Understanding Traumatic Brain Injury. Andrew Baker, MD Chief, Department of Critical Care St. Michael s Hospital

Size: px

Start display at page:

Download "Understanding Traumatic Brain Injury. Andrew Baker, MD Chief, Department of Critical Care St. Michael s Hospital"

Gillian Adams
5 years ago
Views:

1 Understanding Traumatic Brain Injury Andrew Baker, MD Chief, Department of Critical Care St. Michael s Hospital

2 Current approaches to TBI GCS defines mild moderate or severe Combined with age, maps onto GOS or GOSE Scan for hematomas that can be removed Supportive ICU care Treat ICP and maybe CPP mtbi treated with rest

3 Parallels to modern approach to disease Multifactorial determinants of disease premorbid, pathophysiologic and resilience Anatomic, physiologic, metabolic, immunologic / cytology and genetic taxonomy Validated functional patient-centred outcome measures

4 Diagnosis Treatment Outcome Accurate classification Targeted interventions Relevant improved outcomes

5 Premorbid Genetic Socioeconomic Prior injury Mental health Markers of resilience immunologic phenotypes

7 Park, Bell and Baker, CMAJ

12 mtbi 6 months later only 38% described in best outcome category 3 months later 27% meet DSM IV PTSD criteria

13 J Head Trauma Rehabil Copyright c 2012 Wolters Kluwer Health Lippincott Williams & Wilkins Is Rest After Concussion The Best Medicine? : Recommendations for Activity Resumption Following Concussion in Athletes, Civilians, and Military Service Members Noah D. Silverberg, PhD; Grant L. Iverson, PhD Practice guidelines universally recommend an initial period of rest for people who sustain a sports-related concussion or mild traumatic brain injury (MTBI) in daily life or military service. This practice is difficult to reconcile with the compelling evidence that other health conditions can be worsened by inactivity and improved by early mobilization and exercise. We review the scientific basis for the recommendation to rest after MTBI, the challenges and potential unintended negative consequences of implementing it, and how patient management could be improved by refining it. The best available evidence suggests that complete rest exceeding 3 days is probably not helpful, gradual resumption of pre-injury activities should begin as soon as tolerated (with the exception of activities that have a high MTBI exposure risk), and supervised exercise may benefit patients with persistent symptoms Key words: brain injury, concussion, exercise, military, sports Author Affiliations: GFStrong Rehab Centre&Department of Medicine, Division of Physical Medicine&Rehabilitation (Dr Silverberg) and Department of Psychiatry (Dr Iverson), University of British Columbia, Vancouver, British Columbia, Canada; and Defense and Veterans Brain Injury Center, Washington DC (Dr Iverson).

14 Missed injury mtbi in Multi-system Trauma 69 Non-head injured trauma patients at SMH Those with low Montreal Cognitive Assessment score at discharge had high Post- Concussion Symptom Scale scores at 3 months High rate of elevated PCSS in CT- and no-ct groups

18 Tate, 2012

26 Targeted Therapies: Pre-clinical work Precondtioning Cytoskeleton Progenitor Cell therapy High through put drug re-purposing

28 Is there an underlying physiological basis for mtbi/ptsd comorbidities?

29 Modulation of behavioural deficits through pharmacology

30 b-app b-app b-app Reduction in axon pathology in vivo following postinjury EPC administration. Sham+EPC FPI+vehicle FPI+EPC

32 Clearly visible white matter tracts Zebrafishbrain.org

33 Lithotripsy/Histotripsy Technology (Human) IED (25 mm to 160 mm converted munitions) Standoff distance: ~5-10 m Shockwave duration 4-10 ms. Amplitude kpa (Rat)Baker Lab Shock tube device: Standoff distance: ~10-20 cm Shockwave duration: µsec duration. Amplitude kpa. (Zebrafish) Piezoelectric HF device: Standoff distance: 5-10 cm, 2-6 µsec duration. Amplitude???

34 (Bai et al., Biochim Biophs Acta, 2011)

35 Identifying susceptible targets with mammalian homologues 24 hours post injury Nf 160 GAPDH Neurofilament (nf) 160 Medium neurofilament protein (160kD) Β-III tubulin Microtubule protein found exclusively in neurons Cleaved caspase-3 Activated form of apoptotic protein

36 Behavioural correlates to mtbi

37 Targeted Diagnostics and Therapies: Clinical work Urgent Care Clinic PTSD and Biomarkers Missed injuries

39 PCSS Score 45 Post-Concussive Symptom Score over Time by Baseline CT Scan Status Baseline 3 Months CT+ CT- No CT Baseline CT Scan Status

40 Take Home Messages Newer ways to classify TBI TCDB IMPACT TRACK-TBI Multiple mechanisms relevant Precision targeted therapy is relevant (coming soon) Imaging improvements will soon lead to even more specific classification, targeted therapy and prognostication Mild TBI may be not so mild, and may be easily missed

Mild Traumatic Brain Injury in Sports, Daily Life, and Military Service

Mild Traumatic Brain Injury in Sports, Daily Life, and Military Service Grant L. Iverson, Ph.D. Professor, Department of Physical Medicine and Rehabilitation, Harvard Medical School; Director, MassGeneral