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Postconcussive Syndrome

Postconcussive Syndrome

By: Mark Schnitzer, MD – Neurosurgery

Persistent neuropsychiatric impairment following head injury is a significant public health problem. From 400,000 to 500,000 are hospitalized in the United States every year from head injury; many more people are injured and do not require admission. Head injury is the third most likely cause of dementia, after infection and alcoholism, in people younger than 50 years.

Causes of head injury in civilian populations include car accidents (50%), falls (21%), assault (12%), and recreational activities (10%).  Men experience head injury more frequently than women, but the incidence of PCS is greater in females than males.

Risk Factors

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.

Depending on the definition used and the 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.

Patients with postconcussive syndrome usually do not present immediately after the trauma.  Most patients present shortly after a minor head injury.  Often patients return after a previous examination in the emergency department because of persistent postconcussive symptoms.

Recent studies suggest that postconcussive syndrome is more likely to develop in patients presenting with nausea, headache and dizziness.  Findings may include headache (the most common symptom of PCS) and cranial nerve symptoms and signs like dizziness (the second most common symptom), nausea, blurry vision and diplopia.  There may be psychological problems like anxiety, irritability, depression, sleep disturbance, change in appetite, decreased libido, fatigue and personality change.  Cognitive impairment can occur, with memory impairment, diminished concentration and attention, and delayed information processing and reaction time.

Diagnosis – DSM-IV-TR criteria for Postconcussive disorder

When establishing the diagnosis of PCS, the following criteria define the syndrome:

A.   A history of head trauma that has caused significant cerebral concussion.

B.  Evidence from neuropsychological testing or qualified cognitive assessment of difficulty in attention (concentrating, shifting focus of attention, performing simultaneous cognitive tasks), or memory (learning or recalling information).

C.   Three (or more) of the following occur shortly after the trauma and last at least 3 months.
1.     Becoming fatigued easily
2.     Disordered sleep
3.     Headache
4.     Vertigo or dizziness
5.     Irritability or aggression on little or no provocation
6.     Anxiety, depression or affective lability
7.     Changes in personality (eg, social or sexual inappropriateness)
8.     Apathy or lack of spontaneity

D.  The symptoms in criteria B & C have their onset following head trauma or else represent a substantial worsening of preexisting symptoms.

E.  The disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning.  In school-aged children, the impairment may be manifested by a significant worsening in school or academic performance dating from the trauma.

F.  The symptoms do not meet criteria for dementia due to head trauma and are not better accounted for by another mental disorder (eg, amnestic disorder due to head trauma, personality change due to head trauma).

Postmortem studies of traumatic brain injury (TBI) have demonstrated pathological changes that cannot be detected by conventional neuroimaging studies.   Neuropsychological testing is the most sensitive means of characterizing the cognitive deficits of survivors of head injury.

Prognosis and Treatment

Rapid improvement of head injury typically occurs within the first 6 months.  Problems continuing after 18 months usually continue indefinitely.  Approximately 15% of patients complain of problems more then 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 that seemed to portend a longer and more significant symptom complex. Other studies found that depression, pain, and symptom invalidity were correlated with longer and worse symptoms.

Significant functional impairment, marked by unemployment and marital dysfunction, typically accompanies postconcussive syndrome.  Patients who work night-shift jobs, work with heavy machinery, work off the ground, or who are in overstimulating environments may not be able to return to their previous positions.  Returning to work when cognitive impairments are in flux may lead to failure and regression in recovery.

Consultation with neuropsychologists and physical and occupational therapists are helpful in designing or altering the long-term treatment plan of a patient with head injury, and neurologic consultation is essential to diagnose and treat seizures, subdural or epidural hematomas, or hydrocephalus.  Neurologists also may help with the management of headaches, dizziness or fatigue.

Patients with PCS need to know that headaches, dizziness, fatigue, irritability, poor concentration, and decreased memory are common in the first 3-6 months after injury.  These symptoms fully resolve in most patients after mild injury.  However, persistent impairment is possible.  Stress seems to slow or impede recovery by both psychological and physiological mechanisms.  Patients should know that anxiety, depression, decreased concentration, and other persistent symptoms may improve with rehabilitation, psychological support, and medication.

The prognosis of PCS remains difficult to provide with certainty.  Some patients recover fully from severe injuries with prolonged coma.   Regrettably, others remain disabled for long periods after much milder insults.

Medical-Legal Considerations

Challenges in litigation with cases of PCS include not only establishing the full panoply of symptoms and complications sustained by the patient, but in anticipating the full extent, severity, and duration of these symptoms following head injury.  Thus, litigants must not only consider consultations with the specialists discussed, but with life-care planning and loss economist experts, as well.

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