Postconcussive Syndrome Clinical Presentation
- Author: Eric L Legome, MD; Chief Editor: Trevor John Mills, MD, MPH more...
Most patients present shortly after a minor head injury (MHI). Often, patients return after a previous evaluation in the emergency department (ED) because of persistent postconcussive symptoms. Findings may include the following:
- Headache - This is the most common symptom of postconcussive syndrome. The specific type is variable. One study found a prevalence of persistent posttraumatic headache in 15.3% of patients with minor head injury compared to 2.2% of matched minor injury ED controls.
- Cranial nerve symptoms and signs - Dizziness (the second most common symptom), 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
Tator and Davis performed a retrospective cohort study of 138 patients who had sports-related postconcussion syndrome (PCS) based on three or more postconcussion symptoms lasting 1 month or longer. The patients averaged 3.4 concussions, ranging from 1 to more than 12. Over 80% of the PCS patients had at least one previous concussion, and only 19.6% had no previous concussion. In 21% of patients, the authors identified a history of a previous psychiatric condition, attention-deficit disorder or attention-deficit/hyperactive disorder, learning disability, or previous migraine headaches.
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 (nondermatomal distribution)
- Cognitive deficits
- Neuropsychological testing has revealed that deficits can persist 6 months or longer when other symptoms are present.
- These deficits 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 deficits resolve when other somatic and neurologic symptoms do not.
Risk factors for the development of postconcussive syndrome include nonsporting mechanisms, loss of consciousness, amnesia for the event, female sex, and abnormal neurobehavioral testing results after the incident.
- A common perception is that patients who develop postconcussive syndrome from head injury are those who perceive a source of blame for the injury and desire to pursue litigation. However, a single study evaluating this did not demonstrate a correlation between blame and litigation. In fact, postconcussive syndrome 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 postconcussive syndrome, but the data are conflicting.
- Neck pain after a head injury has not been correlated with the development of postconcussive syndrome.
- 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.
- One study found an inverse association between number of years of education and development of postconcussive syndrome in adult patients.
- Patients with premorbid physical problems have also been found to have a higher incidence of postconcussive syndrome after minor head injury.
- One study found that perception of the illness itself may have an effect on the development of postconcussive syndrome. Patients who believed that their symptoms had serious negative consequences on their lives were at increased risk of developing postconcussive syndrome.
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