A 24-year-old patient is admitted to a head injury unit following a road traffic accident. He recovers well from acute neurological deficits but is diagnosed with post-concussion syndrome.
Which of the following statements pertaining to his condition is true?
B. The term post-concussion syndrome (PCS) is used to describe a cluster of symptoms that results in severe disability following mild head injury. There is no consistent relationship between the prevalence of PCS and the severity of head injury. Sometimes a similar constellation of symptoms may be seen in moderate and severe injury, where it is more likely to be attributed to the actual brain damage. Symptoms are usually vague, but early symptoms may include neurological complaints such as diplopia, dizziness, etc. Additional symptoms include cognitive impairment, fatigue, anxiety, depression, and irritability. In general, most neurological symptoms will have resolved by 2 to 6 months. Several observations support an organic basis, for example diffuse microscopic axonal injury on post mortem, macroscopic brain lesions evident in 8–10% of individuals on CT scan, subtle abnormalities on EEG, etc. Psychosocial factors play a part in the syndrome, especially in those lasting longer than 1 year. This is greatest in those with very mild head injuries and very chronic symptoms. There is an association between severity of post-concussion symptoms and seeking compensation, but very few improve even after the compensation.
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A 30-year-old man who was involved in a road traffic accident was unconscious for 10 minutes. His CT scan was normal and he is now conscious, but complaining of a bad headache. The family is concerned about him developing seizures as his father has a history of epilepsy.
What is the next line of action?
E. Anticonvulsants are not indicated at this point in time, especially since the patient has no symptoms suggestive of seizures. About 2 to 5% of all patients with mild, closed head injury tend to develop long-term seizure disorder. This rises to about 10 to 20% in patients with severe, closed head injury. A higher incidence of seizures has been seen in patients with depressed skull fractures (15%), haematomas (30%), and penetrating brain wounds (50%). Early seizures, within the first week, are relatively benign and are only weak predictors of later epilepsy. This patient has a mild, closed injury, and he is at a low risk for developing seizures, despite positive family history. Randomized controlled studies have shown that the use of anticonvulsants does not prevent the development of post-traumatic epilepsy beyond the first week after injury. There is a limited role for genetic predisposition in developing post-traumatic epilepsy. Those with the ApoE-ε4 allele may be at higher risk for post-traumatic epilepsy.
A 25-year-old patient presented with a history of recurrent, unilateral visual disturbances that resolved completely, on-and-off episodes of pins and needles in her left hand, and recent-onset bladder disturbances.
Which of the following statements regarding this illness is true?
D. This patient is most probably suffering from multiple sclerosis. The lifetime prevalence of major depression in multiple sclerosis (MS) is around 50%. It is three to 10 times the rate in the general population. Suicidal intent occurs in up to 30% of MS patients. This is linked to the presence and severity of depression and degree of social isolation. Suicide rates in MS patients are up to seven times higher than rates in the general population. Depression and suicide rates are higher in MS than in most other neurologic disorders. In MS patients, the lifetime prevalence of bipolar affective disorder is twice the prevalence in the general population. Pathological laughing and crying is a syndrome that presents with inappropriate laughter without associated happiness and inappropriate tears without associated sadness. Approximately 10% of MS patients are affected, with varying degrees of severity. ECT is generally well tolerated by patients with MS, but carries a risk of neurological relapse and exacerbation of the illness.
Which of the following statements regarding cognitive impairment in multiple sclerosis is true?
C. Around 50% of patients with MS have cognitive deficits. Aphasia, apraxia, and agnosia, which are characteristic of predominantly cortical diseases, are generally absent in MS, where pathology is largely confined to subcortical white matter. Although patients with long-lasting and advanced physical disability may also have severe cognitive impairment, the correlation between cognitive dysfunction and disease characteristics (type and duration of MS) is usually weak or modest. Cognitive deficits are also independent of mood symptoms in MS. Deficits in working, semantic, and episodic memories have been reported. MS patients have difficulty both in acquiring and in retrieving information (although performance on recognition tests is better than recall). Procedural memory is usually unaffected. Impaired attention and slowness of thinking is another feature of MS. Frontal lobe deficits may take the form of deficits in conceptualization and abstract thinking. At least one study has shown that donepezil is effective in improving cognitive deficits in MS.
Which of the following statements regarding pathological laughing and crying is true?
D. Pathological laughter and crying is a symptom seen in MS, where approximately 10% of MS patients are affected, with varying degrees of severity. This is similar to descriptions of the pseudobulbar affect, although this symptom can be present without pseudobulbar palsy. Patients are more likely to have frontally mediated cognitive deficits. Commonly used scales to identify and characterize this syndrome include the Pathological Laughter and Crying Scale and the Centre for Neurologic Study–Lability Scale. The most common differential diagnosis is a mood disorder, but patients with pathological crying exhibit the emotional display in the absence of a pervasive and sustained elation or depressed mood. But when mood disorder and pathological laughter and crying coexist, differentiation can be very difficult. TCAs and SSRIs have been found to be effective in the treatment even if no depression is noted.
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