Review Question - QID 221233

This patient with headaches, confusion, and fatigue following a sports collision, is likely experiencing post-concussive syndrome. Post-concussive syndrome is managed with rest from stressful activities.

Post-concussive syndrome involves a constellation of prolonged symptoms that occur 4 or more weeks after a mild traumatic brain injury. Symptoms of post-concussive syndrome include headache, amnesia, confusion, difficulty concentrating at work and school, vertigo, poor mood, sleep disturbance, and anxiety. Most patients with post-concussive syndrome have improvement within 3 months of the initial trauma. Risk factors for post-concussive syndrome include a history of multiple concussions or overly aggressive return to strenuous activities following head trauma. Diagnosis is clinical, although a thorough history and physical exam are required to exclude more severe head injuries. If focal neurological deficits are present, head imaging should be obtained. Management of post-concussive syndrome consists of rest from stressful activities and restarting those activities, including sports, in a graduated fashion. Symptomatic treatment may also be considered, such as non-steroidal anti-inflammatory drugs for headaches.

Polinder et al. reviewed the management of post-concussive syndrome. They discuss how 10-25% of patients who sustain concussions may develop post-concussive syndrome. They recommend that longitudinal studies be performed in these patients to better understand how to optimize recovery after concussion.

Figure/Illustration A is a head CT demonstrating no significant bleeding or mass effect in the ventricles (red circle). Normal findings are consistent with a diagnosis of post-concussive syndrome.

Incorrect Answers:
Answer 1: Initiation of a selective serotonin reuptake inhibitor such as fluoxetine may be appropriate for patients with major depressive disorder. Though this patient exhibits features of this disorder, such as fatigue and difficulty concentrating, she does not satisfy the criteria for depression.

Answer 2: Lumbar puncture with measurement of opening pressure may be useful in the evaluation of pseudotumor cerebri, also known as idiopathic intracranial hypertension. This disorder involves a high intracranial pressure due to increased production of cerebrospinal fluid. Though this disorder may cause persistent headaches and fatigue, imaging will show widened cerebral ventricles.

Answer 4: Surgical evacuation may be required in cases of epidural and subdural hematomas. Chronic subdural hematomas may occur over the course of weeks or months following head injury, but would typically present with more profound neurologic symptoms. These are more common in elderly patients due to tearing of fragile bridging veins.

Answer 5: Thiamine followed by glucose is the treatment for Wernicke encephalopathy, which presents in patients with alcohol use disorder who are malnourished. Wernicke encephalopathy classically presents with the triad of gait dysfunction, ophthalmoplegia/nystagmus, and altered mental status. Though this patient should be counseled to reduce her alcohol use, she does not have findings indicative of Wernicke encephalopathy.

Bullet Summary:
Post-concussive syndrome presents following a concussion with a constellation of symptoms including headache, amnesia, confusion, and difficulty concentrating, and is treated with avoidance of strenuous activities.