Post-Concussive Syndrome

[Guest UVAPAC]

I am looking for opinions from those who have worked in the field of Neurology:

I have seen an enormous rise in patients with "post-concussive syndrome."  All kinds of mechanisms of injury... MVA, punched, fell, hit head on fireplace, walked into steal beam, etc.

I have read as much literature as I can, and seemingly the United States of America is just about the only place the post-concussion syndrome exists.  UpToDate goes as far as suggesting that a suspected reason is monetary gain / litigation against others.

 

1)  Do you feel post concussive syndrome is real?

2)  A patient has negative CT of the brain, negative MRI of the brain, but continues to have symptoms for months after injury occurred... is there any good explanation for this?

3)  With these patients... we have tried TCA's for headaches, SSRIs for apathy/depression, neuropsych testing, psychiatry consults, with an extremely low rate of success.  Any other suggestions as to how to treat these patients?

4)  As far as returning to work and activities, is there any timeframe you suggest?  I have had patients 3-4 months after a blow to the head with a completely negative workup claiming photosensitivity, apathy, fatigue, headaches, nausea, tinnitus, etc.  

5)  For the record, after managing these patients in our office for 2 weeks I have began to refer to Neurology simply for the fact I have lost confidence/faith that any of these patients will "get better."  Therefore I defer to a specialist to determine when they are fit to return to work/school/etc.  

[Guest ral]

Preface: I am very skeptical of many "syndromes" that are purely subjective.

That said, I actually had this discussion with an acquaintance of mine (an NP actually) about eight years ago. We belonged to a motorcycling group, and we both had been in rather major bike accidents (separate circumstances, dates and locations).  Both had documented head injuries, apart from other major stuff.  With no prompting from either side, we began to talk about after effects, and it lead us down a path of how we each felt our brains just weren't working the way they did pre-accident.  As we each described various symptoms, we would nod in agreement, and sometimes with wide eyes saying, "Wow, you too?"  It is very hard to describe the feeling of "just not quite right".  Neither of us can attribute our findings to anything other than the head injuries.  Of course, these many years later I still like to toss it around when my wife gets upset because I have forgotten to do something, or if I'm just plain acting stupid.  "Not my fault. I've had a head injury."

[narcan]

I suspect those patients who had an isolated, low mechanism head injury who are minimally responsive to treatment but claim symptoms which preclude them from working are much more likely to be motivated by secondary gain than someone who had a serious head injury or series of head injuries but is making progress/wants to return to work/is partially returning to work, etc. I think we generally can recognize the people who are working the system instead of working when they present to us. Disability fraud is massive in this country and something nondescript and unverifiable like PCS is just the new hotness.

Is it real? Definitely. Is it also easy to fake? Oh yeah.

You do the math.

[MedicinePower]

I'm a little concerned with the questions and some of the answers. Post-concussion syndrome is not only real but it's also awful. The reason is doesn't show up on CT or MR is due to the microscopic nature of the damage. I am troubled that you aren't referring these patients to neurology far sooner than what you imply.

I'd like to refer you to an online training which I did last year. This provides answers many of your questions and suggests treatment protocols.

https://www.cdc.gov/concussion/headsup/clinicians/

[jmj11]

2 hours ago, MedicinePower said:

I'm a little concerned with the questions and some of the answers. Post-concussion syndrome is not only real but it's also awful. The reason is doesn't show up on CT or MR is due to the microscopic nature of the damage. I am troubled that you aren't referring these patients to neurology far sooner than what you imply.

I'd like to refer you to an online training which I did last year. This provides answers many of your questions and suggests treatment protocols.

https://www.cdc.gov/concussion/headsup/clinicians/

I agree. We (in the headache medicine world) did not believe, it was real in the 1980s. There have been some landmark studies since 2003-4, mosting involving returning soldiers from war zone. The most amazing findings were an inverse relationship between the severity of the injury and the duration of the symptoms. It was the mild to moderate head injury patients who had the worst symptoms and they had no secondary gain. It is a microscopic, circuit issue, poorly defined, but the symptoms are consistent and believed to be real. As far as the headaches go, we say you treat them the way they look. If they look like migraine, you treat them like migraine and etc. There has been some experimentation with things like namenda for the cognitive changes with mixed results. 

[11BtoPA]

Speaking from personal experience, while in Iraq I was hit with an IED on 2 separate occasions.  The last one I was in the gunners turrent and resulted in me losing my hearing for a few days. While there was no physical impact like an MVC, I was diagnosed with having suffered from 2 concussions.  The last one was towards the end of my deployment and when I got home I had headaches and these intermittent episodes of the sensation you get when suddenly descending in an airplane.  The symptoms lasted for about 6 months.  It's hard to say if the irritability, personality changes, etc are also related because those are can also be related to combat stress.  I've had negative MRI and CT scans.  Either way, PCS is real.