Complications
Sleep disturbance (e.g., somnolence, drowsiness) forms part of the criteria for diagnosis of mild traumatic brain injury in sports-related head injuries.[7] One longitudinal study found that 65% of 346 adults with mild TBI experienced sleep difficulties (insomnia, hypersomnia, nightmares) within the first 2 weeks after the injury; 41% continued to have sleep difficulties 1 year later.[103] Sleep medications may be utilised, but only short-term while behavioural strategies are implemented, owing to high potential for causing dependency.[90][100][104]
Although rare, occurs when the brain receives a second concussive blow before it has had a chance to recover from the first blow. This can result in cerebral autodysregulation and brain oedema, leading to permanent brain damage or even death in some cases.[4]
Any severity of head injury can cause pituitary dysfunction. This may present immediately, hours, weeks or months after the injury.[42] A variety of symptoms could indicate hypopituitarism including weakness, fatigue, weight loss, hypotension, hyponatraemia, hypoglycaemia, hypercalcaemia, anaemia and fatigue, energy, low mood, neuropsychiatric and cognitive symptoms, decreased lean body mass, increased fat mass, altered metabolic profile and decreased exercise capacity, hot flushes, fatigue, tiredness, loss of body hair, reduced sex drive, irregular periods, erectile dysfunction and reduced fertility, slow growth, fatigue, lethargy, cold intolerance and weight gain, polyuria, polydipsia, nocturia, and incontinence. In people admitted to hospital with a head injury who have persistently abnormal low sodium levels or low blood pressure, consider investigations for hypopituitarism.[42] In the community for patients with persistent symptoms consistent with hypopituitarism in the weeks or months after a head injury, consider investigations or referral for hypopituitarism.[42] Most head injury neurologists assess pituitary status (ACTH, posterior pituitary hormone, TSH, and LH/FSH) at 3-6 months after the injury.[105] If hormone levels are deficient, appropriate replacement is required.[105]
A depressed mood after mild traumatic brain injury may reflect an underlying pathophysiological abnormality consistent with a limbic-frontal model of depression.[27][28] However, although several studies have linked mild TBI and depression, most have low methodological quality, high risk of bias or both.[3] Mental health issues are common, multifactorial and often present independently of participation in contact or collision sport.[3]
In many cases, psychotherapy can alleviate secondary complications due to anxiety and depression.[94] Patients can often become overly anxious or depressed if symptoms do not resolve in a typical time-frame. Some studies have shown that even a single counselling session can drastically reduce anxiety and depressive symptoms and improve overall injury-related symptoms, whereas others report mixed results.[95][96] Cognitive behavioural techniques can be particularly helpful to patients with affective disorders, either premorbid or resultant from the mild traumatic brain injury, in understanding their anxiety and depression, to decrease the stresses associated with functional consequences of their injury.[90][97]
Psychotropics can be prescribed to control psychiatric symptoms such as depression, anxiety, and fatigue.[98]
Antidepressants such as sertraline are reported to be more effective than tricyclic antidepressants in patients with mild traumatic brain injury and are also helpful in patients with anxiety.[28][99][100]
In many cases psychotherapy can alleviate secondary complications due to anxiety and depression.[94]
Patients can often become overly anxious or depressed if symptoms do not resolve in a typical time frame. Some studies have shown that even a single counselling session can drastically reduce anxiety and depressive symptoms and improve overall injury-related symptoms, whereas others report mixed results.[95][96] Cognitive behavioural techniques can be particularly helpful to patients with mood disorders, either premorbid or resultant from the mild traumatic brain injury, in understanding their anxiety and depression, to decrease the stresses associated with functional consequences of their injury.[97]
Psychotropics can be prescribed to control psychiatric symptoms such as depression, anxiety, and fatigue.[98]
Antidepressants such as sertraline are reported to be more effective than tricyclic antidepressants in patients with mild traumatic brain injury and are also helpful in patients with anxiety.[28][99][100]
Risk factors for PTSD after mild TBI include lower education, antecedent psychiatric disorder, and injury resulting from violence.[2] In a study of civilian survivors of traumatic injury, PTSD was identified 3 months post-injury in 11.8% of patients with mild TBI compared to 9.4% of patients with no history of mild TBI. This increased rate of PTSD occurred even after controlling for injury severity.[101] In the TRACK-TBI trial, the rate of probable PTSD for individuals with mild TBI at 6 months was 19.2%.[102]
In some cases where the head trauma was sustained under emotionally charged circumstances (car accidents, combat), the injury can become more complicated to manage. In many cases it is difficult to separate the physical effects of the injury from the emotional effects of the trauma. That is to say, there are several overlapping symptoms between mild traumatic brain injury and PTSD: namely, those symptoms associated with poor or altered sleep and emotional changes.
In many cases, psychotherapy can alleviate secondary complications due to anxiety and depression.[94] Patients can often become overly anxious or depressed if symptoms do not resolve in a typical time frame. Some studies have shown that even a single counselling session can drastically reduce anxiety and depressive symptoms and improve overall injury-related symptoms, whereas others report mixed results.[95][96] Cognitive behavioural techniques can be particularly helpful to patients with mood disorders, either premorbid or resultant from the mild traumatic brain injury, in understanding their anxiety and depression, to decrease the stresses associated with functional consequences of their injury.[97]
Psychotropics can be prescribed to control psychiatric symptoms such as depression, anxiety, and fatigue.[98]
Antidepressants such as sertraline are reported to be more effective than tricyclic antidepressants in patients with mild traumatic brain injury and are also helpful in patients with anxiety.[28][99][100]
Traumatic encephalopathy syndrome (TES) refers to a clinical disorder associated with neuropathologically diagnosed chronic traumatic encephalopathy (CTE).[106] Diagnosis of TES as defined by consensus-based diagnostic criteria requires (1) substantial exposure to repetitive head impacts from contact sports, military service, or other causes; (2) core clinical features of cognitive impairment (in episodic memory and/or executive functioning) and/or neurobehavioural dysregulation; (3) a progressive course; and (4) that the clinical features are not fully accounted for by any other neurological, psychiatric, or medical conditions. Among patients meeting criteria for TES, functional dependence is graded in 5 levels ranging from independent to severe dementia.[106] CTE has been described in former athletes with a history of concussion or repetitive head impact exposure, typically accompanied by behavioural change.[3] However, a cause and effect relationship between postmortem CTE changes and antemortem behavioural and cognitive manifestations has not been demonstrated, and asymptomatic players have had confirmed CTE pathology at autopsy.[3][107][108] CTE is a postmortem diagnosis based on neuropathological evidence. Currently there are no clear in-life clinical criteria for diagnosing probable CTE.[4]
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