post concussion syndrome
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Introduction
A constellation of findings following head injury, generally mild head injury (initial Glasgow coma scale 13-15). Loss of consciousness does not have to occur for postconcussion syndrome to develop.
Etiology
- coup injury
- contrecoup injury
- cerebral contusion
- diffuse axonal injury
- release of excitatory neurotransmitters
Epidemiology
- 5% of military personelle returning from combat deployment[2]
Clinical manifestations
- common manifestations
- headache 30-90%
- tension headache
- migraine headache
- intracranial hypotension
- greater occipital neuralgia (cervicogenic headache)
- headaches resolve in 3 months in 50% of patients
- dizziness 50%
- fatigue
- psychological symptoms 50%
- irritability
- anxiety
- depression
- frustration
- insomnia or hypersomnia
- decreased libido
- diminished appetite
- cognitive impairment
- memory impairment 20%
- difficulty concentrating 20%
- resolution in 3-6 months
- slower reaction time[4]
- headache 30-90%
- less common manifestations
- benign positional vertigo
- hearing loss
- anosmia
- photophobia
- visual impairment
- difficulty focusing vision
- blurry vision
- diplopia
- sleep disturbance
- hyperacusis
- tinnitus
- dysgeusia
- anosmia
- rare manifestations
- delayed subdural hematoma
- delayed epidural hematoma
- seizure disorder
- transient global amnesia
- movement disorder
Diagnostic criteria
Laboratory
- X-ray if skull fracture suspected
- computed tomography (CT)
- magnetic resonance imaging (MRI)
- electroencephalography (EEG): post-traumatic seizure
- electronystagmography (ENG)
- audiogram if indicated
- visual testing
- neuropsychiatric testing
Radiology
- neuroimaging with MRI may show diminished hippocampal volume[4]
Differential diagnosis
- chronic subdural hematoma
- chronic epidural hematoma
- psychiatric disturbance
- malingering
- symptoms are common after concussion & not necessarily new or related to traumatic brain injury[5]
Management
- recognition of symptoms
- treatment is supportive[2]
- rehabilitation
- pharmacologic agents aimed at specific symptoms[2]
- transcutaneous electrical nerve stimulation (TENS)
- biofeedback
- physical therapy
- awareness of sequelae
- learning difficulties
- concentration difficulties
- emotional lability
- counseling
More general terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1076-79
- ↑ 2.0 2.1 2.2 2.3 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17. American College of Physicians, Philadelphia 2009, 2012, 2015
- ↑ Evans RW. Persistent post-traumatic headache, postconcussion syndrome, and whiplash injuries: the evidence for a non-traumatic basis with an historical review. Headache. 2010 Apr;50(4):716-24. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20456159
- ↑ 4.0 4.1 4.2 Singh R et al. Relationship of collegiate football experience and concussion with hippocampal volume and cognitive outcomes. JAMA 2014 May 14; 311:1883 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24825643 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1869211
- ↑ 5.0 5.1 Iverson GL, Silverberg ND, Mannix R et al Factors Associated With Concussion-like Symptom Reporting in High School Athletes. JAMA Pediatr. 2015 Oct 12:1-9 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26457403
- ↑ Zemek R, Barrowman N, Freedman SB et al Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED. JAMA. 2016;315(10):1014-1025 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26954410 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=2499274