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Postconcussive Syndrome

Eric Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital, Manhattan
Rachel Alt, MD, Staff Physician, Department of Emergency Medicine, New York University Bellevue Hospital; Tina Wu, MD, Staff Physician, Department of Emergency Medicine, New York University Medical Center, Bellevue Hospital Center

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

Differential Diagnoses

Depression
Dissection, Vertebral Artery
Fibromyalgia
Posttraumatic Stress Disorder

Other Problems to Be Considered

Chronic fatigue syndrome

Workup

Laboratory Studies

No specific laboratory studies are needed, unless concomitant illness is suspected or unless the diagnosis is unclear and believed to be of toxic or metabolic origin.

Imaging Studies

Neurological examination and CT scan findings are frequently normal in patients with postconcussive syndrome; however, this does not confirm the absence of damage to the brain. Imaging modalities such as MRI, SPECT, and MEG have been shown to be more sensitive than CT at detecting brain injuries associated with postconcussive syndrome. These modalities have demonstrated an association between basal ganglia hypoperfusion and headaches, temporal lobe abnormalities and memory deficits, parietal lobe abnormalities and attention problems, and frontal lobe abnormalities and problems with executive function in patients with postconcussive syndrome. Interestingly, these imaging modalities have not born out associations between posttraumatic brain abnormalities and psychiatric symptoms in postconcussive syndrome.

It has been hypothesized that axonal injury at the time of trauma could underlie postconcussive syndrome. Shear strain on the neurons that leads to diffuse axonal injury can occur without CT abnormalities. However, a recent study of a biomarker for axonal injury, serum cleaved tau (C-tau), showed no correlation between C-tau levels at the time of injury and the later development of postconcussive syndrome.3 Studies looking at serum levels of S-100B, a protein found most commonly in astrocytes, in patients with minor head injury have found conflicting results regarding a correlation between initial levels of the protein and development of postconcussive syndrome.4

  • CT scanning is used to determine the presence of intracranial abnormalities and skull fractures. In young patients with no loss of consciousness and a normal neurologic examination, CT scanning is of very low yield and is unlikely to be positive. Patients with postconcussive syndrome (PCS) usually do not present immediately after the trauma.
    • If a CT scan has already been obtained, the utility of a repeat scan is minimal in the absence of focal neurologic signs or unless the patient is at risk for delayed hemorrhage (eg, an elderly patient on warfarin.)
    • If a CT scan has not been obtained and if the patient had a loss of consciousness and a GCS of 15, the likelihood of finding an operable lesion is extremely limited. Unfortunately, these patients with symptoms and a normal examination may still harbor an injury that requires intervention. A more detailed discussion on head trauma and CT scan can be found in the eMedicine article Emergency Neuroradiology.
    • In general, a single head CT scan is still a reasonable, fast, and effective screening test in the significantly symptomatic patient, although it should be balanced by the risks of radiation, especially in children.
  • MRI, SPECT, and positron emission tomography (PET) scans are more sensitive than CT scans in detecting abnormalities associated with minor head injury and postconcussive syndrome.
    • An MRI obtained in the acute period has little clinical significance. If one is obtained, it should be obtained on an outpatient basis in conjunction with follow-up. Although traumatic lesions may be depicted on MRIs in patients with minor head injury and a normal nonenhanced CT scan, they rarely influence the acute clinical course.
    • An MRI, SPECT, or PET scan obtained 4-24 months after injury may reveal a variety of abnormalities, though this rarely influences treatment or outcome.

Other Tests

  • Neuropsychological testing
    • This testing rarely is performed in the acute setting, although it may have some value in predicting the development of symptoms.
    • A series of standardized tests and questionnaires are used to measure attention, language, memory, emotional functioning, and other neurobehavioral parameters.
    • The Rivermead Postconcussion Symptoms Questionnaire is used to quantify postconcussive syndrome symptoms.
    • Neuropsychological assessments may be used. These include the Wechsler Adult Intelligence Scale and specific subtests (digit span and vocabulary), Trail Making Test, complex figure drawings (eg, Rey Osterreith), copy trials and memory trials, category tests, controlled oral word association (Hopkins Verbal Learning Test), Wisconsin Card Sorting Test, and the Paced Auditory Serial Addition Task.
    • The objective personality measure, Minnesota Multiphasic Personality Inventory, Second Edition (MMPI2), may be used.
    • The Hospital Anxiety and Depression Scale, Impact of Even Scale, Galveston Orientation and Amnesia Test, and assessments of posttraumatic amnesia are used together as prognostic screening instruments for predicting postconcussive syndrome persistence.

Treatment

Emergency Department Care

No specific care is required in the ED. Patients with the symptom constellation consistent with postconcussive syndrome (PCS) require thorough physical and neurological examinations. A CT scan should be obtained if significant concern about intracranial hemorrhage exists, although this injury is rare in the patient presenting late with nonfocal findings at examination.

  • Supportive care may include the use of nonnarcotic analgesics and antiemetics. However, there does not appear to be any medications at discharge that can prevent or hasten the resolution of postconcussive syndrome. Several drugs are under investigation, but none have proven to be clinically useful yet.
  • Several studies have shown that providing patients with an explanation of symptoms as well as expectations may decrease the severity and duration of postconcussive symptoms.
  • Although rare, patients may be admitted if symptoms are severe, the majority can be discharged. Several studies have revealed that patients admitted acutely after a minor head injury (MHI) may have a lower incidence of postconcussive syndrome and its attendant social and psychological morbidity. This finding, however, may be due to active interventions at follow-up.
  • Prompt follow-up care and reassurance may hasten resolution of symptoms. Patients should be referred to a primary care doctor, neurologist, or psychiatrist depending on their symptoms.

Consultations

Rarely is consultation warranted in the ED once the diagnosis is made. Outpatient referral is the cornerstone of treatment. One study suggests that findings of early neuropsychological assessment may determine the prognosis; however, this assessment rarely is performed in the ED.

Follow-up

Further Outpatient Care

Outpatient care is the cornerstone of treatment of patients with postconcussive syndrome (PCS) and involves multidisciplinary teams that provide testing and treatment, including cognitive rehabilitation, psychotherapy, stress management, vocational counseling, and symptomatic treatment with medications.

  • No treatments have been proven effective, though neurotherapy or quantitative EEG biofeedback is a modality that has been shown in recent studies to improve symptoms of postconcussive syndrome. More controlled studies are needed at this point.
  • A neurologist, physical medicine specialist, primary care physician, or psychologist specializing in these disorders usually coordinates treatment.

Deterrence/Prevention

  • The emergency physician should encourage the use of interventions to decrease the incidence of traumatic brain injury. This approach is particularly important in young adults, who have a higher incidence of head injury than others.
    • Encourage patients to wear a seatbelt.
    • Encourage patients to wear a helmet when riding bicycles or motorcycles, or playing high-risk sports.

Prognosis

  • True prognosis is difficult to define given that many patients with minor symptoms may not enter the health care system and those that participate in research appear to have more significant symptoms at baseline. In addition, a wide heterogeneity exists in patients enrolled in studies.
  • Most patients recover fully in less than 3 months, although some small studies suggest persistence of minor cognitive defects for asymptomatic minor traumatic brain injury patients.5
  • Approximately 15% of patients complain of problems more than 12 months after injury. This group is likely to experience persistent and intrusive symptoms that may be refractory to treatment and impose a lifelong disability.
  • At least one study found the persistence of dizziness as a symptom seemed to portend a longer and more significant symptom complex.6 Other studies found the depression, pain, and symptom invalidity were correlated with longer and worse symptoms.7

Patient Education

  • Educate the patient about the usual self-limited nature of postconcussive syndrome.
  • Education about the usual symptoms may be helpful.
  • Discussions concerning preparation for the graded resumption of vocational and academic routines may lessen postconcussive syndrome persistence.
  • For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Concussion.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize the benefits of reassurance and providing follow-up care.
    • Patients are likely to experience difficulty with symptoms when neurologic examinations, psychological assessments, and physical examinations reveal limited evidence of or explanation for the persistence of the symptoms.
    • Patients' veracity may be questioned; they may be treated as if they are neurotic or merely seeking compensation.
    • Practitioners may be confused about complaints when objective evidence is not present.
    • Follow-up during recovery may aid in preventing symptom persistence.
  • Failure to provide patients with information regarding the sequelae of minor head injury.

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Keywords

postconcussive syndrome, concussion, postconcussive symptoms, PCS, minor head injury, MHI, head trauma, loss of consciousness, brain injury, traumatic brain injury 

Contributor Information and Disclosures

Author

Eric Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital, Manhattan
Eric Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Rachel Alt, MD, Staff Physician, Department of Emergency Medicine, New York University Bellevue Hospital
Disclosure: Nothing to disclose.

Tina Wu, MD, Staff Physician, Department of Emergency Medicine, New York University Medical Center, Bellevue Hospital Center
Tina Wu, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Senior Vice President, Chief Medical Officer, Medical Director, Attending Physician in Department of Emergency Medicine, Saint Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jon Mark Hirshon, MD, MPH, Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine
Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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