Anesthesia in Patients With Postconcussion Syndrome: Is There Evidence?

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To JNA Readers:
Concussion or mild traumatic brain injury (MTBI) following motor vehicle accidents or sports-related injuries comprise 70% to 90% of all TBI. Majority of patients usually recover from the subjective symptoms within 3 months of the concussion. However, in 10% to 20% of patients, the constellation of symptoms in cognitive (difficulties in concentration and memory), physical (fatigue, headaches, dizziness), and emotional (irritability, anxiety) domains may persist for weeks, months, and even years after MTBI.1 This is known as postconcussion syndrome (PCS) and the true incidence is not known due to lack of clear diagnostic criteria and high attrition rates during the follow-up.2 Among the symptoms of PCS, cognitive complaints are noted to be most common.3 A recent study investigating the long-term effects of MTBI showed that cognition was significantly impaired in MTBI patients with persistent PCS compared with those without PCS.4 Although neurological and psychiatric factors are known to contribute to PCS, the etiology still remains elusive.
Many patients often undergo urgent and emergency surgeries following MTBI; however, some patients with PCS may present for an elective surgery. While the consequences of PCS are still being conceptualized and actively researched, currently there are no guidelines on the anesthetic management of patients who present with PCS. Recently, we came across a 32-year-old male patient presenting for a urological procedure with persistent PCS symptoms following MTBI 3 months ago (hit by golf ball). He was neurologically intact with normal neuroimaging studies, but he did have persistent PCS with symptoms of irritability, anxiety, dizziness, and memory lapses. He was seen in preoperative anesthesia consult clinic and was informed of the risks of postoperative worsening of his cognitive symptoms. He successfully underwent the procedure under subarachnoid block with no sedation. He did not have any adverse perioperative events and was discharged home the next day. Although we successfully managed this patient with regional anesthesia with no adverse events, this case illustrates the potential difficulties of caring for these patients.
We did a literature search seeking the answer for this, and currently, there is no literature on the anesthetic concerns when a patient presents with PCS. Monk and Price5 have found that patients with preoperative cognitive deficits are at higher risk for postoperative worsening in cognitive symptoms, confusion, delirium, and agitation following anesthesia, either during emergence or in the immediate postoperative period. However, we do not know whether patients with PCS are at increased risk for worsening of their symptoms postoperatively. Therefore, the following questions should be considered during the preanesthetic evaluation of patients with PCS:
With an increasing number of sports-related concussions in young adults, we should focus our research on the anesthetic implications of PCS in this group of patients and begin discussion about best anesthetic management, answering the questions listed above and developing guidelines to improve care and outcomes.

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