Postconcussion Syndrome (Mild Traumatic Brain Injury)
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- Postconcussion syndrome (PCS) is a constellation of symptoms involving physical, cognitive, and/or behavioral symptoms persisting after a concussion (mild traumatic brain injury [MTBI]) and may continue for weeks to years (1).
- It is unclear when concussive symptoms become postconcussive syndrome. A recent consensus defines persistent symptoms as lasting >10 to 14 days in adults and 4 weeks in children (2).
- Symptoms of PCS include (1)
- Poor focus
- Poor organization
- Diminished academic/intellectual performance
- Slowed response time
- Visual changes
- Light and noise sensitivity
- Dizziness and balance problems
- Fatigue and sleep disturbance
- Irritability/emotional lability
- Increased sensitivity to alcohol
- Diagnosis is based on history and clinical symptoms.
The reported range of MTBI patients who develop PCS varies between 5% and 80%.
- This is due to difficulty differentiating postconcussion symptoms from PCS.
- 80–90% of concussion victims recover from postconcussion symptoms within 7 to 10 days, slightly longer in children/adolescents (2). A diagnosis of PCS is generally made in those patients whose concussive symptoms persist beyond the usual course.
Predominant sex: female > male. Female gender is not universally considered a risk factor.
Etiology and Pathophysiology
- Controversial; exact mechanism(s) unknown
- Microscopic axonal injury from shearing forces leads to inflammation causing secondary brain injury.
- Conflicting data on structural brain damage and correlation of imaging with physical symptoms (1,3,4)
- Because the pathophysiology of PCS is not well understood and because of symptom overlap with other psychiatric conditions, PCS remains a difficult condition to diagnose and to manage.
- Only some with MTBI develop PCS; it is unclear what causes PCS symptoms to persist (4).
- Psychiatric factors are commonly associated with, and may play a role in, the development of PCS. It can be challenging to differentiate pure psychiatric dysfunction from PCS (1,4).
- Neuropsychiatry evaluation help differentiate PCS from other behavioral disorders.
- Patient reported high symptom burden following MTBI is associated with increased risk of PCS (5)[B].
- Strongest predictor is severity of initial symptoms (2).
- Retrograde amnesia, migraine, self-reported cognitive decline, insomnia, noise and light sensitivity developing or worsening after MTBI (1,3)
- Preexisting psychiatric disease including depression, anxiety, personality disorder, and posttraumatic stress disorder (PTSD)
- Preexisting expectation of poor outcomes following MTBI (1,3)
- Nonsport concussion/MTBI
- Unclear if previous history of concussion(s) is a risk factor for PCS
- Low socioeconomic status
- Loss of consciousness not predictive of PCS
- Education of players, coaches, parents, and athletic trainers about concussion, PCS, and appropriate safety rules
- Head injury precautions are advised. Evidence is lacking that these decrease incidence of MTBI/PCS.
- Screening and intervention for anxiety and depression
Commonly Associated Conditions
- Personality disorders (namely, compulsive, histrionic, and narcissistic)