Post-concussion syndrome is a common complication of traumatic brain injury, observed mainly in concussion of the brain. It is manifested by fatigue, irritability, cephalgia, dizziness, slight intellectual decline, apathy, character change. Post-concussion syndrome is diagnosed according to clinical criteria after excluding other causes of such symptoms. Additional examinations (EEG, electrostagmography, MRI) are carried out for the purpose of differential diagnosis. Treatment includes pharmacotherapy and psychotherapeutic techniques.
ICD 10
F07.2 Post-concussion syndrome
General information
Post-concussion syndrome (PCS) occurs as a result of brain commotion (concussion). In some literature sources on neurology, there is a synonymous name — post-concussion syndrome. PCS is a common consequence of traumatic brain injury, the prevalence, according to various data, is up to 50% of the total number of TBI. Post-concussion syndrome is significantly more common in patients with mild TBI (concussion of the brain) than with moderate and severe (brain injury). In most of the victims, the symptoms regress in the period from 3 to 6 months, in 15-30% of the manifestations of PCS are noted for more than six months, in 8-15% – up to a year. In cases where symptoms persist for more than a year, post-concussion syndrome is considered chronic (persistent).
Causes
The etiofactor that directly causes PCS is TBI. There is an inverse relationship between the severity of the injury and the frequency of the syndrome. There are a number of factors that increase the likelihood of developing post-traumatic complications, including PCS. These include the fact of loss of consciousness, prolonged post-traumatic amnesia, old age, subarachnoid hemorrhage, damage to the skull (cracks, fractures of the cranial bones), alcoholism. However, none of these criteria is a reliable prognostic sign of the occurrence of PCS.
Psychogenic factors, rather than the severity of the injury, have a predominant influence on the process of chronization of PCS. Many researchers assume the multifactorial nature of the violations occurring. Among the possible causes of persistence are:
- Premorbid character traits. Emotional lability, increased anxiety, irritability, selfish mood lead to a long-term experience of stress associated with TBI. The tendency to hypochondria reinforces a distorted perception of events, which contributes to the chronization of PCS.
- Somatic diseases. Disorders of the gastrointestinal tract that existed before the injury, hemodynamic shifts, vegetative-vascular dystonia negatively affect the course of PCS. The transition of an acute process to a chronic one may be based on the patient’s poor health due to background pathology.
- Psychosocial problems. Low socio-economic status, poor family relationships leave a negative imprint on the patient’s psyche. Financial difficulties are often the basis of a motivational factor — the desire of the victim to get insurance, compensation for injury.
- Iatrogenic factors. Reassessment of the severity of TBI by specialists of outpatient practice, additional examinations and hospitalization without significant indications support the patient’s stressful state. Unjustified prescription of medication has a negative impact on health and well-being.
Pathogenesis
The causal relationship with trauma and the mechanism of pathology development have not been definitively clarified. Some clinicians believe that post-concussion syndrome has an organic nature, others put forward a psychogenic theory of its pathogenesis. Macroscopic morphological changes detected during cerebral MRI in 8-10% of patients indicate in favor of the organic origin of PCS. The hypothesis is confirmed by the detection of diffuse axonal lesions during brain microscopy during autopsy of patients who had mild TBI combined with severe polytrauma. The components of the organic nature of PCS may be metabolic disorders arising after injury, disorders of cerebral microcirculation. A PET-CT study showed a reduced level of glucose metabolism in the temporal regions of the brain of patients with post-concussion symptoms.
The psychogenic theory is supported by the high incidence and severity of the course of PCS in patients with a history of mental disorders, the aggravation of the course under the influence of stress, the similarity of anxiety-depressive symptoms of PCS with neurotic disorders. Some researchers claim that PCS is more common in women who have a more pronounced tendency to psychoemotional reactions than men. A combined mechanism of development is possible, including the implementation of psychogenic mechanisms against the background of organic cerebral changes.
Symptoms
The symptoms of PCS are characterized by a lack of specificity and a large polymorphism. The most characteristic complaints are persistent headaches, dizziness, nausea, sleep disorders, hyperacusis, fatigue, anxiety, low mood background. Sleep disorders occur within insomnia with difficulties falling asleep, night awakenings. The post-concussion symptom complex includes mild cognitive impairment – a decrease in memory, the ability to concentrate attention.
In the psycho-emotional sphere, there is affective lability, low self-esteem, irritability, apathy, decreased motivation, a tendency to depression. The patient’s relatives note changes in his personality. Sexual disorders are possible: decreased libido, frigidity, dyspareunia. There is a decrease in alcohol tolerance, a significant drop in the level of stress resistance. In some cases, there are manifestations of autonomic dysfunction: hot flashes in the body, chills, palpitations, episodic sweating.
Complications
The main complication of PCS is the chronization of the process. The symptoms in this case are of a lifelong nature. There is a persistent cognitive decline, a pathological change in personality. Possible mental disorders in the form of severe depression, affective reactions. These violations actually invalidate the patient, deprive him of the opportunity to continue his professional activity. Job loss can aggravate post-concussion syndrome, provoke serious mental disorders.
Diagnostics
The diagnosis is based on anamnestic and clinical data. In 1992, the ICD-10 for the first time formulated clinical criteria for PCS, which greatly facilitated the detection of this condition. The main criteria are the presence of a history of TBI, cognitive deficits, the presence of 3 of the following symptoms: sleep disorder, headache, fatigue, dizziness, personality changes, irritability, emotional lability, apathy. Instrumental studies are necessary for differential diagnosis. The standard list of surveys includes:
- Neurologist’s examination. There are no signs of focal neurological deficit in the neurological status. An objective examination reveals the symptoms of autonomic dysfunction.
- Neuropsychological testing. Performed by a neuropsychologist, psychiatrist, clinical psychologist. It is necessary to assess the state of cognitive functions and emotional-volitional sphere.
- Electroencephalography. It is carried out for the purpose of differential diagnosis. Confirms nonspecific diffuse changes in the form of a decrease in the amplitude of the main rhythm.
- Electronistagmography. The study is performed by an ophthalmologist, aimed at determining the hidden nystagmus, which acts as one of the signs of organic brain damage. The presence of nystagmus is uncharacteristic for PCS.
- MRI of the brain. After 3 weeks from the moment of injury, it detects foci of brain tissue damage in 10% of victims. These changes tend to regress and disappear completely within 3 months.
The diagnosis of “Post-concussion syndrome” is valid in the presence of typical symptoms 3 months after the injury. A necessary condition is the exclusion of other post-traumatic complications (intracerebral hematoma) and background cerebral diseases (multiple sclerosis, encephalopathy, multisystem atrophy). With the repeated nature of TBI, these symptoms most likely fit into the framework of traumatic encephalopathy.
Treatment
Optimal management of patients with PCS is ambiguous and widely discussed by specialists. Comprehensive correction of the main clinical manifestations, psychological and psychotherapeutic support is carried out. Along with this, it is necessary to avoid the use of pharmaceuticals with a pronounced sedative effect that slows down the recovery processes. Treatment includes two main components:
- Pharmacotherapy. Most clinicians prefer to prescribe drugs of combined action containing the alkaloids of belladonna, phenobarbital, ergotamine. The positive effect is associated with vegetative stabilizing, mild sedative, antispasmodic effect. In order to restore cognitive functions, nootropics (piracetam, aminalon), neurometabolites (glutamic acid) are indicated.
- Psychocorrection. Taking into account the severity of violations, psychological counseling, psychotherapy, cognitive behavioral therapy are used. Cognitive trainings are recommended to improve intellectual abilities.
Prognosis and prevention
In most cases, the prognosis is favorable, post-concussion syndrome regresses within six months. In 8-15% of cases, symptoms are observed for a year or longer. In cases when post-concussion syndrome turns into a chronic form, the prognosis for recovery is doubtful. Since the main etiopathogenetic link in the development of the disease is the psychogenic mechanism, prevention consists in creating a favorable psychological climate for the traumatized patient, excluding factors contributing to the chronization of the process. During the recovery period, the patient is recommended to have classes with a psychologist, a psychotherapist.
