Postconcussive Symptoms in the Emergency Department Predict Functional Outcomes Following Mild Traumatic Brain Injury

United States emergency departments (EDs) evaluate approximately 3 million patients annually for traumatic brain injury (TBI), most of which are mild (mTBI). While recovery without intervention is common, up to one-third of patients develop persistent symptoms that impair daily functioning. Current ACEP guidelines for mTBI in the ED emphasize neuroimaging and discharge safety but fail to provide discrete guidance for clinicians on identifying individuals at increased risk for adverse functional outcomes and long-term morbidity.

In a prospective observational study of mTBI patients from three Johns Hopkins EDs, research coordinators (RCs) administered the 22-item Post-Concussion Symptom Scale (PCSS) during ED visit to quantify symptom burden across physical, cognitive, sleep, and emotional clusters. At 30 and 90 days post-visit, RCs administered the Extended Glasgow Outcome Scale (GOSE) to evaluate functional status across seven domains: consciousness, independence (home and outside), work, social/leisure activities, relationships, and return to normal life. GOSE scores were dichotomized into favorable (7-8) and unfavorable (1-6) outcomes per established literature. Lower scores indicate greater functional disability. Logistic regression models assessed whether 1) PCSS total scores, and 2) PCSS cluster scores predicted GOSE outcomes at both time points.

366 participants enrolled. At 30 days, 126 (34%) had unfavorable outcomes; at 90 days, 84 (23%) had unfavorable outcomes as determined by GOSE. After adjusting for age and sex, higher PCSS scores were associated with significantly lower odds of a favorable outcome at 30 (p<0.01, 95% CI [0.97, 0.99]) and 90 days (p<0.001, 95% CI [0.97, 0.99]). Higher emotion-related PCSS symptoms (feeling more emotional, irritability, sadness, and nervousness or anxiety) were independently associated with lower odds of a favorable outcome at 30 (p<0.05, 95% CI [0.92, 0.99]) and 90 days (p<0.01, 95% CI [0.90, 0.98]).

Higher baseline post-concussive symptom burden was associated with unfavorable outcomes at 30 and 90 days after mTBI. This association was largely driven by emotional lability and remained significant after adjusting for age and sex. If validated, these findings may inform ED clinical guidelines for early stratification of mTBI patients at greatest risk for long-term adverse sequelae and morbidity.