eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Postconcussive Syndrome
Updated: Feb 6, 2009
Introduction
Background
Postconcussive syndrome (PCS), a sequela of minor head injury (MHI), has been a much-debated topic. 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, postconcussive syndrome (PCS) remains controversial. Depending on the definition and the population examined, 29-90% of patients experience postconcussive symptoms shortly after the traumatic insult.
Minor head injury and concussion are generally used interchangeably in the medical literature; however, it should be noted that the traditional definition of concussion precludes findings of intracranial hemorrhage on CT scan, whereas the definition minor head injury does not (though it does preclude the presence of a skull fracture). A minor head injury typically indicates a blow to the head with a brief period of loss of consciousness (LOC) or posttraumatic amnesia or disorientation. At presentation, the Glasgow Coma Scale (GCS) score ranges from 13-15. However, more recent literature suggests, and many clinicians concur, that a GCS score of 14 or 15 denotes an injury with a significantly less chance of intracranial injury on CT scan than a GCS score of 13.
Although no universally accepted definition of postconcussive syndrome exists, most of the literature defines the syndrome as the development 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. Persistent postconcussive syndrome (PPCS) is generally defined as symptoms lasting more than 6 months, though some authors define it as symptoms lasting more than 3 months.
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
Debate in the literature exists over which symptoms of postconcussive syndrome are due to organic causes and which have a psychological basis. Researchers have hypothesized that early postconcussive syndrome symptoms are more likely to be organic, whereas postconcussive syndrome symptoms that persist beyond 3 months have a nonorganic, psychological basis. While recent research has shown that psychological factors may be present early, other studies using imaging techniques such as magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), and magnetoencephalography (MEG) have demonstrated the presence of organic brain injury in patients with persistent postconcussive syndrome at greater than 1 year after injury.
Neuropsychological assessments have pointed toward an organic basis for some of the symptoms of postconcussive syndrome. Patients with PCS have been found to have cognitive deficits in memory, attention, and learning when compared with controls. 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 postconcussive syndrome.
Frequency
United States
More than 1 million instances of minor head injury occur in the United States each year. The overall incidence rate of minor head injury for persons not hospitalized, with data compiled by the National Hospital Ambulatory Medical Care Survey (1998-2000), was 503 per 100,000 population or 1,367,101 visits per year to hospital EDs in the United States. Depending on the definitions used and population examined, approximately 50% of patients with minor head injury have symptoms of postconcussive syndrome at 1 month and 15% have symptoms at 1 year.
Mortality/Morbidity
Morbidity is mainly due to the persistence of symptoms, which make it difficult for patients to resume premorbid functions.
Sex
Men experience minor head injury more frequently than women, but the incidence of postconcussive syndrome is greater in females than in males.
Age
Fifty percent of those who experience minor head injury are aged 15-34 years. However, postconcussive syndrome has no predilection for any specific age group.
Clinical
History
Most patients present shortly after an 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.
- 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
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 (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.
Causes
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.1
- 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.2
More on Postconcussive Syndrome |
 Overview: Postconcussive Syndrome |
| Differential Diagnoses & Workup: Postconcussive Syndrome |
| Treatment & Medication: Postconcussive Syndrome |
| Follow-up: Postconcussive Syndrome |
| References |
| Next Page » |
References
Dawson KS, Batchelor J, Meares S, Chapman J, Marosszeky JE. Applicability of neural reserve theory in mild traumatic brain injury. Brain Inj. Aug 2007;21(9):943-9. [Medline].
Whittaker R, Kemp S, House A. Illness perceptions and outcome in mild head injury: a longitudinal study. J Neurol Neurosurg Psychiatry. Jun 2007;78(6):644-6. [Medline].
Ma M, Lindsell CJ, Rosenberry CM, Shaw GJ, Zemlan FP. Serum cleaved tau does not predict postconcussion syndrome after mild traumatic brain injury. Am J Emerg Med. Sep 2008;26(7):763-8. [Medline].
Lima DP, Simao Filho C, Abib Sde C, de Figueiredo LF. Quality of life and neuropsychological changes in mild head trauma. Late analysis and correlation with S100B protein and cranial CT scan performed at hospital admission. Injury. May 2008;39(5):604-11. [Medline].
Rees RJ, Bellon ML. Post concussion syndrome ebb and flow: longitudinal effects and management. NeuroRehabilitation. 2007;22(3):229-42. [Medline].
Meares S, Shores EA, Batchelor J, et al. The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury. J Int Neuropsychol Soc. Nov 2006;12(6):792-801. [Medline].
Yang CC, Tu YK, Hua MS, Huang SJ. The association between the postconcussion symptoms and clinical outcomes for patients with mild traumatic brain injury. J Trauma. Mar 2007;62(3):657-63. [Medline].
Alexander MP. Mild traumatic brain injury: pathophysiology, natural history, and clinical management. Neurology. 1995;45 (7):1253-60. [Medline].
Barrett K, Ward AB, Boughey A, Jones M, Mychalkiw W. Sequelae of minor head injury: the natural history of post-concussive symptoms and their relationship to loss of consciousness and follow-up. J Accid Emerg Med. Jun 1994;11(2):79-84. [Medline].
Bazarian JJ, McClung J, Shah MN, Cheng YT, Flesher W, Kraus J. Mild traumatic brain injury in the United States, 1998--2000. Brain Inj. Feb 2005;19(2):85-91. [Medline].
Bazarian JJ, Wong T, Harris M, Leahey N, Mookerjee S, Dombovy M. Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population. Brain Inj. Mar 1999;13(3):173-89. [Medline].
Bernstein DM. Recovery from mild head injury. Brain Inj. Mar 1999;13(3):151-72. [Medline].
Bigler ED. Neuropsychology and clinical neuroscience of persistent post-concussive syndrome. J Int Neuropsychol Soc. Jan 2008;14(1):1-22. [Medline].
Boake C, McCauley SR, Levin HS, et al. Diagnostic criteria for postconcussional syndrome after mild to moderate traumatic brain injury. J Neuropsychiatry Clin Neurosci. Summer 2005;17(3):350-6. [Medline].
Bohnen N, Twijnstra A, Wijnen G. Tolerance for light and sound of patients with persistent post-concussional symptoms 6 months after mild head injury. J Neurol. Dec 1991;238(8):443-6. [Medline].
Chan RC. How severe should symptoms be before someone is said to be suffering from post-concussion syndrome? An exploratory study with self-reported checklist using Rasch analysis. Brain Inj. Dec 2005;19(13):1117-24. [Medline].
Chen JK, Johnston KM, Collie A, McCrory P, Ptito A. A validation of the post concussion symptom scale in the assessment of complex concussion using cognitive testing and functional MRI. J Neurol Neurosurg Psychiatry. Nov 2007;78(11):1231-8. [Medline].
Collie A, Makdissi M, Maruff P, Bennell K, McCrory P. Cognition in the days following concussion: comparison of symptomatic versus asymptomatic athletes. J Neurol Neurosurg Psychiatry. Feb 2006;77(2):241-5. [Medline].
de Kruijk JR, Leffers P, Meerhoff S, Rutten J, Twijnstra A. Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry. Aug 2002;73(2):167-72. [Medline].
De Kruijk JR, Leffers P, Menheere PP, Meerhoff S, Rutten J, Twijnstra A. Prediction of post-traumatic complaints after mild traumatic brain injury: early symptoms and biochemical markers. J Neurol Neurosurg Psychiatry. Dec 2002;73(6):727-32. [Medline].
de Kruijk JR, Leffers P, Menheere PP, Meerhoff S, Twijnstra A. S-100B and neuron-specific enolase in serum of mild traumatic brain injury patients. A comparison with health controls. Acta Neurol Scand. Mar 2001;103(3):175-9. [Medline].
Duff J. The usefulness of quantitative EEG (QEEG) and neurotherapy in the assessment and treatment of post-concussion syndrome. Clin EEG Neurosci. Oct 2004;35(4):198-209. [Medline].
Erlanger DM, Kutner KC, Barth JT, Barnes R. Neuropsychology of sports-related head injury: Dementia Pugilistica to Post Concussion Syndrome. Clin Neuropsychol. May 1999;13(2):193-209. [Medline].
Evans RW. Post-traumatic headaches. Neurol Clin. Feb 2004;22(1):237-49, viii. [Medline].
Groswasser Z, Reider-Groswasser I, Soroker N, Machtey Y. Magnetic resonance imaging in head injured patients with normal late computed tomography scans. Surg Neurol. Apr 1987;27(4):331-7. [Medline].
Guerrero JL, Thurman DJ, Sniezek JE. Emergency department visits associated with traumatic brain injury: United States, 1995-1996. Brain Inj. Feb 2000;14(2):181-6. [Medline].
Ingebrigtsen T, Waterloo K, Marup-Jensen S, Attner E, Romner B. Quantification of post-concussion symptoms 3 months after minor head injury in 100 consecutive patients. J Neurol. Sep 1998;245(9):609-12. [Medline].
Kibby MY, Long CJ. Minor head injury: attempts at clarifying the confusion. Brain Inj. Mar 1996;10(3):159-86. [Medline].
Larrabee GJ. Neuropsychological Outcome, Post Concussion Symptoms, and Forensic Considerations in Mild Closed Head Trauma. Semin Clin Neuropsychiatry. Jul 1997;2(3):196-206. [Medline].
Lee LK. Controversies in the sequelae of pediatric mild traumatic brain injury. Pediatr Emerg Care. Aug 2007;23(8):580-3; quiz 584-6. [Medline].
Levin HS, Amparo E, Eisenberg HM, et al. Magnetic resonance imaging and computerized tomography in relation to the neurobehavioral sequelae of mild and moderate head injuries. J Neurosurg. May 1987;66(5):706-13. [Medline].
Lewine JD, Davis JT, Bigler ED, et al. Objective documentation of traumatic brain injury subsequent to mild head trauma: multimodal brain imaging with MEG, SPECT, and MRI. J Head Trauma Rehabil. May-Jun 2007;22(3):141-55. [Medline].
Lovell MR, Iverson GL, Collins MW, McKeag D, Maroon JC. Does loss of consciousness predict neuropsychological decrements after concussion?. Clin J Sport Med. Oct 1999;9(4):193-8. [Medline].
McCullagh S, Feinstein A. Outcome after mild traumatic brain injury: an examination of recruitment bias. J Neurol Neurosurg Psychiatry. Jan 2003;74(1):39-43. [Medline].
Mooney G, Speed J, Sheppard S. Factors related to recovery after mild traumatic brain injury. Brain Inj. Nov 2005;19(12):975-87. [Medline].
Olver J. Traumatic brain injury--the need for support and follow up. Aust Fam Physician. Apr 2005;34(4):269-71. [Medline].
Potter S, Leigh E, Wade D, Fleminger S. The Rivermead Post Concussion Symptoms Questionnaire: a confirmatory factor analysis. J Neurol. Dec 2006;253(12):1603-14. [Medline].
Rosenthal M. Mild traumatic brain injury syndrome. Ann Emerg Med. Jun 1993;22(6):1048-51. [Medline].
Satz PS, Alfano MS, Light RF, et al. Persistent Post-Concussive Syndrome: A proposed methodology and literature review to determine the effects, if any, of mild head and other bodily injury. J Clin Exp Neuropsychol. Oct 1999;21(5):620-8. [Medline].
Savola O, Hillbom M. Early predictors of post-concussion symptoms in patients with mild head injury. Eur J Neurol. Mar 2003;10(2):175-81. [Medline].
Stalnacke BM, Bjornstig U, Karlsson K, Sojka P. One-year follow-up of mild traumatic brain injury: post-concussion symptoms, disabilities and life satisfaction in relation to serum levels of S-100B and neurone-specific enolase in acute phase. J Rehabil Med. Sep 2005;37(5):300-5. [Medline].
Stalnacke BM, Elgh E, Sojka P. One-year follow-up of mild traumatic brain injury: cognition, disability and life satisfaction of patients seeking consultation. J Rehabil Med. May 2007;39(5):405-11. [Medline].
Stulemeijer M, van der Werf S, Borm GF, Vos PE. Early prediction of favourable recovery 6 months after mild traumatic brain injury. J Neurol Neurosurg Psychiatry. Aug 2008;79(8):936-42. [Medline].
van der Naalt J, Hew JM, van Zomeren AH, Sluiter WJ, Minderhoud JM. Computed tomography and magnetic resonance imaging in mild to moderate head injury: early and late imaging related to outcome. Ann Neurol. Jul 1999;46(1):70-8. [Medline].
Voller B, Benke T, Benedetto K, Schnider P, Auff E, Aichner F. Neuropsychological, MRI and EEG findings after very mild traumatic brain injury. Brain Inj. Oct 1999;13(10):821-7. [Medline].
Wade DT, King NS, Wenden FJ, Crawford S, Caldwell FE. Routine follow up after head injury: a second randomised controlled trial. J Neurol Neurosurg Psychiatry. Aug 1998;65(2):177-83. [Medline].
Wood RL. Understanding the 'miserable minority': a diasthesis-stress paradigm for post-concussional syndrome. Brain Inj. Nov 2004;18(11):1135-53. [Medline].
Further Reading
Keywords
postconcussive syndrome, concussion, postconcussive symptoms, PCS, minor head injury, MHI, head trauma, loss of consciousness, brain injury, traumatic brain injury
