Postconcussive Syndrome in Emergency Medicine Workup

  • Author: Eric L Legome, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 7, 2011
 

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. 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.

Next

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.[8] 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.[9]

  • 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.
Previous
Next

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.
Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L 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.

Specialty Editor Board

Jerry Balentine, DO  Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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.

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 

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

References

  1. 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. Oct 2009;132:2850-70. [Medline].

  2. 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. Feb 2009;66(2):289-96; discussion 296-7. [Medline].

  3. 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. Sep-Oct 2009;24(5):333-43. [Medline].

  4. 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].

  5. Faux S, Sheedy J. A prospective controlled study in the prevalence of posttraumatic headache following mild traumatic brain injury. Pain Med. Nov 2008;9(8):1001-11. [Medline].

  6. 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].

  7. 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].

  8. 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].

  9. 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].

  10. Cunningham J, Brison RJ, Pickett W. Concussive symptoms in emergency department patients diagnosed with minor head injury. J Emerg Med. Mar 2011;40(3):262-6. [Medline].

  11. Rees RJ, Bellon ML. Post concussion syndrome ebb and flow: longitudinal effects and management. NeuroRehabilitation. 2007;22(3):229-42. [Medline].

  12. 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].

  13. 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].

  14. Alexander MP. Mild traumatic brain injury: pathophysiology, natural history, and clinical management. Neurology. 1995;45 (7):1253-60. [Medline].

  15. 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].

  16. 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].

  17. Bernstein DM. Recovery from mild head injury. Brain Inj. Mar 1999;13(3):151-72. [Medline].

  18. Bigler ED. Neuropsychology and clinical neuroscience of persistent post-concussive syndrome. J Int Neuropsychol Soc. Jan 2008;14(1):1-22. [Medline].

  19. 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].

  20. 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].

  21. 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].

  22. 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].

  23. 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].

  24. 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].

  25. 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].

  26. 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].

  27. 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].

  28. 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].

  29. Evans RW. Post-traumatic headaches. Neurol Clin. Feb 2004;22(1):237-49, viii. [Medline].

  30. 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].

  31. 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].

  32. 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].

  33. Kibby MY, Long CJ. Minor head injury: attempts at clarifying the confusion. Brain Inj. Mar 1996;10(3):159-86. [Medline].

  34. 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. Sep-Oct 2009;24(5):344-54. [Medline].

  35. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. Sep-Oct 2006;21(5):375-8. [Medline].

  36. 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].

  37. 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].

  38. 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].

  39. 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].

  40. 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].

  41. 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].

  42. Mooney G, Speed J, Sheppard S. Factors related to recovery after mild traumatic brain injury. Brain Inj. Nov 2005;19(12):975-87. [Medline].

  43. Olver J. Traumatic brain injury--the need for support and follow up. Aust Fam Physician. Apr 2005;34(4):269-71. [Medline].

  44. 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].

  45. 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. Mar 2009;1(3):245-53. [Medline].

  46. Rosenthal M. Mild traumatic brain injury syndrome. Ann Emerg Med. Jun 1993;22(6):1048-51. [Medline].

  47. 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].

  48. 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].

  49. 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].

  50. 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].

  51. 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].

  52. 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].

  53. 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].

  54. 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].

  55. Wood RL. Understanding the 'miserable minority': a diasthesis-stress paradigm for post-concussional syndrome. Brain Inj. Nov 2004;18(11):1135-53. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.