Resolution Of Neuropsychiatric Symptoms Of Post-Concussion Syndrome With An Acetylcholinesterase Inhibitor

HISTORY: 30 year old amateur rugby union player. Reported a concussion in 2019, which ended his season that year. He sustained a further 3 concussions in 3 consecutive weeks in June 2020. After the 3rd concussion, he was off work for 3 weeks living in darkness. He had severe blurred vision, post traumatic headache, severe fatigue, dizziness, intermittent waves of nausea and severe photophobia. He experienced intermittent migraine-like headaches with aura and tinnitus every 2 to 3 weeks, requiring a day off work. He was first seen in Aug 2021, 14 months after his last concussion. PHYSICAL EXAMINATION: Diminished executive functions, with poor short-term memory, procrastination, difficulty solving problems and difficulty in regulating emotions. Difficulty word finding, poor concentration, “brain fog” and distressing panic attacks every 3 to 4 weeks. DIFFERENTIAL DIAGNOSIS: PTSD secondary to concussion induced neuroinflammation. TESTS AND RESULTS: His High Frequency (HF) Heart Rate Variability (HRV) was 4.5%, indicating cholinergic withdrawal (normal range 45-55%). These symptoms were similar to those reported by PTSD patients, so a Post-Traumatic Checklist-Civilian (PCL-C) was administered. He scored 75/85, with a score 50/85 being the diagnostic threshold. FINAL WORKING DIAGNOSIS: PTSD secondary to concussion induced neuroinflammation. TREATMENT AND OUTCOMES: Commenced on Acetylcholinesterase inhibitor (AChEi) Rivastigmine 4.6 mg patch, consistent with its reported benefit in PTSD (1). At Week 2 follow-up his PCL-C score was 43/85, a 32 point decrease. At week 7, his PCL was 37/85 and his Rivastigmine was increased to the 9.5 mg patch. At Week 15 follow up his PCL score was 27/85, indicating remission. At Week 22 he had sustained remission and the Rivastigmine was ceased. He was followed up at 14 months post cessation and his PCL was 26/85 and he reported feeling cognitively and emotionally well. The common underlying factor could be neuro-inflammation. Cholinergic dysfunction has been reported following concussion and Rivastigmine has been shown to reduce neuroinflammation (2) 1.Rudzki SJ 2023. Five-Year PTSD Symptom Remission in Two Patients Following Treatment With Rivastigmine2.Nizri E 2008. Suppression of neuroinflammation and immunomodulation by the acetylcholinesterase inhibitor rivastigmine