STEP 2: Concussion Live Course - October 21-22, 2025, in Salt Lake City, UT-Assessment: Persisting Symptoms After Concussion

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This document reviews the assessment of persisting symptoms following concussion through clinical case examples, highlighting the challenges in diagnosis and management.

Concussion is a clinical diagnosis primarily aimed at ruling out severe brain injury acutely and identifying subtle lesions post-acutely to explain symptoms and forecast recovery. Imaging is used selectively for these purposes.

<strong>Case #1:</strong> A 46-year-old Navy SEAL with extensive blast exposures presented months after successive blasts with gradually worsening headaches, tinnitus, hearing loss (right side), and incoordination without light/sound sensitivity or neck pain. Examination revealed right-sided facial sensory reduction and hearing loss, normal strength, coordination, and reflexes, but an unsteady gait with lateral listing. His symptoms have been slowly worsening over 12 months despite no clear triggers or medication benefit.

<strong>Case #2:</strong> A 61-year-old scientist with a biking concussion and prior sports-related concussions presented 9 months post-injury with cognitive complaints (multi-tasking, distractibility, slowed processing), balance difficulties increased by dual-tasking, and work stress but normal sleep and good exercise habits. Neuro exam was mostly intact with mild dizziness on vestibular testing and minimal loss of balance. Cognitive testing showed mild executive function deficits, with a history of childhood seizures and compensated hydrocephalus. Plans include monitoring imaging and neuropsychological testing over time, as concussion may have unmasked subtle cognitive issues.

<strong>Case #3:</strong> A 75-year-old woman with hypertension and diabetes experienced mild head trauma from a fall, presenting weeks later with mild balance and cognitive symptoms, insomnia, and anxiety. Examination showed mild sensory reduction in feet, cautious wide-based gait worsened by dual-tasking, and mild cognitive deficits in memory and executive functioning. She had high baseline intellectual functioning with mild relative weaknesses. Treatment includes continuing physical and speech therapy, sleep hygiene, and psychotherapy, with improvement noted.

<strong>Case #4:</strong> A 42-year-old woman post motor vehicle collision concussion struggled initially with headaches, fogginess, and cognitive sluggishness. After three months of therapy, symptoms improved by 50%, with normal neurological exam except mild dizziness on vestibular testing and myofascial pain. Despite a normal MOCA, she remains concerned and requests additional imaging.

In summary, persisting post-concussion symptoms vary widely, involving headaches, cognitive dysfunction, balance issues, and emotional symptoms, often overlapping with pre-existing conditions. A thorough clinical exam and targeted testing guide management, which includes rehabilitation therapies and symptomatic treatment, while imaging is reserved for specific concerns or new symptoms. Regular follow-up is essential to monitor progress and adjust care plans.

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Ginger R. Polich, MD

Keywords

persisting post-concussion symptoms

concussion diagnosis

clinical case examples

cognitive dysfunction

balance issues

headaches after concussion

vestibular testing

rehabilitation therapies

neuropsychological testing

imaging in concussion