Concussion: symptoms

Concussion symptoms are quite characteristic, but there are also post-concussion disorders, delayed signs of head injury syndrome, which you should also be aware of and be attentive to the slightest atypical manifestations, so as not to miss a serious pathology.

This is a typical consequence of any injury to the head. Even the slightest blow can lead to craniocerebral disorders, moreover, according to statistics, the consequences of TBI are the most common cause of death worldwide. Symptoms of concussion directly depend on the severity, in clinical surgical practice they are divided into the following categories:

• Mild trauma and concussion;
• Moderate to severe TBI and concussion;
• Severe trauma and concussion.

The most common are mild concussions. In the total number of injuries, these conditions account for about 80% of all cases. Threatening symptoms of concussion are severe forms of TBI: diffuse damage, compression, hematomas located inside the skull, trauma accompanied by the indentation of bone fragments, a fracture of the base of the skull. The most promising in terms of recovery is considered to be a mild degree of injury, when a person loses consciousness for several minutes, and more often the injury occurs without loss of consciousness at all. All life support functions remain normal, neurological symptoms are observed, but are not threatening. Short-term changes in the conductivity of nerve impulses are compensated by rest and bed rest. This type of concussion usually passes quite quickly, functions are restored within two to three weeks.

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How to differentiate concussion symptoms from more severe head injuries?

Mild concussion is characterized by the following main groups of symptoms:

• Signs concerning the head. This is unusual fatigue and drowsiness, some confusion. Headache or dizziness may be present, nausea is common. Memory loss is usually not observed. Painful sensations when moving the eyes, stiffness of the neck muscles, jumps in blood pressure, changes in pulse may appear.
• Neurological signs expressed locally. These are nystagmus (twitching, twitching of the eyes), blurred vision, indistinctness, unsteadiness when walking, general muscle weakness.

Symptoms of a concussion can also be delayed, they are called post-concussion. Post-concussion syndrome often occurs weeks or months after the injury, which a person may not pay due attention to.

ICD-10 describes this syndrome as a consequence of head trauma, usually following concussion.

The signs of post-concussion are as follows:

• A squeezing, compressive headache, which is often confused with typical TH - tension headache. Post-concussion pain appears 7-10 days after the injury, less often after a month.
• Dizziness not associated with fatigue or other autonomic disorders.
• Increasing fatigue, asthenia.
• Irritability
• Gradual decrease in the activity of cognitive functions – memory, attention.
• Difficulty concentrating and trouble completing simple tasks
• A feeling of inexplicable anxiety, increasing aggressiveness, often tearfulness.
• Sleep disturbance, daytime sleepiness.
• Manifestations of sensory impairments include decreased vision, hearing, and tinnitus.
• Sexual dysfunctions not associated with urological or gynecological pathology.
• Decreased stress tolerance, emotional agitation or alcohol problems.
• Anxiety and depression are often present here.

Headaches and dizziness persist for several months in more than half of cases, but after a year they are detected in only 1% (and in most of these cases, examination does not reveal any abnormalities).

Post-concussion disorders usually appear a month after the injury, but in 10-15% of all cases, concussion symptoms that are not immediately visible may be noticeable even after six months.

The data on the comparative role of organic and psychogenic factors in the persistence of the above-mentioned symptoms are rather contradictory. Thus, it has been suggested that these symptoms simply reflect the desire to receive material compensation. In some large surveys, it was possible to establish a pronounced connection with the previous constitution, belonging to a certain social class, the nature of the accident and litigation. In other reviews and follow-up studies, a connection with early neurological symptoms (diplopia, anosmia, duration of post-traumatic amnesia) is noted. Lishman notes that these symptoms begin on an organic basis and mostly disappear, but they can also be maintained by psychological factors. In a prospective study, the reasons for the persistence of symptoms were mixed (organic and social), and the desire to receive compensation was not included among the factors.

Psychiatrists are often asked to prepare reports in connection with claims for financial compensation following head injuries. When preparing such reports for civil courts, the following issues should be addressed:

• authenticity of symptoms;
• whether a head injury contributed to the development of these symptoms;
• and if so, to what extent (i.e. could these symptoms have arisen without injury?);
• what is the prognosis?

The court will accept that a more vulnerable person will suffer more from an injury than a stronger person.

It is generally accepted that increased irritability and aggression, particularly following head injury, can lead to criminality. The management of such patients is difficult and usually requires a combination of cognitive behavioural approaches and appropriate pharmacotherapy. It has therefore been argued that special services are needed for people suffering from head injuries, and especially for those with neuropsychiatric sequelae. In 1992, the Department of Health set up twelve such services as a pilot project for five years. However, their future is far from assured and their performance will be closely monitored. If we had better services, fewer people would be in inappropriate settings, including prisons.

Psychiatric symptoms after head injury

Lishman and McClelland review this topic. Long-term psychiatric sequelae are common after severe concussion and may cause many social and psychological problems. Some injuries may cause neurological symptoms that tend to improve over time. Mild injuries may be associated with dizziness, transient confusion, or loss of consciousness without subsequent signs of gross neurological damage.

In severe concussion, the period of unconsciousness is followed by a period of confusion which, depending on the severity of the injury and the physical condition of the subject (worse in older people and those suffering from atherosclerosis and alcoholism), may last from a few seconds to several weeks. During the period of confusion, there may be slowness or irritability and bewilderment, disorientation, interpretation disorders, depression or "stormy" behavior, and there may be hysterical, aggressive or paranoid symptoms with delusions and hallucinations. Memories may be fragmentary or absent altogether (post-traumatic amnesia). Violence may occur. Crimes may be committed in this state and they may appear, at least at first glance, to be highly motivated, as is the case with athletes who, after a blow to the head, may quit the game and remember nothing at all about what happened after the blow.

Posttraumatic (anterograde) amnesia may be complete or fragmentary. The duration of posttraumatic amnesia indicates the severity of the injury and the prognosis. Posttraumatic amnesia lasting more than one week indicates an unfavorable prognosis with disability for up to one year.

Retrograde amnesia concerns events before the impact and is usually very short-lived (seconds to minutes): "I remember seeing the hammer fall, but I don't remember the impact." In very severe head injuries, retrograde amnesia may extend over days or weeks. Over time, the "catch-up period" of retrograde amnesia may shorten. Long-term retrograde amnesia in minor head injuries suggests exaggeration and deception.

Psychiatric symptoms following head injury can vary greatly and are related partly to organic factors and mental constitution, partly to psychogenic factors, including environmental and legal factors. Symptoms may include:

1. Headaches, dizziness, fatigue, difficulty concentrating and irritability.
2. Neurotic symptoms (phobias, anxiety, depression) can sometimes appear after fairly mild injuries (but also after severe ones). They may be related to other life problems and are not so much organic as psychogenic. A careful anamnesis may reveal their presence even before the injury.
3. Major affective psychosis.
4. Schizophrenic psychosis.
5. Intellectual impairment and memory disorders (reflect the severity of the injury).
6. A wide range of personality changes (decreases), usually following severe head injury, including frontal lobe syndrome, temporal lobe syndrome, and basal lobe syndrome.
7. Sexual dysfunction.
8. Epileptic manifestations.

The prognosis is worse for older patients (possibly due to the decline of the aging brain and associated illnesses). The prognosis is worsened by features of inadequacy and neurosis, as well as emotional manifestations related to the incident (e.g., fear). The patient's recovery is also affected by domestic and work problems that he or she faces after the injury.

How is the disease diagnosed?

The clinical picture of concussion is often quite typical, its characteristic signs are loss of consciousness, usually short-term (80-5% of all cases), impaired consciousness, nausea, sometimes to vomiting. Loss of consciousness that lasts more than half an hour, additional examinations are prescribed to exclude a more severe, life-threatening degree of injury.

Symptoms of a concussion may include vertigo (dizziness), headache, muscle weakness, sweating as an autonomic response to injury, and sensory impairment (vision, hearing).

Clinical manifestations of concussion include oculomotor dysfunctions:

• Spontaneous eye movements (nystagmus);
• The eyes cannot be directed left, right, or up and down (paresthesia);
• Feelings of pain with open eyes, Gurevich-Mann syndrome;
• Sedan's symptom - the patient cannot read a test written in small print with relatively normal vision;
• Convergence of the visual axes is a traumatic short-term strabismus;
• Anisocoria may be observed – different pupil diameters.

Facial symptoms of concussion:

• Loss of sensitivity or increased sensitivity in various areas of the face;
• Change of nasolabial folds (smoothing);
• Changing the position of the lips and tongue.

Clinical signs are reflexive:

• Impaired tendon reflexes;
• Impaired skin reflexes;
• Anisoreflexia is the asymmetry of reflexes in the right and left parts of the body;
• Muscle weakness (neurological test according to Panchenko and Barre);
• Violation of the palmomental reflex as an indicator of damage to the subcortical area (Marinescu-Radovici reflex) - normally, the mental muscle should automatically contract in response to irritation of a special area of the palm.

The following signs are life-threatening and you need to know them in order to take appropriate measures in time:

• Bruises under the eyes in the form of glasses - "glasses" syndrome, this is a sign of a fracture of the base of the skull;
• Loss of consciousness for more than half an hour;
• Convulsive syndrome;
• Slowing of the pulse;
• Respiratory arrest;
• Nausea, turning into uncontrollable vomiting;
• Dizziness that lasts more than three days.

Concussion of the brain shows symptoms quite clearly, the main thing in this condition is timely medical care. If all necessary measures are taken, concussion is successfully treated and, after several weeks, less often after months, the brain restores its functions, and the person returns to normal active activity.