Postconcussion (postconcussive) syndrome (PCS), a sequela of minor head injury (MHI), has been a much-debated topic. Muddled by conflicting findings regarding symptom duration, an absence of objective neurologic findings, inconsistencies in presentation, poorly understood etiology, and significant methodologic problems in the literature, PCS remains controversial. Depending on the definition and the population examined, 29-90% of patients experience postconcussion symptoms shortly after the traumatic insult. [1, 2, 3, 4]
Minor head injury and concussion are generally used interchangeably in the medical literature; however, it should be noted that the traditional definition of concussion precludes findings of intracranial hemorrhage on CT scan, whereas the definition minor head injury does not (though it does preclude the presence of a skull fracture). A minor head injury typically indicates a blow to the head with a brief period of loss of consciousness (LOC) or posttraumatic amnesia or disorientation. At presentation, the Glasgow Coma Scale (GCS) score ranges from 13-15. However, more recent literature suggests, and many clinicians concur, that a GCS score of 14 or 15 denotes an injury with a significantly less chance of intracranial injury on CT scan than a GCS score of 13.
Although no universally accepted definition of postconcussion syndrome exists, most of the literature defines the syndrome as the development of at least 3 of the following symptoms: headache, dizziness, fatigue, irritability, impaired memory and concentration, insomnia, and lowered tolerance for noise and light. Confusion exists in the literature, with some authors defining it as symptoms of at least 3 months’ duration, while others define it as symptoms appearing within the first week. In this article, the syndrome is loosely defined as symptom occurrence and persistence within several weeks after the initial insult. In defining persistent postconcussive syndrome (PPCS), most authors use greater than one month, and still others use 6 months or a year. However, it generaly applies to ongoing chronic symptoms that continue past expected resolution.
In a study of patients aged 5 to younger than 18 years who presented with acute head injury in pediatric emergency departments, 801 of 2584 patients (31%) experienced PPCS, or acute concussion followed by ongoing somatic, cognitive, and psychological or behavioral symptoms. 
The ICD-10 criteria include a history of traumatic brain injury (TBI) and the presence of 3 or more of the following 8 symptoms: (1) headache, (2) dizziness, (3) fatigue, (4) irritability, (5) insomnia, (6) concentration or (7) memory difficulty, and (8) intolerance of stress, emotion, or alcohol.
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), postconcussion syndrome is given a diagnosis of either major or mild neurocognitive disorder (NCD) due to TBI.  The DSM-5 criteria for neurocognitive disorder due to TBI include the following:
Findings may include headache; cranial nerve signs and symptoms such as dizziness, vertigo, and nausea; psychological and neurovegetative problems such as anxiety, depression, or sleep disturbance; and cognitive impairment such as memory loss and decreased ability to concentrate. 
Imaging modalities such as MRI, SPECT, and MEG have been shown to be more sensitive than CT at detecting brain injuries associated with postconcussion syndrome.
Patients with the symptom constellation consistent with postconcussion syndrome require thorough physical and neurological examinations. A CT scan should be obtained if significant concern about intracranial hemorrhage exists.
See Pediatric Concussion and Other Traumatic Brain Injuries, a Critical Images slideshow, to help identify the signs and symptoms of TBI, determine the type and severity of injury, and initiate appropriate treatment.
Debate in the literature exists over which symptoms of postconcussion syndrome are due to organic causes and which have a psychological basis. Researchers have hypothesized that early postconcussion syndrome symptoms are more likely to be organic, whereas PCS symptoms that persist beyond 3 months have a nonorganic, psychological basis. While recent research has shown that psychological factors may be present early, other studies using imaging techniques such as magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT), and magnetoencephalography (MEG) have demonstrated the presence of organic brain injury in patients with persistent PCS at greater than 1 year after injury.
Neuropsychological assessments have pointed toward an organic basis for some of the symptoms of postconcussion syndrome. Patients with PCS have been found to have cognitive deficits in memory, attention, and learning when compared with controls. A prospective study found impaired eye movements in patients with PCS, as compared to controls, that were both persistent and independent of factors such as depression or intellectual ability.  Findings from neuropsychological evaluations demonstrate that symptom severity is not necessarily dependent on neurologic status immediately following injury. However, in other series, the length of LOC or posttraumatic amnesia may be correlated with the probability of developing PCS.
Some studies have found certain characteristics such as female sex, noise sensitivity, and anxiety predict development of symptoms.  Another study found a simple test in the ED of immediate and delayed memory for 5 words and a VAS for acute headache provided an 80% sensitivity and 76% specificity for the development of PCS.  In addition, another study found that higher educational levels, along with mild symptoms and no extracranial symptoms predicted a low likelihood of significant dysfunction from PCS.
More than 1 million instances of minor head injury occur in the United States each year. The overall incidence rate of minor head injury for persons not hospitalized, with data compiled by the National Hospital Ambulatory Medical Care Survey, was 503 per 100,000 population or 1,367,101 visits per year to hospital EDs in the United States.  Depending on the definitions used and population examined, approximately 50% of patients with minor head injury have symptoms of postconcussion syndrome at 1 month and 15% have symptoms at 1 year. The number of patients who sustain minor head injury and do not present for medical care is unknown; therefore, the number of patients with PCS is likely significantly underdiagnosed.
Morbidity is mainly due to the persistence of symptoms, which make it difficult for patients to resume premorbid functions. Between 14 and 29% of children with mild traumatic brain injury will continue to have postconcussion symptoms at 3 months. [11, 12]
Approximately 500,000 children a year visit the ED for traumatic brain injuries (TBIs). TBIs are largest cause of ED visits for adolescents. Eighty to ninety percent of these are mild (mTBIs), or concussions, and are not life-threatening, but even a mild TBI can have ongoing effects. Young children are more susceptible to concussion than adults not only because they are more likely to be active and involved in sports but also because their brains are not yet fully developed and therefore are more vulnerable to injury. 
According to the University of Pittsburgh’s Brain Trauma Research Center, more than 300,000 sports-related concussions occur annually in the United States, and the likelihood of suffering a concussion while playing a contact sport is estimated to be as high as 19% per year of play. More than 62,000 concussions are sustained each year in high school contact sports, and among college football players, 34% have had one concussion and 20% have had multiple concussions. Estimates show that between 4 and 20% of college and high school football players will sustain a brain injury over the course of one season. The risk of concussion in football players is 3 to 6 times higher in players who have had a previous concussion. 
A study conducted by McGill University found that 60% of college soccer players reported symptoms of a concussion at least once during the season and that concussion rates in soccer players were comparable to those of football players. Athletes who suffered a concussion were found to be 4 to 6 times more likely to suffer a second concussion. 
True prognosis is difficult to define given that many patients with minor symptoms may not enter the health care system and those that participate in research appear to have more significant symptoms at baseline. In addition, a wide heterogeneity exists in patients enrolled in studies.
Most patients recover fully in less than 3 months, although some small studies suggest persistence of minor cognitive defects for asymptomatic minor traumatic brain injury patients. 
Approximately 15% of patients complain of problems more than 12 months after injury. This group is likely to experience persistent and intrusive symptoms that may be refractory to treatment and impose a lifelong disability.
At least one study found the persistence of dizziness as a symptom seemed to portend a longer and more significant symptom complex.  Other studies found the depression, pain, and symptom invalidity were correlated with longer and worse symptoms.  Another found patients with early clinical symptoms, such as headache, dizziness, and intracranial lesions were more likely to have persistent PCS.
PCS is commonly associated with multiple concussions, but in one series, 23.1% of patients experienced PCS after only 1 concussion (average was 3.3 concussions). Median duration of symptoms in this series was 7 months. 
Hiploylee et al found that time to recovery often depended on the number of initial symptoms reported, with each symptom reducing recovery rate by about 20%. They also found that PCS may be permanent if recovery hasn’t occurred withiin 3 years. Those who did not recover were more likely to be noncompliant regarding the recommendation to not return to play. 
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Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai
Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Jon Mark Hirshon, MD, MPH, PhD Professor, Department of Emergency Medicine, University of Maryland School of Medicine
Jon Mark Hirshon, MD, MPH, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, Society for Academic Emergency Medicine
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Pfizer.
Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine
Disclosure: Nothing to disclose.
Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine
Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association
Disclosure: Nothing to disclose.
Tina Wu, MD Staff Physician, Department of Emergency Medicine, New York University Medical Center, Bellevue Hospital Center
Tina Wu, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, Emergency Medicine Residents’ Association
Disclosure: Nothing to disclose.
Rachel Alt, MD Staff Physician, Department of Emergency Medicine, New York University Bellevue Hospital
Disclosure: Nothing to disclose.
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