Neurotrauma and Critical Care Section Update
Author: Julian E. Bailes
There are many new and emerging technologies for the delivery of care and achievement of better outcomes for traumatic brain injury (TBI) patients. These include assessment and imaging of cerebrovascular functioning, inpatient and outpatient rehabilitation and resource utilization, implementation of the electronic medical record in the trauma setting, and others. It is estimated that 50 million people in the United States live one hour or more from a trauma center, so access to specialty care remains paramount.
Clinical research continues to be active and relevant for concussion, as it continues to remain an important and current topic in civilian life, for military service members, and in athletes. The diagnosis remains elusive, as a concussion is ordinarily a subjective presentation and there are no outward or visible signs of injury. The diagnosis of concussion remains one of the most challenging tasks facing the clinician, and emerging technologies are implementing oculomotor function assessment, electroencephalography network patterns, brain pulsatility, and other methods. A recent study by Adrian et al. utilized the biomarkers UCHL1 and GFAP to predict the presence of intracranial lesions on CT scans, representing the first FDA approved blood test to document a mild TBI. This technology is not, however, a concussion test nor is it approved for use in pediatric patients.
However, we must remember that the pursuit of science in neurotrauma is vitally important for advances in the field as well as for optimal patient care and outcomes. There has been pessimism in the past on the heels of innumerable failed clinical trials for TBI intervention. New thinking has led to efforts for more individualized approaches, which resemble the personalized care and genetic analysis which has led to advances in other areas of medicine. Recently there has been over $100 million dollars committed to conducting large studies, including the NCAA-U.S. Department of Defense Concussion Assessment, Research and Education (CARE) Consortium, which is the largest concussion and repetitive head impact study ever undertaken. Funded jointly by the NCAA and DOD, it began in 2014 and now includes subjects across the U.S. on 30 college campuses. The CARE Consortium is part of the broader NCAA-DOD Grand Alliance and consists of two parts: clinical study, which aims to define neurological symptoms and signs, and how they are expressed and evolve, representing the natural history of concussion. In addition, an advanced research project aims to better understand the neurobiology of concussion and repetitive head impact exposure.
Another large study, the NINDS-funded, multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK- TBI) is a public-private partnership which is collecting and evaluating clinical data from 18 U.S. medical centers, including detailed neuroimaging, blood samples for biomarkers, and clinical outcomes, with a goal of enrolling 3,000 subjects. Geoffrey Manley, David Okonkwo, and other neurosurgeons have been actively involved in this cutting edge research. In my lab, we are working with an in-vitro assay using patient-specific neurons created through stem cells from blood samples. The ability to analyze the patients’ genotypes, clinical phenotypes and response to in-vitro assessments should usher in a new era of looking at the heterogeneous TBI problem through a personalized approach. The JSNTCC continues to be on the cutting edge and very relevant to our members and the public which they serve.