New framework modernizes diagnosis of traumatic brain injury after 50 years

New framework modernizes diagnosis of traumatic brain injury after 50 years

Advanced tools provide improved insights into patients' conditions and their recovery potential.

What's new:After more than half a century, the assessment of traumatic brain injuries is being revised.

Why it matters:Clinicians say the proposed framework will lead to more accurate diagnoses and treatment, providing more rigorous care for some patients and preventing premature discussions about withdrawing life support in others.

Trauma centers nationwide will begin testing a new approach to assessing traumatic brain injury (TBI) that is expected to lead to more accurate diagnoses and more appropriate treatment and follow-up for patients.

The new framework, developed by a coalition of experts and patients from 14 countries and spearheaded by the National Institutes of Health, expands assessment beyond immediate clinical symptoms. Additional criteria include biomarkers, CT and MRI scans, as well as factors such as other medical conditions and how the trauma occurred.

The framework appears in the May 20 issue ofLancet Neurology.

For 51 years, trauma centers have used the Glasgow Coma Scale to evaluate patients with TBI, broadly dividing them into mild, moderate, and severe categories based solely on their level of consciousness and a handful of other clinical symptoms.

This diagnosis resulted in patients receiving care in the emergency room and thereafter. In severe cases, it also influenced the guidance doctors gave to patients' families, including recommendations about removing life support. However, doctors have long understood that these tests did not tell the whole story.

There are patients diagnosed with a concussion whose symptoms are dismissed and receive no follow-up because it is just a concussion and they live with debilitating symptoms that destroy their quality of life. On the other hand, there are patients who were diagnosed with “severe” TBI and lived full lives whose families had to consider eliminating life-sustaining treatment. “

Geoffrey Manley, MD, PhD,corresponding author,Professor of Neurosurgery at UC San Francisco and member of the UCSF Weill Institute for Neuroscience

In the United States, TBI resulted in approximately 70,000 deaths in 2021 and accounted for approximately half a million permanent disabilities each year. Motor vehicle accidents, falls and bodily harm are the most common causes.

New system better matches patients with treatments

Known as CBI-M, the framework includes four pillars—clinical, biomarkers, imaging, and modifiers—developed by working groups of federal partners, TBI experts, scientists, and patients.

“The proposed framework is a major step forward,” said co-senior author Michael McCrea, professor of neurosurgery and co-director of the Center for Neurotrauma Research at the Medical College of Wisconsin in Milwaukee. “We will be much better equipped to match patients with treatments that give them the best chance of survival, recovery and normal life function.”

The framework was spearheaded by the NIH National Institute of Neurological Disorders and Stroke (NIH-Ninds), for which Manley, McCrea, and their co-first and co-senior authors are members of the Steering Committee for Improving TBI Characterization.

The clinical pillar retains the Glasgow Coma Scale total score as the central element of assessment and measures consciousness along with pupillary reactivity as an indication of brain function. The framework recommends including scale responses to ocular, verbal, and motor commands or stimuli, presence of amnesia, and symptoms such as headache, dizziness, and sensitivity to noise.

“This pillar should be evaluated as a first priority in all patients,” said co-senior author Andrew Maas, MD, PhD, professor emeritus of neurosurgery at Antwerp University Hospital and the University of Antwerp, Belgium. “Research has shown that the elements of this pillar are highly predictive of injury severity and patient outcome.”

Biomarkers, imaging, modifiers provide critical clues to recovery

The second pillar uses biomarkers identified in blood tests to provide objective indicators of tissue damage and overcome the limitations of clinical assessment that may inadvertently include symptoms unrelated to TBI.

Significantly, low levels of these biomarkers determine which patients do not require CT scans, thereby reducing unnecessary radiation exposure and healthcare costs. These patients can then be discharged. For those with more severe injuries, CT and MRI imaging – the third pillar of the framework – are important for identifying blood clots, bleeding and lesions that indicate existing and future symptoms.

The biomarkers also identify appropriate patients to enroll in clinical trials to develop new TBI drugs that have not been advanced in the past 30 years. A recently launched trial that will be rolled out at 18 trauma sites nationwide may eventually lead to new treatments.

“These biomarkers are critically important in clinical trials,” Manley said. "In the past, we couldn't tell the difference between a tap on the head and a TBI. Thanks to the biomarkers, we can make that distinction and ensure that it is the TBI patient who is signing up for the trial."

The final column, modifiers, evaluates how the violation occurred, such as: It also includes existing medical conditions and medications, access to health care, previous TBIs, substance abuse, and living circumstances.

“This pillar summarizes the factors that research informs us when we interpret a patient's clinical, blood biomarker and neuroimaging tests,” said Kristen-Dams-O'Connor, PhD, professor of rehabilitation and human performance, and the director of the Brain Tooth Research Center at the Icahn School of Medicine at Mount, in New York.

“An example is a patient with underlying cognitive impairment who may require acute monitoring for risk of clinical deterioration, regardless of initial clinical assessment findings,” she said.

The proposed framework will be implemented in trauma centers on a trial basis. It will be refined and validated before being fully implemented.

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