Post-Concussive Syndrome


Background
  1. Usually the result of mild/ minor head injury
  2. Usually occurs within the first few weeks
  3. Usually resolves within 3 months

Pathophysiology

  1. Pathophysiology unclear
    • CT scan, MRI, SPECT may or may not show pathology
    • Organic evidence and symptoms often do NOT match
    • Physical-emotional co-morbidity is common
  2. Prognosis for complete long-term recovery is good

Range of Symptoms

  1. Many symptoms can be noted
    • Headaches
      • Muscle contraction or tension
      • Cranial myofascial injury
      • Cervicogenic (2° to neck injury)
      • Myofascial injury
      • Intervertebral discs
      • Cervical spondylosis
      • Third occipital headache (C2–C3 facet joint)
      • 2° to temporomandibular joint injury
      • Migraine
        • With and without aura
        • Footballer's migraine
      • Greater and lesser occipital neuralgia
      • Mixed headache
      • Cluster
      • Supraorbital and infraorbital neuralgia
      • From scalp lacerations or local trauma
      • Dysautonomic cephalgia
      • Orgasmic cephalgia
      • Carotid or vertebral artery dissection
      • Subdural or epidural hematomas
      • Hemorrhagic cortical contusions
    • Cranial nerve symptoms and signs
      • Dizziness
      • Vertigo
      • Tinnitus
      • Hearing loss
      • Blurred vision
      • Diplopia
      • Convergence insufficiency
      • Light and noise sensitivity
      • Diminished taste and smell
    • Psychological and somatic complaints
      • Irritability
      • Anxiety
      • Depression
      • Personality change
      • Fatigue
      • Sleep disturbance
      • Decreased libido
      • Decreased appetite
      • Cognitive impairment
      • Memory dysfunction
      • Impaired concentration and attention
      • Slowing of reaction time
      • Slowing of information processing speed
    • Rare occurrences
      • Subdural and epidural hematomas
      • Seizures
      • Transient global amnesia
      • Tremor
      • Dystonia

Diagnosis

  1. Common symptoms
    • Headache
    • Dizziness, disequilibrium
    • Inability to concentrate (days to months after head trauma)
    • Irritability (days to months after head trauma)
  2. Neuro exam usually non-focal
  3. Diagnostic Criteria 
    • Prevalence is higher using the International Classification of Diseases, 10th edition (ICD-10) diagnostic criteria than using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria
    • Symptom number and severity reported by patients is increased using structured evaluation instruments compared with open-ended interviews
  4. Lab tests
    • No specific lab tests needed
    • Serum S-100 and neuron-specific enolase may eventually be useful biochemical markers
      • Correlate negatively with development of PCS
        • One v.small study
        • Clinical utility unclear as of yet
  5. CT scanning:
    • If CT was obtained at time of injury:
      • CT only if
        • Neurological findings (new)
        • Pt at risk for delayed bleed
    • If CT NOT obtained at time of injury
      • If patient has GCS = 15
        • Minimal chance of finding operable lesion
      • CT may still be a reasonable screening tool
        • Fast and effective
        • Decide based on individual patient

 

Treatment

  1. Symptomatic support and reassurance
    • Non-narcotic pain control for HA
    • Antiemetic: Ondansetron, phenergan
    • Sleep aids
  2. Neurology consult for severe symptoms, focal neuro exam or positive CT
  3. Outpatient referral is cornerstone of treatment

 

Disposition

  1. Admit for severe sx or significant findings
  2. Otherwise d/c with early follow-up