Post-concussion syndrome
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ICD9 = | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = emerg | eMedicineTopic = 865 | MeshID = |Post-concussion syndrome, also known as postconcussive syndrome or PCS, is a set of symptoms that a person may experience for weeks, months, or even years after a concussion, a mild form of traumatic brain injury. As many as 50% of patients who have experienced concussion have PCS,Bazarian JJ and Atabaki S. 2001. Predicting postconcussion syndrome after minor traumatic brain injury. Academic Emergency Medicine Volume 8, Number 8, Pages 788-795. Accessed January 1, 2007. and some sources say as many as 90% of patients experience postconcussion symptoms.Legome E. 2006. Postconcussive syndrome. eMedicine.com. Accessed January 1, 2007. Some doctors make a diagnosis of PCS in patients who have symptoms resulting from concussion for more than three months after the injury, McHugh T, Laforce R Jr, Gallagher P, Quinn S, Diggle P, Buchanan L. 2006 Natural history of the long-term cognitive, affective, and physical sequelae of mild traumatic brain injury. Brain and Cognition. Volume 60, Issue 2, Pages 209-211. PMID 16646125. Accessed August 14, 2007. while others make the diagnosis in patients who have symptoms starting within a week of trauma. In late, or persistent PCS, symptoms last for over six months.It is not known what causes PCS symptoms to occur and persist or why some patients who suffer a mild traumatic brain injury (MTBI) develop PCS while others do not. King NS. 1996. Emotional, neuropsychological, and organic factors: their use in the prediction of persisting postconcussion symptoms after moderate and mild head injuries. Journal of Neurology, Neurosurgery, and Psychiatry. Volume 61, Issue 1, Pages 75-81. Accessed January 8, 2007. It is commonly believed that physiological and psychological factors before, during, and after the injury all take part in the development of PCS.
Signs and symptoms
People who have had concussions may experience physical, mental, or emotional symptoms. Symptoms can appear immediately or weeks to months after the initial injury. Physical symptoms can include:
History and controversy
The name "post-concussive syndrome" was first coined by S. H. Auerbach.Centre for Neuro Skills. 2006. Mild traumatic brain injury (MTBI): Identification, assessment and treatment: Does MTBI really exist? Accessed January 1, 2007.PCS is a controversial diagnosis.Smith-Seemiller L, Fow NR, Kant R, Franzen MD. 2003. Presence of post-concussion syndrome symptoms in patients with chronic pain vs mild traumatic brain injury. Brain Injury. Volume 17, Issue 3, Pages 199-206. Accessed January 8, 2007. Though people have known about the syndrome for hundreds of years, it is not known to exactly what degree the symptoms are due to microscopic damage to the brain or to other factors, for example psychological factors. This question has been heavily debated for many years. Psychological factors are known to affect post concussion symptoms; however, it has been shown that structural damage does occur after some concussions.In the 1860s, a group of doctors began to support the idea that structural features were to blame for symptoms, but the prevailing sentiment was still that psychological factors caused PCS.Fisher JD. 1998. Post concussion syndrome. Head Injury Hotline. Accessed January 1, 2007. It was not until a century later, in the 1960s, that such structural damage could be visualized using new brain scanning technology. Experiments have shown that physiological damage such as apoptosis does occur after minor TBI such as concussion, Tashlykov V, Katz Y, Gazit V, Zohar O, Schreiber S, and Pick CG. 2006. Apoptotic changes in the cortex and hippocampus following minimal brain trauma in mice. Brain Research. Volume 1130, Issue 1, Pages 197-205. PMID 17174280. Accessed August 14, 2007. Sterr A, Herron K, Hayward C, and Montaldi D. 2006. Are mild head injuries as mild as we think? Neurobehavioral concomitants of chronic post-concussion syndrome. BMC Neurology. Volume 6, Issue 1, Page 7. PMID 16460567. Accessed January 25, 2007. and brain dysfunction measured by EEG is correlated with post-concussion symptoms. Watson MR, Fenton GW, McClelland RJ, Lumsden J, Headley M, and Rutherford WH. 1995. The post-concussional state: neurophysiological aspects. British Journal of Psychiatry. Volume 167, Issue 4, Pages 514-521. Accessed January 8, 2007.Many researchers now believe that PCS does have a physical basis, though the evidence supporting this hypothesis is still not conclusive. Other researchers doubt the existence of PCS and attribute symptoms to psychological or social factors, such as patients' expectations that they will experience these symptoms. Mickeviciene D, Schrader H, Obelieniene D, Surkiene D, Kunickas R, and Stovner LJ, and Sand T. 2004. A controlled prospective inception cohort study on the post-concussion syndrome outside the medicolegal context. European Journal of Neurology. Volume 11, Issue 6, Pages :411-419. Accessed January 8, 2007.Meares S, Shores EA, Batchelor J, Baguley IJ, Chapman J, Gurka J, Marosszeky JE. 2006. 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. Journal of the International Neuropsychological Society. Volume 12, Issue 6, Pages 792-801. PMID 17064443. Accessed January 25, 2007. Malingering may be suspected, especially in cases involving litigation or other potential gain for the patient. Hall RC, Hall RC, Chapman MJ. 2005. Definition, diagnosis, and forensic implications of postconcussional syndrome. Psychosomatics. Volume 46, Issue 3, Pages 195-202. Accessed January 9, 2007. Also, symptoms may be psychogenic, that is, they may be a result of the patient's psychological or emotional state, rather than a physiological phenomenon. Necajauskaite O, Endziniene M, and Jureniene K. 2005. The prevalence, course and clinical features of post-concussion syndrome in children. Medicina (Kaunas). Volume 41, Issue 6, Pages 457-464. PMID 15998982. Accessed January 25, 2007. It is widely believed that physiological factors are responsible for early symptoms that occur after mild head trauma, whereas symptoms that occur later are due to psychological factors. PCS is more prevalent in patients who had psychiatric symptoms, such as depression or anxiety, before the injury. Traumatic Brain Injury: Hope Through Research. NINDS. Publication date February 2002. NIH Publication No. 02-2478. Prepared by: Office of Communications and Public Liaison, National Institute of Neurological Disorders and Stroke, National Institutes of HealthAnother reason that PCS is a controversial diagnosis is that its symptoms may manifest spontaneously in the general population; thus the syndrome may be diagnosed in a patient who is actually healthy. Symptoms that can be indicative of post-concussion syndrome occur spontaneously in the general population of young, healthy adults at a fairly high rate.Wang Y, Chan RC, and Deng Y. 2006. Examination of postconcussion-like symptoms in healthy university students: relationships to subjective and objective neuropsychological function performance. Archives of Clinical Neuropsychology. Volume 21, Issue 4, Pages 339-347. PMID 16765018. Accessed January 26, 2007. In addition, symptoms of PCS may actually be caused by other conditions.Differential diagnosis
Because of the similarities to other conditions, such as depression, there is a risk that doctors may misdiagnose PCS. Iverson GL and Lange RT. 2003. Examination of "postconcussion-like" symptoms in a healthy sample. Applied Neuropsychology. Volume 10, Issue 3, Pages 137-144. Accessed January 8, 2007. For example, depression may be mistaken for PCS. Iverson GL. 2006. Misdiagnosis of the persistent postconcussion syndrome in patients with depression. Archives of Clinical Neuropsychology. Volume 21, Issue 4, Pages 303-310. PMID 16797916. Accessed August 14, 2007. Traumatic brain injury may cause damage to the hypothalamus or the pituitary gland. Deficiencies of pituitary hormones (hypopituitarism) can cause similar symptoms to post-concussion syndrome and should thus be considered as a cause for symptoms before diagnosing post-concussion syndrome. Hypopituitarism can be treated by replacing any hormone deficiencies.Diagnosis in children
Some researchers believe that children's brains have enough plasticity that they are not affected by long-term consequences of concussion (though such consequences are well known to result from moderate and severe head trauma). Other research has shown that children do experience post-concussion symptoms such as deficits in memory and concentration, though they may be due to psychogenic factors or preexisting conditions individual to the child.Treatment
Patients who have suffered a head injury must be examined by emergency medical care providers to ensure that the head injury is not worse than concussion and potentially life threatening. Thus, head injury patients with symptoms that may indicate a dangerous injury are given CT scans or MRIs and are observed by medical staff. Later, the patient may be tested to determine his or her level of cognitive functioning. A test called the Rivermead Postconcussion Symptoms Questionnaire exists to measure the severity of the patient's symptoms. There is no scientifically established treatment for PCS,Willer B and Leddy JJ. 2006. Management of concussion and post-concussion syndrome.
Current Treatment Options in Neurology. Volume 8, Issue 5, Pages 415-426.
Accessed January 8, 2007. so the syndrome is usually not treated, except with pain relievers for headaches and medicine to relieve depression, nausea, or dizziness. Rest is also advised but is only somewhat effective. When patients have ongoing disabilities, they are treated with therapy to help them function at work, socially, or in other contexts. Patients are aided in gradually returning to work and other preinjury activities as symptoms permit. Since stress exacerbates post concussion symptoms, and vice versa, an important part of treatment is letting the patient know that symptoms are normal and helping the patient deal with impairments.Prognosis
For most patients, post concussion symptoms go away within a few days to several weeks after the original injury occurs. In others, symptoms may remain for three to six months. In a small percentage of patients, symptoms may persist for years or may be permanent. If symptoms are not resolved by one year, they are likely to be permanent (though some people report improvements after even 2 or 3 years time). However, the prognosis for PCS is generally considered excellent, with total resolution of symptoms in the large majority of cases.If a patient receives another blow to the head after a concussion but before concussion symptoms have gone away, there is a slight risk that he or she will develop the very rare but deadly second-impact syndrome (SIS). In SIS, the brain rapidly swells, greatly increasing intracranial pressure.Epidemiology
The incidence of PCS is higher in females than in males. People over the age of 55 are more likely to have long-lasting symptoms.Graber MA. Post-concussive syndrome. Accessed through web archive January 1, 2007. Since PCS by definition only exists in people who have suffered a head injury, demographics and risk factors are similar to those for head injury; for example, young adults are at higher risk than others for receiving head injury. Some studies have questioned the validity of a diagnosis of PCS in children after finding differences in PCS symptoms between head injured and control groups of children not to be statistically significant.Nacajauskaite O, Endziniene M, Jureniene K, and Schrader H. The validity of post-concussion syndrome in children: a controlled historical cohort study. Brain Development Volume 28, Issue 8, Pages 507-514. Accessed January 7, 2007. Others have found the incidence of PCS to be quite similar between children and adults.Mittenberg W, Wittner MS, Miller LJ. 1997. Postconcussion syndrome occurs in children. Neuropsychology. Volume 11, Issue 3, Pages 447-452. Accessed January 8, 2007.
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