Neuropsychology and clinical neuroscience of persistent post-concussive syndrome

Abstract
The term concussion and mild traumatic brain injury (mTBI) have been used interchangeably Persistent post-concussive syndrome has been a label given when symptomps persist for more than three months post-concussion There studies implicate common regions of injury, including the upper brainstem, base of the frontal lobe, hypothalamic-pituitary axis, medial temporal lobe, fornix, and corpus callosum

Introduction
In the US there are more than one million concussion that occur anually. Approximately 70% of all head injury cases seen in the ER are mTBI with annual incidence rate 503.1/100,000 10% will develop PPCS

mTBI
Consequence of blunt impact with sudden acceleration, deceleration or rotation of the head with GCS scores of 13-15 on admission to hospital Acute brain injury resulting from mechanical energy to the head from external physical forces, with :
LOC < 30 minutes PTA < 24 hours GCS 13 15 after 30 minutes post injury

mTBI
A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function as manifested by at least one of following :
Any period of LOC Any loss of memory for events immediately before or after the accident Any alteration in mental state at the time of the accident (feeling dazed, disoriented or confused) Focal neurological deficit (LOC < 30 minutes, PTA < 24 hour, GCS 13-15)

PPCS
Persistent Post-Concussion Syndrome

In majority, symptoms abate within minutes to hours to days post injury, some refer to PCS if the symptoms persist for more than a week. If the symptoms last more than 3 months then the term Persistent Post-Concussion Syndrome (PPCS) has been used

Pathophysiology
The pathophysiology of post concussive syndrome (PCS) results from contusions and diffuse axonal injury (DAI). Disruption of axons triggers a cascade of further insults, including :
Calcium influx Excitotoxin release Phospholipase activation Lipid peroxidation.

PPCS Symptoms
The pattern of symptoms reflects the nature of the injury and the location of tissue damage. Symptoms related to particular brain areas include the following:
Prefrontal cortex :
Disinhibition, apathy, personality change decreased fluency of speech, delusions

Basal ganglia :
Depression, mania, obsessions, compulsions tremor, cog wheeling, bradykinesia

 Thalamus :
Apathy, irritability, pathological crying paresthesias, pain, hypersomnia

White matter :
Apathy, lability, loss of spontaneity transient hemiparesis or hemiplegia, bradykinesia

Cerebellum/pons :
Mild avolition, disinhibition cerebellar signs, loss of ability to execute motor routines

Computed Tomography

Comparison between mild TBI, Severe TBI and control

male

12 year old male had sustained a concussion with LOC approximately 7 minutes. CT scan showed multiple foci of hemosiderin deposition

Conclusion
Concussion can lead to structural damage

Vulnerability of the upper brain stem, hypothalamic-pituitary axis, medial temporal lobe, basal forebrain, corpus callosum and fornix most likely to give rise to post concussive syndrome