to pathophysiology, neuropsychological outcome, and the persistent postconcussion syndrome will be integrated into the existing literature.[doi.org]
  • This condition of concussion‐induced brain vulnerability is the basic pathophysiology of the second impact syndrome.[doi.org]
  • The pathophysiological basis of mild brain injury is frequently a diffuse axonal damage of variable degree. In the acute phase of mild brain injury we have to identify 1% of patients who will undergo neurosurgery because of vital need.[ncbi.nlm.nih.gov]

Prevention

  • A comprehensive diagnostic and therapeutic approach, primarily based on the ability to conduct a complete physical workup, is necessary in order to prevent long-term impairment.[symptoma.com]
  • A review of controlled treatment outcome studies conducted over the past 2 decades in Scandinavia, Great Britain, Canada, and the United States suggests that early single session treatment can prevent the syndrome as effectively as traditional outpatient[ncbi.nlm.nih.gov]
  • The role of the school nurse includes being knowledgeable about management of head injuries and return-to-play guidelines, providing follow-up for athletes who have concussions, and providing education on prevention and management of head injuries.[ncbi.nlm.nih.gov]

References

Article

  1. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med 2009;19(3):185-200.
  2. Leddy JJ, Sandhu H, Sodhi V, Baker JG, Willer B. Rehabilitation of Concussion and Post-concussion Syndrome. Sports Health. 2012;4(2):147-154.
  3. WHO (World Health Organization) International Statistical Classification of Diseases and Related Health Problems. 2010. [October 3, 2013]. (10th Revision. [Online version.]). http://apps.who.int/classifications/icd10/browse/2010/en.
  4. Willer B, Leddy JJ. Management of concussion and post-concussion syndrome. Curr Treat Options Neurol. 2006;8(5):415-426.
  5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fifth Edition. Arlington, VA: American Psychiatric Publishing; 2013.
  6. Dischinger PC, Ryb GE, Kufera JA, Auman KM. Early predictors of postconcussive syndrome in a population of trauma patients with mild traumatic brain injury. J Trauma. 2009;66(2):289-96;296-297.
  7. Iverson GL. Misdiagnosis of the persistent postconcussion syndrome in patients with depression. Arch Clin Neuropsychol. 2006;21(4):303-310.
  8. Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010;20(1):21-27.

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Last updated: 2019-07-11 20:43