102 J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 96–100 Original Demographic Evaluation of Post-Concussion Syndrome in Referrals to Bandar Abbas Forensic Medical Center, South of Iran from March 2020 to August 2021 Saeed Mohammadi1, Seyed Javad Mirhadi2, Hosein Javadi Vasigh1, Khatere Asadi1, Azadeh Memarian3,* , Farahnaz Nikkhah4,5 1Legal Medicine Center of Hormozgan, Bandar Abbas, Iran. 2Legal Medicine Research Center, Iranian Legal Medicine Organization, Bandar Abbas, Iran. 3Department of Neonatology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. 4Operating Room Nursing, Rasool Akram Medical Complex Clinical Research, Iran University of Medical Sciences, Tehran, Iran. Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran. *Correspondence to: Azadeh Memarian (E-mail: a.memarian@mazums.ac.ir) (Submitted: 17 December 2021 – Revised version received: 04 January 2022 – Accepted: 25 January 2022 – Published online: 26 April 2022) Abstract Objectives: The aim of the present study is the demographic assessment of PCS in referrals to forensic medical centers in Bandar Abbas. Methods: This cross-sectional and descriptive study was performed on 72 patients with mild brain trauma who were referred to Bandar Abbas forensic medical center. PCS was confirmed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Information on age, sex, mechanism of trauma, the time interval between the first visit to the forensic medical center, level of consciousness, number of hospitals stays days, number of days in ICU, and symptoms at initial referral were recorded in the designed form. Results: The mean age of patients was 30.81 ± 13.39 years. There was a significant difference in sex and mechanisms of trauma (P < 0.001). The average time interval of the first referral to forensic medical center was 9.44 ± 18.37 days. 87.5% were hospitalized and only 9.7% were hospitalized at ICU. The consciousness level of all patients was in the range of 12 to 15 (mild range). Among symptoms, headache (87.5%) and dizziness (81.9%) were the most significant prevalent symptoms. 70.8% of patients had no symptoms one month after the accident but 12.5% still had symptoms and only 9.7% still had symptoms of concussion after 3 months. Conclusion: According to the results, PCS mostly happened in the male gender and the main mechanism of trauma was an accident. Headache and dizziness were the main symptoms. Only a small percentage of patients have symptoms after one month and three months, post-injury. Keywords: Post-Concussion Syndrome (PCS), Mild traumatic brain injury (MTBI), Symptoms ISSN 2413-0516 Introduction Traumatic brain injury is a significant public health concern globally and they may begin a series of metabolic reactions which lead to post-concussion syndrome (PCS).1 PCS after a traumatic brain injury and mild traumatic brain injury (MTBI) are very prevalent.2 PCS is a prototypal psychosomatic dis- order and both psychosocial and physical factors playing a sig- nificant role in its etiology.3 Numerous factors raise the PCS development risk after brain injury. A previous mental dis- order like anxiety or depression, acute post-traumatic stress, and pain were predictive of PCS.4,5 Age above 40, female gender, prior head injuries, and substance abuse are reported as other risk factors for PCS.6 PCS can be diagnosed using the International Classifica- tion of Diseases (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders DSM-IV.7,8 The prognosis of PCS is commonly good. Most of the patients recover by 3 months.9 However, in 10–20% of the cases, PCS may continue for weeks or months as a result of metabolic and structural brain inju- ries. Among these patients, 25–33% experience persistent post-concussion syndrome and the symptoms become chronic and last for more than 6 months.10,11 PCS symptoms comprise three clinical areas: somatic symptoms such as headache, insomnia, fatigue, tinnitus, dizzi- ness, sensitivity to noise or light; cognitive symptoms including reduced memory, concentration, and attention; and affective symptoms such as depression, anxiety, and irritability.1 In the assessment of PCS, the clinician had better evaluate consciousness loss, the post-traumatic amnesia duration, and the Glasgow Coma Scale after trauma. They should assess the information about the accident and hospital stays and the out- comes of treatment should be recorded.3 It was shown that the differences in the incidence of PCS could be as a result of cultural diversities.12 Moreover, in a study, it has been shown that the effect of culture and language should be considered in PCS assessments.13 Subsequently, prevalence rates and demographic features of PCS in popula- tions may vary between countries. This study aimed to investi- gate the prevalence of post-concussion syndrome in patients referred to Bandar Abbas Forensic Medicine Center. Materials and Methods This is a cross-sectional and descriptive study. In one year, patients with mild brain trauma, no structural change in CT Scan, mild level of consciousness (Glasgow Coma Scale (GCS) = 13–15), and mild memory impairment before and after the traumatic event (less than 1 hour) who referred to Bandar Abbas Forensic Medical Center, South of Iran, from March 2020 to August 2021, for whom the diagnosis of concussion was made were selected. 5 https://orcid.org/0000-0002-6872-1870 103J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 96–100 S. Mohammadi et al. Original Demographic Evaluation of PCS in Referrals to Bandar Abbas Forensic Medical Center Information on age, sex, mechanism of trauma (accident, quarrel), the time interval between the first visit to the forensic medical center, level of consciousness, number of hospitals stays days, number of days in ICU, and symptoms at initial referral (headache, dizziness, anger, sleep disturbance, fatigue, forgetfulness, memory impairment, and concentration dis- order) were recorded in the designed form. If there are at least three of the above symptoms, re- examination was considered for patients. At one month after the accident, the symptoms were re-examined and if they did not improve, neurological counseling was performed to con- firm the symptoms. If symptoms do not improve, re-examina- tion was done for 3 months after the accident, and symptoms were re-examined at 3 months post-accident and confirmed by a neurologist. Post-Concussion Syndrome was confirmed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria if there were at least three of these symptoms for at least 3 months. Statistical Analysis SPSS version 20 was used to analyze the data. Data are pre- sented as frequency and percentage and MEAN and standard deviation. Univariate chi-square test was used to show the dif- ference of variables between the research samples. Values were significant at P < 0.05. Result Seventy-two patients met the criteria and selected for the study. The mean age of patients was 30.81 ± 13.39 years. The univariate chi-square test showed that there was a significant difference between the research sample in terms of sex and mechanisms of trauma (Table 1). The average time interval between the accident and the first referral to forensic medical center was 9.44 ± 18.37 days. As shown in Table 2, the level of consciousness of all indi- viduals was in the range of 12 to 15 (mild range). Also, most of the patients, 53 (73.6%), had a level of consciousness of 15. The univariate chi-square test showed that there was a significant difference in terms of the level of consciousness. Among the patients, 63 patients (87.5%) were hospital- ized and 9 patients (12.5%) were not hospitalized. Most of the patients, 65 (90.3%), were not hospitalized in the ICU and only 7 patients (9.7%) had a history of being admitted to the ICU. The univariate chi-square test showed that there was a significant difference in terms of the prevalence of hospitalization and the prevalence of hospitalization in the intensive care unit (Table 3). The average days of hospitalization and hospitalization in the ICU are shown in Table 4. At referral, 87.5% had a headache and 81.9% had dizzi- ness. Most of the patients (61.1%) did not have the “anger” symptom. However, this symptom was present in 38.9% of patients. 44 patients (61.1%) had “sleep disorder”. 51.4% had a sign of “fatigue” and 48.6% did not have. 35 patients (48.6%) had “forgetfulness” and 37 patients (51.4%) did not have “forgetfulness”. Most patients (91.7%) did not have “ Param- nesia” and 64.88% did not have “concentration disorder” and only 8 patients (11.1%) had. Univariate chi-square test showed that there was a significant difference in terms of headache, dizziness, Paramnesia, and concentration disorder symptoms. On the other hand, the univariate chi-square test showed that there was no significant difference in terms of “anger” sign, sleep disorder, fatigue, and “forgetfulness” symptoms (Table 5). Most of the patients (70.8%) had no symptoms one month after the accident but 12.5% still had symptoms of concussion one month after the accident. The univariate chi-square test showed that there was a significant difference in terms of the prevalence of symptoms at the referral one month after the Table 1. The frequency of gender prevalence and mechanism of trauma between the accident and the first referral of patients with the diagnosis of PCS Variable Frequency Percent %CF P-value Gender Male 51 70.8 70 P < 0.001 Female 21 29.2 100 Total 72 100 Mechanism of trauma Accident 57 79.2 79.2 P < 0.001 Quarrel 15 20.8 100 Total 72 100 Table 2. Level of consciousness in patients with the diagnosis of PCS Level of consciousness Frequency Percent %CF P-value 12 2 2.5 2.8 < 0.001 13 8 11.1 14.1 14 8 11.1 25.4 15 53 73.6 100 Missing data 1 1.4 Total 72 100 Table 3. Prevalence of hospitalization and hospitalization in ICU in patients with the diagnosis of PCS Frequency Percentage %CF P-value Prevalence of hospitalization Yes 63 87.5 87.5 < 0.001 No 9 12.5 100 Total 72 100 Prevalence of hospitalization in the ICU Yes 7 9.7 9.7 < 0.001 No 65 90.3 100 Total 72 100 Table 4. Mean of hospitalization days and hospitalization days in ICU in patients with the diagnosis of PCS Variable No. Mean SD Min. Max. Days of hospitalization 71 2.02 1.58 1 8 Days of hospitalization in the ICU 71 1.80 1.30 1 4 104 J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 96–100 Demographic Evaluation of PCS in Referrals to Bandar Abbas Forensic Medical Center Original S. Mohammadi et al. accident. 36.1% had no symptoms three months after the acci- dent. 9.7% still had symptoms of concussion at the referral three months after the accident. Data from 54.2% of patients were also not reported. The univariate chi-square test showed that there was a significant difference between the study sam- ples in terms of the prevalence of symptoms at the referral three months after the accident (Table 6). Table 5. Prevalence of symptoms at initial referral in patients diagnosed with PCS Variable Frequency Percentage %CF P-value Headache Yes 63 87.5 87.5 < 0.001 No 9 12.5 100 Total 72 100 Dizziness Yes 59 81.9 81.9 < 0.001 No 13 18.1 100 Total 72 100 Anger Yes 28 38.9 38.9 > 0.05 No 44 61.1 100 Total 72 100 Sleep disorder Yes 44 61.1 61.1 > 0.05 No 28 38.9 100 Total 72 100 Fatigue Yes 37 51.4 51.4 > 0.05 No 35 48.6 100 Total 72 100 Forgetfulness Yes 35 48.6 48.6 > 0.05 No 37 51.4 100 Total 72 100 Paramnesia Yes 6 8.3 8.3 < 0.001 No 66 91.7 100 Total 72 100 Concentration disorder Yes 8 11.1 11.1 < 0.001 No 64 88.9 100 Total 72 100 Other symptoms Yes 3 4.2 4.2 < 0.001 No 69 95.8 100 Total 72 100 Table 6. Prevalence of symptoms in one month and three months after the accident in patients with the diagnosis of PCS Variable Frequency Percentage %CF P-value Prevalence of symptoms in a month after the accident Yes 9 12.5 15 < 0.001 No 51 70.8 100 Missing data 12 16.7 Total 72 100 Prevalence of symptoms in referral three months after the accident Yes 7 9.7 21.2 < 0.001 No 26 36.1 100 Missing data 39 54.2 Total 72 100 Discussion In the present study, the demographic evaluation of PCS was performed in patients who were referred to the Forensic Med- ical Center of Bandar Abbas as a result of mild brain injury. According to the result of this study, the mean age of the patients with PCS was 30.81 ± 13.39 years. Most of the patients were male and the main mechanism of trauma was an acci- dent. The level of consciousness of all patients was in the mild range (12 to 15) and most of them had the level of conscious- ness of 15. Most of the patients were hospitalized but only 9.7% being admitted to the ICU. Headache and dizziness were significantly the most prevalent symptoms in PCS patients. There was no significant difference in terms of anger, sleep dis- order, fatigue, and forgetfulness symptoms. The prevalence of concentration disorder and paramnesia was very low in patients. Most of the patients had no symptoms one month and 3 months after injury but only 12.5% at one month and 9.7% at 3 months after still had symptoms of concussion. Dean et al. compared PCS prevalence in individuals with mild TBI and without head injury and reported a higher prev- alence of headaches and significantly higher cognitive prob- lems were those with MTBI in comparison to the control group.14 Similar to the result of the present study the preva- lence of headaches was high. Balakrishnan et al. evaluated the PCS after MTBI and in contrast to this study, they reported the female gender as the dominant gender for PCS. Similar to the result of the current study the prevalence of PCS was low after 2 weeks, 3, and 6 months and they were 9.6%, 8.1%, and 8.1%. Again like this study, the main reason for injury was traffic accidents.15 Varner et al. study in adults with acute mild traumatic brain injury, 20.3% had persistent concussion symptoms. Headache, use of drugs or alcohol at the time of injury, the injury happening by bike or motor vehicle crash, history of depression or anxiety, and numbness were defined to be inde- pendently related to persistent concussion symptoms in a month.16 Consistent with the present study headache was the main symptom. Beauchamp et al. compared PCS symptoms in sports- related MTBI with non-sports-related MTBI and reported that patients with sports-related MTBI might be at lower risk for symptoms like dizziness and fatigue in 90 days after injury. They suggested that patients with non-sports-related MTBI may show more PCS symptoms and that the physical activity level could affect the rehabilitation of the patient.17 105J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 96–100 S. Mohammadi et al. Original Demographic Evaluation of PCS in Referrals to Bandar Abbas Forensic Medical Center Acknowledgments All the researchers who have helped us in this research project. The authors also thank the Rasool Akram Medical Complex Clinical Research Development Center (RCRDC) for its tech- nical and editorial assists. Conflict of Interest The author reports no conflicts of interest in this work. Ethical Consideration The study is approved by the Ethics Committee of Forensic Medicine Organization of the country of Iran (code: 2062(24.12.98 ). Written informed consent was obtained from patients. Consent for Publication Written informed consent was obtained from the patients for publication of this paper. Informed Consent Written informed consent was obtained from the patients for participation in the study. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Data Availability Statement The data that support the findings of this study are available from corresponding author on reasonable request. Funding The authors declare that this research did not receive any spe- cific grant from funding agencies in the public, commercial, or not-for-profit sectors.  In a study by van der Vlegel 22.0% of the 1282 patients in the general injury population met the PCS criteria. Patients with head injuries showed a high frequency of PCS (29.4%). Patients with PCS had lesser HRQL, lesser coming back to work levels, and greater health care utilization, in comparison to non-PCS patients.18 Patients with mild traumatic brain injuries frequently complain about a group of physical, cognitive, as well as emo- tional, or behavioral symptoms. The most frequent symptoms for PCS are headache, dizziness, reduced concentration, memory complications, fatigue, visual disorders, irritability, noise sensitivity, judgment issues, anxiety, and depression. Even though these symptoms normally resolve during one month, in some cases PCS may remain for months or years or even permanently. Physiological as well as psychological fac- tors have been recommended as reasons for persistent PCS. Researchers believe that a range of injury-associated, pre- and post-morbid neuropathological, and psychological elements play role in the progression and prolongation of these symp- toms.19 Therefore, it is significant to develop approaches to prevent PCS symptoms in injured patients, increase awareness of patients as well as physicians on the incidence of PCS, detect PCS at the earliest time, and develop approaches to improve recovery in these patients. Declarations Author Contributions Study concept and design: SM, SJM, AM Drafting of the manuscript: SM, AM Literature searching: All authors Statistical analysis and interpretation of the data: HJV, KA, AM Critical revision of the manuscript for important intellectual content and taking responsibility for the integrity and the accuracy of the data: All authors Study supervision: AM Reviewed and modified the manuscript: FN, AM All authors read and approved the final manuscript. References 1. Hadanny A, Efrati S. Treatment of persistent post-concussion syndrome due to mild traumatic brain injury: current status and future directions. Expert Rev Neurother. 2016;16(8):875-87. 2. Evans RW. The postconcussion syndrome and the sequelae of mild head injury. Neurol Clin. 1992;10(4):815-47. 3. Foy K, Murphy KC. Post-concussion syndrome. Br J Hosp Med (Lond). 2009;70(8):440-3. 4. Meares S, Shores EA, Taylor AJ, Batchelor J, Bryant RA, Baguley IJ, et al. The prospective course of postconcussion syndrome: the role of mild traumatic brain injury. Neuropsychology. 2011;25(4):454-65. 5. Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A, Schonberger M. Predictors of postconcussive symptoms 3 months after mild traumatic brain injury. Neuropsychology. 2012;26(3):304-13. 6. Edna TH, Cappelen J. Late post-concussional symptoms in traumatic head injury. An analysis of frequency and risk factors. Acta Neurochir (Wien). 1987;86(1-2):12-7. 7. Diagnostic A. statistical manual of mental disorders. Washington. DC: American Psychiatric Association. 1994;4. 8. Organization WH. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines: World Health Organization; 1992. 9. Binder LM. A review of mild head trauma. Part II: Clinical implications. J Clin Exp Neuropsychol. 1997;19(3):432-57. 10. King NS, Kirwilliam S. Permanent post-concussion symptoms after mild head injury. Brain Inj. 2011;25(5):462-70. 11. Sterr A, Herron KA, Hayward C, Montaldi D. Are mild head injuries as mild as we think? Neurobehavioral concomitants of chronic post-concussion syndrome. BMC Neurol. 2006;6:7. 12. Wang Y, Chan RC, Deng Y. Examination of postconcussion-like symptoms in healthy university students: relationships to subjective and objective neuropsychological function performance. Arch Clin Neuropsychol. 2006;21(4):339-47. 13. Zakzanis KK, Yeung E. Base rates of post-concussive symptoms in a nonconcussed multicultural sample. Arch Clin Neuropsychol. 2011;26(5):461-5. 14. Dean PJ, O’Neill D, Sterr A. Post-concussion syndrome: prevalence after mild traumatic brain injury in comparison with a sample without head injury. Brain Inj. 2012;26(1):14-26. 15. Balakrishnan B, Rus RM, Chan KH, Martin AG, Awang MS. Prevalence of Postconcussion Syndrome after Mild Traumatic Brain Injury in Young Adults from a Single Neurosurgical Center in East Coast of Malaysia. Asian J Neurosurg. 2019;14(1):201-5. 16. Varner C, Thompson C, de Wit K, Borgundvaag B, Houston R, McLeod S. Predictors of persistent concussion symptoms in adults with acute mild 106 J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 96–100 Demographic Evaluation of PCS in Referrals to Bandar Abbas Forensic Medical Center Original S. Mohammadi et al. traumatic brain injury presenting to the emergency department. CJEM. 2021;23(3):365-73. 17. Beauchamp F, Boucher V, Neveu X, Ouellet V, Archambault P, Berthelot S, et al. Post-concussion symptoms in sports-related mild traumatic brain injury compared to non-sports-related mild traumatic brain injury. CJEM. 2021;23(2):223-31. 18. van der Vlegel M, Polinder S, Toet H, Panneman MJM, Haagsma JA. Prevalence of Post-Concussion-Like Symptoms in the General Injury Population and the Association with Health-Related Quality of Life, Health Care Use, and Return to Work. J Clin Med. 2021;10(4). 19. Ryan LM, Warden DL. Post concussion syndrome. Int Rev Psychiatry. 2003;15(4):310-6. This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly. https://doi.org/10.22317/jcms.v8i2.1157