Postconcussion Syndrome in the ED
Post-traumatic stress disorder (PTSD) is increasingly recognised as a critical factor in the development of PCS, occurring more commonly in patients after mTBI compared with non-TBI controls (11.8% vs 7.5%) but also seemingly contributing to PCS symptomatology, with rates of PCS three times higher for individuals with existing PTSD. It was previously held that TBI and PTSD were incompatible, the former insult perhaps being protective, masking the memories of a 'traumatic' event. However, the consensus view seems to be that this is not the case, with factors such as 'memory islands' or 'confabulated memories' providing a focus for the development for some form of stress response to the injury. Some groups believe that TBI may not in fact be required for the development of PCS and that PTSD may be a key factor in its development, making it more of an acute stress disorder. That many of the symptoms associated with PCS occur in the absence of mTBI has undoubtedly complicated the diagnostic process. Up to 80% of 'healthy, uninjured' people have reported three or more postconcussive symptoms in some studies. In recent years many studies have focused on military personnel returning from combat in an attempt to delineate the relative roles of TBI, PCS and PTSD. Improvements in protective equipment have led to the survival of many personnel with injuries that previously may have been fatal, with almost a quarter having injuries to the head and neck. A recent study of military personnel returning from Iraq and Afghanistan showed that a history of mTBI predicted a range of health problems with 40% of those with loss of consciousness fulfilling the criteria for PTSD. The implications of this are complex as the effects were significantly decreased after PTSD and depression were considered, suggesting that the traumatic event may be the major precipitant of the sequelae rather than the TBI. What is evident is that the interaction is extremely complex and that the precise relationship remains unclear and may remain so because of the inherent difficulties of teasing out physical and psychological precipitants in a scenario where both have a part to play.
From an Emergency Medicine perspective, the fact that PCS is a genuine entity with significant morbidity that requires early recognition and prompt intervention is more important, perhaps, than its aetiology. While our initial attention correctly focuses on the exclusion of significant pathology that may perhaps require prompt neurosurgical intervention, to ignore the potential for the development of a condition with such associated morbidity is akin to ignoring the potential for adverse outcome in a patient with a normal ankle radiograph after injury, but in whom significant ligamentous disruption may cause major limitation of normal function.
Is PCS an Acute Stress Response?
Post-traumatic stress disorder (PTSD) is increasingly recognised as a critical factor in the development of PCS, occurring more commonly in patients after mTBI compared with non-TBI controls (11.8% vs 7.5%) but also seemingly contributing to PCS symptomatology, with rates of PCS three times higher for individuals with existing PTSD. It was previously held that TBI and PTSD were incompatible, the former insult perhaps being protective, masking the memories of a 'traumatic' event. However, the consensus view seems to be that this is not the case, with factors such as 'memory islands' or 'confabulated memories' providing a focus for the development for some form of stress response to the injury. Some groups believe that TBI may not in fact be required for the development of PCS and that PTSD may be a key factor in its development, making it more of an acute stress disorder. That many of the symptoms associated with PCS occur in the absence of mTBI has undoubtedly complicated the diagnostic process. Up to 80% of 'healthy, uninjured' people have reported three or more postconcussive symptoms in some studies. In recent years many studies have focused on military personnel returning from combat in an attempt to delineate the relative roles of TBI, PCS and PTSD. Improvements in protective equipment have led to the survival of many personnel with injuries that previously may have been fatal, with almost a quarter having injuries to the head and neck. A recent study of military personnel returning from Iraq and Afghanistan showed that a history of mTBI predicted a range of health problems with 40% of those with loss of consciousness fulfilling the criteria for PTSD. The implications of this are complex as the effects were significantly decreased after PTSD and depression were considered, suggesting that the traumatic event may be the major precipitant of the sequelae rather than the TBI. What is evident is that the interaction is extremely complex and that the precise relationship remains unclear and may remain so because of the inherent difficulties of teasing out physical and psychological precipitants in a scenario where both have a part to play.
From an Emergency Medicine perspective, the fact that PCS is a genuine entity with significant morbidity that requires early recognition and prompt intervention is more important, perhaps, than its aetiology. While our initial attention correctly focuses on the exclusion of significant pathology that may perhaps require prompt neurosurgical intervention, to ignore the potential for the development of a condition with such associated morbidity is akin to ignoring the potential for adverse outcome in a patient with a normal ankle radiograph after injury, but in whom significant ligamentous disruption may cause major limitation of normal function.