Homework answers / question archive / 1 Running head: A COMPARISON BETWEEN PCS AND TBI A Comparison between Post-Concussion Syndrome (PCS) and Traumatic Brain Injury (TBI) Angela Soria Chamberlain University A COMPARISON BETWEEN PCS AND TBI2 Table of Contents Introduction

1 Running head: A COMPARISON BETWEEN PCS AND TBI A Comparison between Post-Concussion Syndrome (PCS) and Traumatic Brain Injury (TBI) Angela Soria Chamberlain University A COMPARISON BETWEEN PCS AND TBI2 Table of Contents Introduction

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1 Running head: A COMPARISON BETWEEN PCS AND TBI A Comparison between Post-Concussion Syndrome (PCS) and Traumatic Brain Injury (TBI) Angela Soria Chamberlain University A COMPARISON BETWEEN PCS AND TBI2 Table of Contents Introduction................................................................................................................................. 3 Presentation .............................................................................................................................. 3 Pathophysiology ........................................................................................................................ 4 Assessment ................................................................................................................................ 5 Diagnosis .................................................................................................................................... 6 Treatment .................................................................................................................................. 7 Conclusion ................................................................................................................................. 8 A COMPARISON BETWEEN PCS AND TBI3 A Comparison between Post-Concussion Syndrome (PCS) and Traumatic Brain Injury (TBI) Introduction Post-Concussion Syndrome (PCS) is a medical condition that persists for a period, ranging from weeks to some months, after experiencing a head injury or trauma. It is considered as a concussion or a mild traumatic brain injury (DerSarkissian, 2019). Traumatic Brain Injury (TBI), on the other hand, is a temporary or permanent disruption of the healthy brain functioning of the human brain caused by a jolt to the head, blow, or a bump (Centers for Disease Control and Prevention [CDC], 2020). Estimates show that US experiences about 1.7 million cases of TBI annually, while about 5.3 million US citizens have TBI-disability (American Association of Neurological Surgeons [AANS], 2020). The two conditions, which occur as a result of head injury, exhibit some similarities and differences. This paper, therefore, provides a comparison of the two conditions in terms of presentation, pathophysiology, assessment, diagnosis, and treatment. Presentation Even though signs and symptoms for PCS are often non-specific and vague, a patient with this condition may present the following symptoms: psychological conditions such as anxiety, irritability, and depressed mood, problems in concentrating, remembering, and thinking, sleeping problems, dizziness, and headache (DerSarkissian, 2019). Some cases of PCS go unreported because victims may not feel any pain or discomfort. Patients with TBI, on the other hand, may report the following signs and symptoms, which may appear immediately after brain injury or take some time before being noticed. Some of these symptoms are the same as those for patients with PCS; they include thinking and remembering problems such as difficulties in concentrating, remembering new information, and thinking clearly, headache, irritability, sadness, anxiety/nervousness, and trouble falling asleep (CDC, 2019). A COMPARISON BETWEEN PCS AND TBI4 Some signs specific to TBI include balance problems, sensitivity to noise or light, nausea/vomiting, convulsions, or seizures (CDC, 2019). It is also worth noting that even though patients with PCS and TBI depict almost similar signs, those reported among patients with TBI are more severe than for PCS. In some severe TBI cases, the patients may report paralysis, oozing of cerebrospinal fluid (CSF) through ears or nose, tingling/numbness, breathing problems, and loss of consciousness (CDC, 2019; American Association of Neurological Surgeons [AANS], 2020). Pathophysiology The pathophysiology of PCS involves a combination of microstructural, physiology, and metabolic injuries with the brain (Permenter, Fernández-de Thomas, & Sherman, 2020). The various signs and symptoms associated with PCS are caused by the damaging of the autonomic nervous system. This damage that takes place in the white matter tracks between the vagal nerve and cortical control centers, through the spinal cord, hence affecting parasympathetic and sympathetic nervous systems (Permenter et al., 2020). This leads to depressive moods in the patient diagnosed with this condition. The damaging of the autonomic nervous system further affects the body’s ability to control cerebral blood flow (CBF), heart rates, and blood pressure, leading to symptoms such as concentration difficulties, irritability, confusion, headache, and dizziness. Inflation of CBF also leads to a feeling of dizziness, blurring of vision, intolerance to exercises. The damage of vagal nerve tracts leads to the inflation of blood pressure and heart rate, hence leading to early fatigue during exercises (Permenter et al., 2020). Contrastingly, the occurrence of TBI results in the damaging of direct tissue and impairment of the regulation of metabolism and cerebral blood flow (CBF). This results in the formation of edema, an increase in membrane permeability, and anaerobic glycolysis, which consequently lead to the accumulation of lactic acid (Werner &Engelhard, 2007; Prins, Greco, Alexander, & Giza, 2013; Lee & Ng, 2019). Due to the inadequacy of anaerobic metabolism, A COMPARISON BETWEEN PCS AND TBI5 which is required for maintaining cellular energy states, the ATP stores become depleted, leading to the malfunctioning of energy-dependent membrane ion pumps. In the second phase of pathophysiology, the terminal membrane gets depolarized, leading to releasing of excessive excitatory neurotransmitters and activation of voltage-dependent Na+and Ca2+-, aamino-3-hydroxy-5-methyl-4-isoxazolpropionate, and N-methyl-D-aspartate channels (Lee & Ng, 2019; Werner &Engelhard, 2007). The influx of Na+- and Ca2+- initiates intracellular selfdigesting processes; Ca2+ activates phospholipases, proteases, and lipid peroxidases, which lead to increased intracellular concentration of free radicals and fatty acids as well as caspases, which cause structural alterations of nucleosomal DNA and biological membranes. All these events ultimately lead to the death of cells (apoptosis) (Werner &Engelhard, 2007; Prins, Greco, Alexander, & Giza, 2013; Lee & Ng, 2019). Assessment Assessment of PCS involves a physical examination of the patient's head and neck as well as medical examination of history of previous TBIs and symptoms, which should be done by a multidisciplinary team (Polinder et al., 2018). Therefore, the various assessments that are conducted to determine whether a patient has PCS are (1) clinical examination and history, which captures information relating the medical history and injury event history, including dizziness, memory, speech fluency, heart rate and respiratory using structured – Clinical Interview DSM, (2) self-reported PCS symptoms using Health and behavior inventory or PCS inventory, (3)neuropsychological impairment using tools such as Trail making Test (TMT), Rey auditory verbal learning test, Cognitive Battery-NIH toolbox, among others; (4) psychological and psychiatric status tests using tools such as Beck depression inventory, patient health questionnaire-9, post-traumatic stress disorder checklist, and Short Mood and Feelings questionnaire, and (5) symptom validity assessment using instruments such as Test of memory malingering (TOMM) and medical symptom validity test (Polinder et al., 2018). A COMPARISON BETWEEN PCS AND TBI6 For TBI, assessment can be classified into two stages. The first stage is the initial rapid trauma assessment, where the healthcare provider conducts an overall assessment of injuries, airways, and breathing challenges. It also includes neurologic assessments using the Glasgow Coma Scale (GCS) and pupillary light response to determine the size and location of the lesion. After that, a complete neurologic assessment is done through neuroimaging (that is, CT scans or MRI) if the patient’s GCS score is less than 15, and is unconscious, persistently vomiting, and experiencing seizures (Wilberger & Mao, 2019). Therefore, the assessments of PCS and TBI are different due to their severity. However, in both conditions, CT or MRI scans can be used to assess the skull and the brain. The use of different assessments for PCS helps to confirm whether the patient is suffering from this condition because, as noted before, there is no specific test for PCS, and patients might exhibit the same symptoms but suffering from a different condition. This is the reason why assessments and diagnoses for PCS are recommended to be done by a multidisciplinary team (Permenter et al., 2020; DerSarkissian, 2019). Diagnosis Diagnosing PCS is not easy because the symptoms could be vague and associated with other conditions (Permenter et al., 2020). Since there is no definitive test for PCS, diagnosis is based on history of head and neck injury and reported symptoms. The past medical history also includes history of chronic pain, anxiety and mood disorders, depression, and headache (Permenter et al., 2020). Diagnosis also involves a detailed description of the extent and number of previous acute concussion symptoms using the standardized measurement instruments discussed above (Lee & Ng, 2019). As per the DSM-IV tool, PCS is diagnosed if the patient reports cognitive deficits in memory or attention, plus at least three of the symptoms stated above (Permenter et al., 2020). Based on the International Classification of Disease (ICD-10), PCS should be diagnosed if the symptoms persist for more than three weeks because most patients recover 7-10 days after the injury (Permenter et al., 2020). A COMPARISON BETWEEN PCS AND TBI7 Just as PCS, history of head injury is an essential step in the diagnosis of TBI. TBI, however, requires a systematic and rapid diagnosis, which includes the assessment of pulmonary and cardiac functionality, full-body assessment, and neurological examination, based on the Glasgow Coma Scale (GCS) (AANS, 2020). Diagnosis also includes testing whether pupils reduce in size when the patient is exposed to a bright light (known as the pupillary light response) (AANS, 2020; Wilberger & Mao, 2019). This helps in determining whether the patient has a large mass lesion (wide /dilated pupil on one side implies that the patient may have a large mass lesion and which is located on the same side as the dilated pupil) (AANS, 2020). Radiological tests are also performed on the patient. Computed Tomography (CT) scan is the widely recommended assessment tool for TBI patients because it is not only easy but also effective in detecting the presence of fractures and blood, which are crucial in identifying TBI. Magnetic Reasoning Imaging (MRI) can also be used to detect fractures and blood in the head. The similarity in PCS and TBI is that, in both, CT scan and MRI are used in the diagnosis (DerSarkissian, 2019). Treatment The majority of people with PCS recover with rest and reducing stress (DerSarkissian, 2019). However, healthcare providers may give prescriptions to treat symptoms associated with this condition. For instance, patients experiencing headache can be given migraine or pain medications, while those with mental health problems can be given antidepressants such as sertraline (Zoloft), fluoxetine (Prozac), and citalopram (Celexa), psychotherapy, or referred to a neurologist or psychiatrist (DerSarkissian, 2019). However, treatment for TBI is more complex and dependent on the severity of head injury (AANS, 2020; Wilberger & Mao, 2019). If the TBI is mild, the treatment targets the symptoms just as the PCS. The patient may be discharged and put under the observation of the family members for 24 hours. However, the patient may be returned for further examination if they develop seizures, mental function deterioration, vomiting, worsening A COMPARISON BETWEEN PCS AND TBI8 headache, and reduced levels of consciousness (DerSarkissian, 2019). For patients with severe TBI, their airway protective reflexes are mostly impaired and high intracranial pressure (ICP). For such patients, treatment includes (1) sedation to prevent agitation and increased muscular activities which lead to increased ICP by using medications such as propofol and Benzodiazepines (e.g., midazolam, lorazepam), (2) administration of opioids to control pain, (3) maintaining serum osmolality and euvolemia at normal state by giving hypertonic saline solution or osmotic diuretics such as mannitol solution, (5) Controlling and monitoring CPP and ICP by elevating the head of the bed to 30o and placing the head of the patient in the midline position, and inserting a ventricular catheter to reduce the ICP, (6) providing adequate oxygenation and ventilation, (7) rapid-sequence oral intubation alongside administering drugs such as Lidocaine, Etomidate, and Succinylcholine, which help in reducing ICP when the airway is altered (Wilberger & Mao, 2019). Another treatment method for severe TBI is surgery. Surgery is mostly recommended for TBI patients with significant intracranial hematomas to prevent herniation, compression, and brain shift (DerSarkissian, 2019; Wilberger & Mao, 2019). Conclusion TBI and PCS exhibit similar symptoms such as thinking and remembering problems such as difficulties in concentrating, remembering new information, and thinking clearly, headache, irritability, sadness, anxiety/nervousness, and trouble falling asleep. However, those specific to TBI include balance problems, sensitivity to noise or light, nausea/vomiting, convulsions, or seizures. Pathophysiologically, PCS involves damaging of the autonomic nervous system, which leads to some of the symptoms mentioned above. However, TBI leads to damaging of direct tissue and impairment of the regulation of metabolism and cerebral blood flow, which leads to edema, increase in membrane permeability, and anaerobic glycolysis, which consequently lead to the accumulation of lactic acid. There is no specific diagnosis for PCS; however, the diagnosis is based on the history of neck and head injury and A COMPARISON BETWEEN PCS AND TBI9 symptoms. For TBI, diagnosis involves assessment of pulmonary and cardiac functionality, fullbody assessment, and neurological examination. However, in both conditions, CT and MRI can be used in assessment and diagnosis. Also, there is no specific treatment for PCSprescriptions are given to treat symptoms. However, in TBI, treatment may include surgery, therapy, and some medications. 10 A COMPARISON BETWEEN PCS AND TBI References American Association of Neurological Surgeons [AANS]. (2020]. Traumatic Brain Injury. Retrieved from https://www.aans.org/en/Patients/Neurosurgical-Conditions-andTreatments/Traumatic-Brain-Injury. DerSarkissian, C. (2019, April 25). Post-Concussion Syndrome. WebMD. Retrieved from https://www.webmd.com/brain/post-concussion-syndrome. LEE, A. Y. W. & Ng, S. Y. (2019). Traumatic brain injuries: pathophysiology and potential therapeutic targets. Frontiers in cellular neuroscience, 13, 528. Polinder, S., Cnossen, M. C., Real, R. G., Covic, A., Gorbunova, A., Voormolen, D. C., & Von Steinbuechel, N. (2018). A multidimensional approach to post-concussion symptoms in mild traumatic brain injury. Frontiers in neurology, 9, 1113. Prins, M., Greco, T., Alexander, D., & Giza, C. C. (2013). The pathophysiology of traumatic brain injury at a glance. Disease models & mechanisms, 6(6), 1307-1315. The Centers for Disease Control and Prevention [CDC]. Traumatic Brain Injury and Concussion. CDC. Retrieved from https://www.cdc.gov/traumaticbraininjury/symptoms.html. Werner, C., & Engelhard, K. (2007). Pathophysiology of traumatic brain injury. BJA: British Journal of Anesthesia, 99(1), 4-9. Wilberger, J. E. &Mao, G. (2019 December. Traumatic Brain Injury. MSD Manual. Retrieved from https://www.msdmanuals.com/professional/injuries-poisoning/traumaticbraininjury-tbi/traumatic-brain-injury-tbi#v1111662.