Postconcussive Syndrome Workup
- Author: Eric L Legome, MD; Chief Editor: Trevor John Mills, MD, MPH more...
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. While some newer studies have searched for evidence of specific proteins or biomarkers as predictive of PCS, there is no definitive correlations as of yet.
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. 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.
In a study by Ramos-Zuniga et al, neuropsychological and spectroscopy testing confirmed the diagnosis of postconcussion syndrome in patients with mild head injury (MHI). According to the authors, spectroscopy revealed neurometabolite disturbances in 54% of cases, particularly N-acetylaspartate (Naa) and the Naa/lactate ratio in the frontal lobe. In addition, the authors noted that 55% of patients experienced physical disturbances such as headache and postural vertigo.
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. 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.
Neuropsychological 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.
In an exploratory factor and confirmatory factor analysis of a 19-item Postconcussion Symptom Scale broken up into 3 factors (neurocognitive, somatic, emotional), patients seen more than 14 days after the concussion injury had worse factor 3 (emotional) scores than those seen less than 14 days after injury. Females and patients with anxiety disorders had significantly worse (higher) scores on all 3 factors.
Butler IJ. Postconcussion Syndrome After Mild Traumatic Brain Injury in Children and Adolescents Requires Further Detailed Study. JAMA Neurol. 2013 Mar 25. 1-2. [Medline].
Sullivan KA, Edmed SL, Cunningham LC. A comparison of new and existing mild traumatic brain injury vignettes: recommendations for research into post-concussion syndrome. Brain Inj. 2013. 27(1):19-30. [Medline].
Heitger MH, Jones RD, Macleod AD, Snell DL, Frampton CM, Anderson TJ. Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression, malingering or intellectual ability. Brain. 2009 Oct. 132:2850-70. [Medline].
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 Feb. 66(2):289-96; discussion 296-7. [Medline].
Sheedy J, Harvey E, Faux S, Geffen G, Shores EA. Emergency department assessment of mild traumatic brain injury and the prediction of postconcussive symptoms: a 3-month prospective study. J Head Trauma Rehabil. 2009 Sep-Oct. 24(5):333-43. [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. 2005 Feb. 19(2):85-91. [Medline].
Barlow KM. Postconcussion Syndrome: A Review. J Child Neurol. 2014 Oct 20. [Medline].
Kolias AG, Guilfoyle MR, Helmy A, Allanson J, Hutchinson PJ. Traumatic brain injury in adults. Pract Neurol. 2013 Mar 13. [Medline].
Reuben A, Sampson P, Harris AR, Williams H, Yates P. Postconcussion syndrome (PCS) in the emergency department: predicting and pre-empting persistent symptoms following a mild traumatic brain injury. Emerg Med J. 2014 Jan. 31 (1):72-7. [Medline].
Faux S, Sheedy J. A prospective controlled study in the prevalence of posttraumatic headache following mild traumatic brain injury. Pain Med. 2008 Nov. 9(8):1001-11. [Medline].
Tator CH, Davis H. The postconcussion syndrome in sports and recreation: clinical features and demography in 138 athletes. Neurosurgery. 2014 Oct. 75 Suppl 4:S106-12. [Medline].
Dawson KS, Batchelor J, Meares S, Chapman J, Marosszeky JE. Applicability of neural reserve theory in mild traumatic brain injury. Brain Inj. 2007 Aug. 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. 2007 Jun. 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. 2008 Sep. 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. 2008 May. 39(5):604-11. [Medline].
Ramos-Zuniga R, Gonzalez-de la Torre M, Jimenez-Maldonado M, Villasenor-Cabrera T, Banuelos-Acosta R, Aguirre-Portillo L, et al. Postconcussion Syndrome and Mild Head Injury: The Role of Early Diagnosis Using Neuropsychological Tests and Functional Magnetic Resonance/Spectroscopy. World Neurosurg. 2013 Sep 18. [Medline].
Joyce AS, Labella CR, Carl RL, Lai JS, Zelko FA. The Postconcussion Symptom Scale: utility of a three-factor structure. Med Sci Sports Exerc. 2015 Jun. 47 (6):1119-23. [Medline].
Reuben A, Sampson P, Harris AR, Williams H, Yates P. Postconcussion syndrome (PCS) in the emergency department: predicting and pre-empting persistent symptoms following a mild traumatic brain injury. Emerg Med J. 2013 Mar 6. [Medline].
Cunningham J, Brison RJ, Pickett W. Concussive symptoms in emergency department patients diagnosed with minor head injury. J Emerg Med. 2011 Mar. 40(3):262-6. [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. 2006 Nov. 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. 2007 Mar. 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. 1994 Jun. 11(2):79-84. [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. 1999 Mar. 13(3):173-89. [Medline].
Bernstein DM. Recovery from mild head injury. Brain Inj. 1999 Mar. 13(3):151-72. [Medline].
Bigler ED. Neuropsychology and clinical neuroscience of persistent post-concussive syndrome. J Int Neuropsychol Soc. 2008 Jan. 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. 2005 Summer. 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. 1991 Dec. 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. 2005 Dec. 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. 2007 Nov. 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. 2006 Feb. 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. 2002 Aug. 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. 2002 Dec. 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. 2001 Mar. 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. 2004 Oct. 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. 1999 May. 13(2):193-209. [Medline].
Evans RW. Post-traumatic headaches. Neurol Clin. 2004 Feb. 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. 1987 Apr. 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. 2000 Feb. 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. 1998 Sep. 245(9):609-12. [Medline].
Kibby MY, Long CJ. Minor head injury: attempts at clarifying the confusion. Brain Inj. 1996 Mar. 10(3):159-86. [Medline].
Kraus J, Hsu P, Schaffer K, Vaca F, Ayers K, Kennedy F, et al. Preinjury factors and 3-month outcomes following emergency department diagnosis of mild traumatic brain injury. J Head Trauma Rehabil. 2009 Sep-Oct. 24(5):344-54. [Medline].
Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006 Sep-Oct. 21(5):375-8. [Medline].
Larrabee GJ. Neuropsychological Outcome, Post Concussion Symptoms, and Forensic Considerations in Mild Closed Head Trauma. Semin Clin Neuropsychiatry. 1997 Jul. 2(3):196-206. [Medline].
Lee LK. Controversies in the sequelae of pediatric mild traumatic brain injury. Pediatr Emerg Care. 2007 Aug. 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. 1987 May. 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. 2007 May-Jun. 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. 1999 Oct. 9(4):193-8. [Medline].
McCullagh S, Feinstein A. Outcome after mild traumatic brain injury: an examination of recruitment bias. J Neurol Neurosurg Psychiatry. 2003 Jan. 74(1):39-43. [Medline].
Mooney G, Speed J, Sheppard S. Factors related to recovery after mild traumatic brain injury. Brain Inj. 2005 Nov. 19(12):975-87. [Medline].
Olver J. Traumatic brain injury--the need for support and follow up. Aust Fam Physician. 2005 Apr. 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. 2006 Dec. 253(12):1603-14. [Medline].
Preiss-Farzanegan SJ, Chapman B, Wong TM, Wu J, Bazarian JJ. The relationship between gender and postconcussion symptoms after sport-related mild traumatic brain injury. PM R. 2009 Mar. 1(3):245-53. [Medline].
Rosenthal M. Mild traumatic brain injury syndrome. Ann Emerg Med. 1993 Jun. 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. 1999 Oct. 21(5):620-8. [Medline].
Savola O, Hillbom M. Early predictors of post-concussion symptoms in patients with mild head injury. Eur J Neurol. 2003 Mar. 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. 2005 Sep. 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. 2007 May. 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. 2008 Aug. 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. 1999 Jul. 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. 1999 Oct. 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. 1998 Aug. 65(2):177-83. [Medline].
Wood RL. Understanding the 'miserable minority': a diasthesis-stress paradigm for post-concussional syndrome. Brain Inj. 2004 Nov. 18(11):1135-53. [Medline].