Post-concussional symptoms following minor head injury

doi:10.1016/0020-1383(89)90109-5

Injury

Volume 20, Issue 4, July 1989, Pages 193-194

https://doi.org/10.1016/0020-1383(89)90109-5 Get rights and content

Abstract

The effect of admission to hospital after a minor head injury on the incidence and duration of post-concussional symptoms was investigated. A total of 114 adults with a minor head injury were randomly allocated to admission for 24 h, or to discharge from the accident department, follow-up was by postal questionnaire. This revealed that 90 per cent of patients suffered symptoms lasting an average of 2 weeks. The patients who were discharged had symptoms that lasted a shorter time. Admission to hospital does not reduce the incidence and severity of symptoms following minor head injuries in adults.

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Biomechanics for forensic methods can be defined as the study of how the human body fails structurally when challenged by a fall, a motor vehicle collision, an aircraft crash, a malfunction of a machine, or one of a myriad of events such as a drowning or a criminal act. For humans, biomechanics can also refer to the study of how the skeletal and musculature systems work under different conditions. Scientists and engineers often try to apply physics, mechanics, and thermodynamics methods to the analysis of the human body during these events to determine, first, what happens and, second, the effects of the event on the human body.
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Citation Excerpt :
One conspicuous feature of concussion is the number of symptoms which may linger long after the head injury has occurred and its acute effects resolved. This potpourri of residual symptoms has been exhaustively catalogued and investigated and is usually described as the post-concussion or post-traumatic syndrome (Strauss and Savitsky, 1934; Taylor, 1967; Kay et al., 1971; Merskey and Woodforde, 1972; Merritt, 1973; Martin, 1974; Symonds, 1974; Rutherford et al., 1977; Walton, 1977; Plum and Posner, 1980; Wrightson and Gronwall, 1981; McMillan and Glucksman, 1987; Hugenholtz et al., 1988; Lishman, 1988; Lowdon et al., 1989; Leininger et al., 1990; Montgomery et al., 1991; Barth et al., 1996; Rizzo and Tranel, 1996). Among the most common features of the post-concussion syndrome are headache, giddiness or vertigo, a tendency to fatigue, irritability, anxiety, aggression, insomnia and depression.
Cerebral concussion is both the most common and most puzzling type of traumatic brain injury (TBI). It is normally produced by acceleration (or deceleration) of the head and is characterized by a sudden brief impairment of consciousness, paralysis of reflex activity and loss of memory. It has long been acknowledged that one of the most worthwhile techniques for studying the acute pathophysiology of concussion is by the recording of neurophysiological activity such as the electroencephalogram (EEG) and sensory evoked potentials (EPs) from experimental animals. In the first parts of this review, the majority of such studies conducted during the past half century are critically reviewed. When potential methodological flaws and limitations such as anesthetic protocols, infliction of multiple blows and delay in onset of recordings were taken into account, two general principles could be adduced. First, the immediate post-concussive EEG was excitatory or epileptiform in nature. Second, the cortical EP waveform was totally lost during this period. In the second parts of this review, five theories of concussion which have been prominent during the past century are summarized and supportive evidence assessed. These are the vascular, reticular, centripetal, pontine cholinergic and convulsive hypotheses. It is concluded that only the convulsive theory is readily compatible with the neurophysiological data and can provide a totally viable explanation for concussion. The chief tenet of the convulsive theory is that since the symptoms of concussion bear a strong resemblance to those of a generalized epileptic seizure, then it is a reasonable assumption that similar pathobiological processes underlie them both. Further, it is demonstrated that EPs and EEGs recorded acutely following concussive trauma are indeed the same or similar to those obtained following the induction of a state of generalized seizure activity (GSA). According to the present incarnation of the convulsive theory, the energy imparted to the brain by the sudden mechanical loading of the head may generate turbulent rotatory and other movements of the cerebral hemispheres and so increase the chances of a tissue-deforming collision or impact between the cortex and the boney walls of the skull. In this conception, loss of consciousness is not orchestrated by disruption or interference with the function of the brainstem reticular activating system. Rather, it is due to functional deafferentation of the cortex as a consequence of diffuse mechanically-induced depolarization and synchronized discharge of cortical neurons. A convulsive theory can also explain traumatic amnesia, autonomic disturbances and the miscellaneous collection of symptoms of the post-concussion syndrome more adequately than any of its rivals. In addition, the symptoms of minor concussion (a.k.a. being stunned, dinged, or dazed) are often strikingly similar to minor epilepsy such as petit mal. The relevance of the convulsive theory to a number of associated problems is also discussed. These include the relationship between concussion and more serious types of closed head injury, the utility of animal models of severe brain trauma, the etiology of the cognitive deficits which may linger long after a concussive injury, the use of concussive (captive bolt) techniques to stun farm animals prior to slaughter and the question of why some animals (such as the woodpecker) can tolerate massive accelerative forces without being knocked out.
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Approximately one million patients in the UK present to hospitals each year with head injuries. Almost half are under 16 years of age. (Royal College of Surgeons of England 1999). The majority of patients who attend for treatment will be suffering from a minor head injury. It is stated that some 92% of these patients will have normal neurology (Klauber 1993) and most will be discharged into the care of a responsible adult with instructions and advice for further observation at home. Only 1% of patients attending with a head injury have a skull fracture (Ramrakha & Moore 1997).
The aim of this article is to guide the practitioner into ensuring a consistent, evidence-based approach to the assessment of patients with head injury when they present at a Minor Injuries Unit. This includes timely, appropriate referral for further investigation and clinical intervention.
Mild head injury in adults. A review
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Hasta hace unos pocos años se había dirigido poca atención al traumatismo craneal no grave, que supone alrededor del 80% de todos los traumas craneales. La elevada incidencia del trauma craneal leve consume abundantes recursos materiales y humanos en los países occidentales, por lo que se ha convertido en un problema sanitario de primer orden. Además, se ha comprobado la importancia que tiene un correcto manejo de estos pacientes con un “bajo riesgo” inicial en la reducción de la mortalidad total del trauma craneal.
Durante muchos años no hubo un consenso generalizado en la definición, indicaciones neuroradiológicas o tratamiento de pacientes con trauma craneal leve, lo que suscitó una gran controversia en el tratamiento de estos casos. En los últimos años, coincidiendo con una mayor disponibilidad de la tomografía computerizada, se han establecido por distintos grupos de trabajo unas guías y protocolos con el fin de manejar más uniformemente a estos pacientes.
El fin último de todos estos estudios es tratar de diagnosticar aquellos pacientes que tienen un mayor riesgo de presentar complicaciones intracraneales tras sufrir un trauma leve inicial con el menor costo posible. En nuestro trabajo analizamos los avances obtenidos en estos últimos años.
Mild head injuries had attracted little interest since a few years ago. Those patients represent 80% of all head injuries. These high admission rates constitute a major public health problem in the occidental world. Besides, a substantial reduction in mortality as a whole can be achieved by addressing more attention to the large number of patients with an initial mild head injury.
For a long time, there had not been a consensus in the definition, radiological test or uniform treatment of patients with mild head injury, which generated a great disagreement in the treatment of these patients. In the last ten years, along with a greater availability of CT scan, different guidelines for management have been published.
The end point of these works is to diagnose a higher number of patients at risk to develop an intracranial haematoma after suffering an initial mild head injury, with the best cost- effectiveness. In our work we analyse the advances obtained in the last years of investigation.
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PaperPost-concussional symptoms following minor head injury

Abstract

Lancet

Lancet

Injury

Paper
Post-concussional symptoms following minor head injury