What is the most appropriate next step for a 21-year-old patient presenting with headaches, dizziness, fatigue, mood swings, and insomnia after a head-to-head collision in college soccer, with a history of loss of consciousness and normal computed tomography (CT) brain scan results?

From the Guidelines

The most appropriate next step for this 21-year-old patient with headaches, dizziness, fatigue, mood swings, and insomnia following a soccer-related head injury is reassurance (option D). The patient is presenting with classic symptoms of post-concussion syndrome, which typically develops after a mild traumatic brain injury 1. The initial evaluation was appropriate with CT imaging showing no structural abnormalities, and the current examination reveals stable vital signs without neurological deficits. Reassurance, along with education about the typically self-limiting nature of post-concussion symptoms, is the standard first-line approach. The patient should be advised that symptoms usually resolve within 3 months, though some may persist longer. Management should include recommendations for gradual return to normal activities, adequate rest without excessive sleep, stress reduction, and avoidance of alcohol and recreational drugs. Pain relievers may be suggested for headaches, but the patient should continue to avoid contact sports until symptom-free. Further imaging or testing is not indicated at this time given the normal initial CT and absence of concerning neurological findings, though follow-up should be arranged to monitor symptom progression.

Some key points to consider in the management of this patient include:

• The importance of educating the patient about post-concussive symptoms and providing written and verbal instructions on what to expect and when to seek further medical attention 1
• The need for gradual return to normal activities, including a stepwise progression of physical activity, as outlined in the return to play protocol 1
• The potential for post-concussive symptoms to persist for an extended period, and the importance of ongoing monitoring and support
• The lack of evidence to support the use of further imaging or testing in patients with mild traumatic brain injury and normal initial CT scans, unless there are concerning neurological findings or a significant change in symptoms 1

From the Research

Diagnosis and Next Steps

The patient's symptoms, including headaches, dizziness, fatigue, mood swings, and insomnia, following a head-to-head collision, suggest a possible diagnosis of post-concussion syndrome (PCS). Given the patient's history and presentation, the most appropriate next step would be to conduct a thorough assessment to evaluate the extent of the concussion's impact on cognitive function.

Assessment Options

• Neuropsychological testing: This approach is supported by studies such as 2 and 3, which highlight the utility of neuropsychological evaluation in assessing concussion. Neuropsychological testing can help identify cognitive deficits and guide rehabilitation efforts.
• Imaging studies: While the patient's initial CT brain scan was unremarkable, studies like 4 and 5 suggest that functional MRI or other advanced imaging techniques may be useful in evaluating patients with persistent post-concussive symptoms.
• Electroencephalography: This option is mentioned in 4 as a potential tool for evaluating patients with PCS, although its utility may be more limited compared to neuropsychological testing or imaging studies.

Considerations

• The patient's symptoms and history suggest a need for a comprehensive assessment to guide management and rehabilitation.
• Studies such as 6 emphasize the importance of considering both neurological and psychosocial factors in the management of PCS.
• The choice of assessment modality should be guided by the patient's specific symptoms and presentation, as well as the availability of resources and expertise.