C35 Developing a Standard for Imaging in Patients with Mild Traumatic Brain Injuries

1. C35 Developing a Standard for Imaging in Patients with Mild Traumatic Brain Injuries

2. Functionality Go back to previous slide Home (Go back to Table of Contents page) Return to previous slide Move on to next slide Play

3. Mild Traumatic Brain Injuries Description Causes Health Impacts Current Treatments Detection Table of Contents Magnetic Resonance Imaging • Description • How it Works • Purpose • Advantages • Disadvantages • Specialized Imaging Imaging in Mild Traumatic Brain Injuries • Current Protocols • Current Issues • Proposed Solutions

4. Abstract • Procedures and care following mild traumatic brain injuries, such as concussions, are varied and ineffective • Protocols across the board are necessary to ensure patient safety and reduce the risk of long term damage

5. Objectives • Understand how mTBI’s affect the brain • Identify the types of imaging used for mTBI’s • Recognize the importance of imaging for mTBI’s • Create a standard practice for treatment of mTBI

6. “A pathophysiologic disturbance in neurologic function characterized by clinical symptomsinduced by biomechanical forces.” 1 Description of Mild Traumatic Brain Injury

7. Signs and symptoms of concussion. Queensland Brain Institute. https://qbi.uq.edu.au/concussion/signs-and-symptoms-concussion. Published May 16, 2018. Accessed November 28, 2018. Clinical Symptoms • Headache • Confusion • Nausea • Vomiting • Lack of coordination • Ringing in the ears • Sensitivity to light • Drowsiness • Fatigue

8. Direct Blow • Any direct contact to the head that causes the brain to move back and forth against the skull • Head to head contact • Head to object contact • Indirect Blow • Anything that forces the head to rotate quickly • Whiplash Causes of Mild Traumatic Brain Injury

9. Health Impacts Short Term Effects 3 • Somatic complaints • Pain • Fatigue • Weakness • Impaired cognition • Mood changes • Sleep disturbances • Loss of consciousness Long Term Effects 4 • Decreased processing speed • Attention deficits • Decreased memory • Loss of productivity • Increased risk factors: 5 • Depression • Memory problems • Dementia • Alzheimer’s disease • Parkinson’s disease • CTE • Cerebrovascular diseases

10. Current Treatments Guidelines: 6 • Limiting physical and cognitive activity • Reducing exposure to symptom-aggravating stimuli “For more chronic symptoms, the standing recommendation for treatment of post-concussion conditions is a symptom-based approach” 6

11. Detection Initial Assessment (Performed by parents, coaches, peers) • Detection of signs • Pupillary dilation test • Determining need for further assessment Further Assessment (Performed by medical professionals) • Sport Concussion Assessment Tool 3 • Medical Imaging

12. An advanced imaging modality that uses radiofrequency and high powered magnets to produce images Description of Magnetic Resonance Imaging

13. Visualization of soft tissue in detail • Evaluate structural abnormalities and injuries • Diagnose diseases and disorders Purpose of Magnetic Resonance Imaging

14. How it Works How does an MRI scan work? 8 • The body contains hydrogen protons • Hydrogen protons are present in different concentrations based on the types of tissues • Magnets in MRI align hydrogen protons • MRI measures the signal produced when the hydrogen protons relax to realign to their normal state

15. Magnetic Resonance Imaging Advantages 9,10 • Provides long term prognostic information • Different techniques • More sensitive • Injuries are better detected Disadvantages 9 • Not as widely available as CT • Requires longer acquisition times • Higher sensitivity to patient motion

16. Functional MRI • Diffusion Tensor Imaging Specialized Magnetic Resonance Imaging

17. fMRI • Utilizes the blood flow to the brain to assess brain activity. • fMRI is a powerful tool to assess brain activity in concussed patients. Di Battista AP, Churchill N, Schweizer TA, et al. Blood biomarkers are associated with brain function and blood flow following sport concussion. J Neuroimmunol. 2018;319:1-8. Available from: Pub Med with Full Text, Accessed October 31, 2018

18. Specialized imaging that estimates the location, orientation, and gives measurement of the brain’s white matter tracts. DTI • “MR imaging technique that uses magnetic gradients to measure water diffusion in the brain, and in turn, brain microstructure” 13 • “Provides a highly sensitive window into tissue microstructure and changes in white matter, greatly improving understanding of the pathophysiology of mTBI.” 13 RESOLVE. Siemens Healthineers Global. https://www.healthcare.siemens.com/magnetic-resonance-imaging/options-and-upgrades/clinical-applications/syngo-resolve. Published 2018. Accessed November 28, 2018

19. “Computed Tomography is primary for TBIs...4 • CT Advantages: 9 • Widely available • Rapid evaluation • Compatible with medical and life support devices • No screening Imaging in mTBI’s Current Protocols • Not imaging based • Mainly palliative care, based on symptoms and signs • Less stimuli prevents symptoms from worsening

20. ...but does not provide long term prognostic information.” 4 • CT Disadvantages: 9 • Ionizing radiation • Increased efforts to reduce the amount of non indicated scans • No long term prognostic information Imaging in mTBI’s Current Issues

21. Initial assessment: • Some patients may have little to no signs • Many patients do not seek further assessment • Further assessment: • Decreased use of non-indicated scans for mTBI’s • Many patients are non-indicated • Follow up treatment and preventative measures are often not taken • Lack of proper diagnosis can lead to severe long term effects Imaging in mTBI’s “It is presently unknown whether these subjective measures [symptom based] are associated with reliable, objective measures of brain physiology” 3 More Issues

22. mTBIprotocols should include imaging • Diagnose patients with varied signs and symptoms • Prevent long-term effects • Provide a diagnosis-based approach vs. symptom-based approach Imaging in mTBI’s Proposed Solutions

23. Conclusions MRI is superior to CT when imaging for mTBI’s • MRI scans soft tissue with better detail • Provides long-term prognostic information • Allows for specialized imaging • Does not have Ionizing radiation

24. Bibliography 1. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology.2013;80(24):2250-2257. Available from: Pub Med with Full Text, Accessed October 31, 2018 2. Signs and symptoms of concussion. Queensland Brain Institute. https://qbi.uq.edu.au/concussion/signs-and-symptoms-concussion. Published May 16, 2018. Accessed November 28, 2018. 3. Churchill NW, Hutchison MG, Graham SJ, Schweizer TA. Connectomic markers of symptom severity in sport-related concussion: Whole-brain analysis of resting-state fMRI. Neuroimage Clin. 2018;18:518-526. Available from: Pub Med with Full Text, Accessed October 31, 2018 4. Wu X, Kirov II, Gonen O, Ge Y, Grossman RI, Lui YW. MR Imaging Applications in Mild Traumatic Brain Injury: An Imaging Update. Radiology. 2016;279:693-707. Available from: Pub Med with Full Text, Accessed October 31, 2018 5. Hasan KM, Keser Z, Schulz PE, Wilde EA. Multimodal Advanced Imaging for Concussion. Neuroimaging Clin N Am. 2018;28:31-42. Available from: Pub Med with Full Text, Accessed October 31, 2018 6. Wing BH, Tucker BJ, Fong AK, Allen MD. Developing the Standard of Care for Post-Concussion Treatment: Neuroimaging-Guided Rehabilitation of Neurovascular Coupling. Open Neuroimag J. 2017;11:58-71. Available from: Pub Med with Full Text, Accessed October 31, 2018

25. Bibliography 7. Simple Sideline Evaluation For Concussion. Sideline Sports Doc. https://www.sidelinesportsdoc.com/simple-sideline-evaluation-for-concussion/. Published September 4, 2012. Accessed November 28, 2018 8.gov NIBIB. How Does an MRI Scan Work? YouTube. https://www.youtube.com/watch?v=1CGzk-nV06g. Published April 16, 2013. Accessed November 28, 2018 9. Useche JN, Bermudez S. Conventional Computed Tomography and Magnetic Resonance in Brain Concussion. Neuroimaging Clin N Am. 2018;28:15-29. Available from: Pub Med with Full Text, Accessed October 31, 2018 10. Functional magnetic resonance imaging. NeuroImage. https://www.sciencedirect.com/topics/medicine-and-dentistry/functional-magnetic-resonance-imaging. Published 2018. Accessed November 28, 2018 11. Di Battista AP, Churchill N, Schweizer TA, et al. Blood biomarkers are associated with brain function and blood flow following sport concussion. J Neuroimmunol. 2018;319:1-8. Available from: Pub Med with Full Text, Accessed October 31, 2018 12. RESOLVE. Siemens Healthineers Global. https://www.healthcare.siemens.com/magnetic-resonance-imaging/options-and-upgrades/clinical-applications/syngo-resolve. Published 2018. Accessed November 28, 2018 13. Weber AM, Torres C, Rauscher A. Imaging the Role of Myelin in Concussion. Neuroimaging Clin N Am. 2018;28:83-90. Available from: Pub Med with Full Text, Accessed October 31, 2018

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