EinsteinTBii

Saeed Fakhran, MD will present "Anatomic-Pathologic Correlation of White Matter Injuries Underlying Symptoms".

Saeed Fakhran, MD | Traumatic Brain Injury Interdisciplinary Symposium 2015 Dr. Fakhran is an Assistant Professor of Radiology at the University of Pittsburgh School of Medicine. Dr. Fakhran graduated with a BA in Foreign Affairs from the University of Virginia. He completed a medicine internship at the University of Hawaii in Honolulu, Hawaii. He then completed a radiology…

Dr. Saeed Fakhran is an author of the study featured at the blog-post.

Studies Point to Quantitative, Prognostic Role for Imaging in Head Injury Radiology can play an integral role in diagnosing mild traumatic brain injury (mTBI) and predicting outcomes for patients who have suffered concussions, according to studies presented at RSNA 2014.

Fascinating dark story of frontal lobe damage from first, second and third person perspectives.

Spalding Gray’s Catastrophe A car crash, a brain injury, and an actor's decline.

Stewart L. Cohen, Esq will present "Duties and Responsibilities of Counsel for a Brain Injured Client" in the Ethics and Law Session.

Stewart L. Cohen, Esq | Traumatic Brain Injury Interdisciplinary Symposium 2015 Whether in the courtroom or the community, Stewart L. Cohen has worked relentlessly as an advocate on behalf of his clients for over thirty seven years. Mr. Cohen is a shareholder in the firm of Cohen, Placitella & Roth, P.C. with offices throughout Pennsylvania and New Jersey, and he focuses his pr…

Discuss these issues with the leading experts .Next week!

Professor Nita Farahany on the ethical implications of neuroscience for the law Renown academic and presidential advisor Nita Farahany recently spoke with BioEdge about neuroscience and the law.

Following commentary yesterday, check out :

Brain death declaration (1) Journal of the American Statistical Association, Associate Editor (since 2014) (2) International Journal of Biostatistics, Associate Editor (since 2013)

Dr. Geoffrey Aguirre will present "The Elusive Neuroimaging Marker of Mild Traumatic Brain Injury" in the Ethics and Law Session, moderated by Dr. Daniel Eisenberg.

Geoffrey K. Aguirre MD, PhD | Traumatic Brain Injury Interdisciplinary Symposium 2015 Dr. Aguirre is the Associate Director of the Penn Center for Neuroscience and Society, Associate Professor of Neurology and Assistant Director of the Neurology Residency Program at the University of Pennsylvania. He is a neurologist and cognitive neuroscientist whose clinical and research work conce…

Dr. Daniel Eisenberg, medical ethicist, briefly renders his opinion on the limitations and potential complications of utilizing current neuroscience knowledge and tools (eg. tests, procedures, life-sustaining treatments) in the ethical decision making processes for brain injured patients:

While level of consciousness may be evaluated clinically, and degree of brain activity measured, the significance of consciousness remains an ethical determination, not a medical one. That is, while based on current science we can prognosticate as to patient prognosis based on clinical and exam and medical testing, there will always be a margin of error. There is a risk that data generated by medical means will be misinterpreted by medical professionals and laypeople alike as representing a statement of meaning, rather than information that must be utilized within an ethical system to decide appropriate patient care.

Even “brain death,” better described as neurological criteria for death, only describes a physiologic state, but cannot intrinsically define death. Death definition takes into account medical data, but has a wider societal context in which it exists. All measurements of consciousness and objective brain function must be taken into account when deciding on patient care and determination of death, but we must remember that the value of life and level of consciousness are not necessarily synonymous as the national battle during the Terri Schiavo episode demonstrated to the entire nation a decade ago. While on the surface that struggle seemed to involve a question of prognosis and rehabilitation, the underlying religious and moral interpretation of consciousness was a driving force in the national and legal debate.

Neuroscience meets psychiatry meets medicine meets surgery - and more- at
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Therapies Based on Latest Cognitive Neuroscience Research Needed for TBI Patients A new study reports many of those with TBI are not benefiting from recent cognitive neurosciense research and findings.

The Remarkable Change in Psychiatry Today I wish to write about the sister field of neurology: psychiatry. I base my comments on two recent writings: “What Has Neuroscience Ever Done for Us?” by Jonathan Roiser and the book, Shrinks: The Untold Story of Psychiatry, by Jeffrey Lieberman, M.D., the chairman of psychiatry at Columbia Uni…

In 2 weeks!
You will have the chance to interact with Dr. Smith, founder of the Smith Neurotrauma Lab at UPenn, whose research focus includes neurodegeneration.

Douglas Smith, MD | Traumatic Brain Injury Interdisciplinary Symposium 2015 Prof. Douglas H. Smith, M.D. serves as Director of the Center for Brain Injury and Repair (CBIR) and is the Robert A. Groff Endowed Professor and Vice Chairman for Research and Education in Neurosurgery at the University of Pennsylvania. Penn’s multidisciplinary CBIR includes over twenty-five princ…

Diminished brain resilience syndrome: A modern day neurological pathology of increased... Surg Neurol Int. 2014 Jun 18;5:97. doi: 10.4103/2152-7806.134731. eCollection 2014. Review

Researchers see promise in treatment to reduce incidence of dementia after TBI Researchers at the University of Kentucky's Sanders-Brown Center on Aging have been attempting to understand the cascade of events following mild head injury that may lead to an increased risk for developing a progressive degenerative brain disease, and their new study, which was published in the cu…

Federal judge approves NFL concussion settlement A federal judge on Monday granted preliminary approval to a landmark deal that would compensate thousands of former NFL players for concussion-related claims.

Explore further on May 14th.

Thomas Watanabe, MD | Traumatic Brain Injury Interdisciplinary Symposium 2015 Dr. Watanabe is the clinical director of the Drucker Brain Injury Center at MossRehab in Philadelphia, PA. He is actively involved in inpatient and outpatient clinical care as well as research and training of resident physicians and medical students. He has lectured extensively at local, national an…

How can we predict outcomes in TBI?
A brief recap from Dr Marino at the Drucker Brain Injury Center at MossRehab:

"Best predictors for recovery of consciousness and functional outcome at 4 months include:

- Time from injury to initial rehab evaluation
- Initial DRS (disability rating scale) level
- Rate of early recovery

fMRI evidence of auditory processing to higher levels of sound and speech predicts better outcome on DRS at 6 months.

Duration of resolution of minimally conscious state is the biggest predictor of posttraumatic amnesia emergence.

One study (Fischer et al) found that coma patients with cognitive evoked potentials did not remain vegetative.

On imaging, patients not conscious at 12 months have higher rates of callosal, corona radiata and dorsolateral brainstem lesions."

How does neuroimaging correlate with clinical outcomes in TBI?

Dr. Joyce Li, EinsteinTBii moderator, comments:

"It depends. Although MRI is more sensitive than CT in detection of subtle intracranial hemorrhages (10-20% more), it has not been established whether finding the additional lesions would significantly change acute management of head trauma. Nonspecific white matter changes and chronic microhemorrhages can also be unrelated to trauma. SPECT and PET are more sensitive for changes in CBF and glucose metabolism in mild TBI patients and are useful for predicting neuropsychologic outcome of patients, but the abnormality seen on SPECT and PET are often larger than the anatomic abnormality and may be remote from the site of injury and therefore may be difficult to interpret. However, in general, neuroimaging is helpful and important in determining clinical outcome."

http://www.natlawreview.com/article/accelerated-atrophy-brain-following-traumatic-brain-injury

Accelerated Atrophy of the Brain Following Traumatic Brain Injury | The National Law Review A new study published in the Annals of Neurology has found that TBI patients’ brains were estimated to be older than their chronological age, “suggesting that TBI accelerates the rate of b

http://www.npr.org/blogs/health/2015/04/13/397044990/i-learned-the-hard-way-that-concussion-isnt-just-for-the-young

I Learned The Hard Way That Concussion Isn't Just For The Young We hear a lot about concussion and kids, but older adults are even more vulnerable to traumatic brain injury. A slip in the kitchen leads one man down the rabbit hole with no clear path out.

Meet Helen Ross-Lee. A Registered Nurse in Queensland, Australia and mother of two, she suffered severe TBI from an accident in a hang-gliding competition.

The Phoenix Rising A brief look at the inspiring life of Helen Ross Lee, from world renowned Hang Glider pilot to tenacious surviver of a traumatic brain injury.

IBRO | 10th IBRO/Kemali Prize - Call for Nominations The Tenth International Prize of 25,000 Euros will be awarded in 2015 by the IBRO-Dargut & Milena Kemali Foundation to a scientist less than 45 years of age on December 31, 2014 who has made outstanding contributions to Basic or Clinical Neuroscience.Nominations in electronic format should be submi…

A braintickling debate:

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In a patient with brain injury, altered states of consciousness can be expected, ranging from mild cognitive disability to coma. Moreover, a patient can transition from one altered state of state of consciousness to another.

Are there ethical boundaries and/or protocols established for patients with impaired consciousness and impaired executive functioning? What are the rights of these patients? Are the rights stratified/classified according to the level of impairment? Are there specific ethical assessment tools? What about the case of reversible consciousness/decision making capacity?

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Dr. Daniel Eisenberg, medical ethicist and moderator for Einstein TBii, responds:

"From a medical perspective one of the basic questions raised by traumatic brain injury is what role cognition should play in planning supportive treatment. In other areas of medicine, it is not the irreversibility of the condition, but pain or suffering that guide supportive care. Disability is only important because of secondary poor quality of a patient’s life as determined by the patient him/herself. We would not unilaterally decide that impairment of the knee joint represents a poor quality of life for which treatment should be withheld or altered.

Cognitive impairment only limits the ability of the provider to determine the wishes of the patient. In and of itself, cognition is not a determinant of life, nor is it an intrinsic barometer of quality of life. While the observer may suffer observing the patient in a persistent vegetative state (because the observer imagining himself lacking cognition is a very jarring thought), it is not clear that the patient himself is suffering.

Over a decade ago, the case of Terri Schiavo brought this issue to the forefront of national debate, involving the governor of Florida, the legislature, the President of the United States, and various courts, including the court of public opinion. She was not brain dead nor was she terminally ill. She had undergone anoxic brain injury and remained in what appeared to be a persistent vegetative state. All of her bodily functions are essentially normal, but she lacks the ability to "meaningfully" interact with the outside world, although her parents claimed that she does minimally responded to their presence and to outside stimuli. The difficulty of accurately determining the degree of impairment is the first hurdle that must be surmounted before any meaningful discussion of prognosis and treatment can be expected.
A legal tug of war ensued pitting her parents who desired continued treatment and “rehabilitation” against her husband who wanted her feeding tube removed which would inevitably lead to her death. Public debate was hot and heavy, with extreme polarization of public opinion.

The main issues involved in the case were: a ) who has a right to speak for the cognitively impaired when they have left no instructions, b) what role does cognition play in determining quality of life, and c) what intrinsic rights do cognitively impaired patients have to life, despite their disability?

Despite the answers to questions a and b, it seems clear to me that the rights of every patient must be protected regardless of their cognitive status, independent of the level of their impairment. That is, the humanity of the patient is not diminished by diminished cognition. That is not to say that the level of cognition should have no role in patient management. It merely means that the interests of the patient remain intact despite their cognition not remaining so. An honest assessment of pain and suffering requires taking the needs of the patient into account, not our own.
We must ask ourselves when we view images of cognitively impaired patients such as Terri Schiavo whether the pain that we feel is Terri's or whether it is our own. While we may suffer watching movies of the severely brain damaged, it is our own thoughts of the horror of a life without cognition that drives us to project that pain onto the victim who may not be suffering at all. The value of life does not intrinsically change due to illness, but the patient’s reaction to their illness may impact on decision-making."

Join the debate with your thoughtful comments now.

More to follow - A world to explore on May 14th.

What are the disorders of consciousness?

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Dr Michael Marino of MossRehab explains them clinically:

I. Coma

Absence of sleep wake cycles, eyes remain closed
Absence of spontaneous and stimulus induced arousal
Typically self limited and resolves within two to four weeks

Pathophysiology :

1. Severe diffuse bihemispheric lesions of cortex
or white matter
2. Bilateral thalamic damage
3. Paramedian tegmental lesion

II. Vegetative State

VS is a transitional state between coma and minimally conscious state.

It is a disorder of cerebral integration at the thalamocortical level.

DAI is the most common pathophysiologic mechanism in traumatic VS.

Multi-Society Task Force stated that all of the following conditions must be present to diagnose VS:

1. Intermittent wakefulness manifested by sleep wake cycles (i.e. times during which the eyes are open – recovery of the reticular activating system)
2. No evidence of sustained reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli
3. No evidence of language comprehension or expression

Persistent VS : 4 weeks or greater, any cause

Permanent VS: Denotes a time point after which the probability
for recovery of consciousness is poor - 3 months or more after hypoxic-ischemic, metabolic, and congenital brain injuries and 12 months following a TBI

III. Minimally Conscious State

MCS is a condition of severely altered consciousness in that there is minimal but definite behavioral evidence of conscious awareness.

There is greater sparing of the corticothalamic connections, therefore retained cognitive processing.

Diagnosis requires at least one of the following:

1. Simple command following
2. Intelligible verbalization
3. Recognizable verbal or gestural “yes/no” responses
4. Movements or emotional responses triggered by relevant environmental stimuli that cannot be attributed to reflexive activity

Pathophysiology:

• Grade 2 or 3 DAI with multifocal cortical contusions
[ Grade 1 – gray white matter junction ; Grade 2 – corpus callosum; Grade 3 – brainstem ]

• Sometimes thalamic injury

Signs of emergence (must be consistent) include functional communication and object use.

What are the structural, functional and molecular neuroimaging tools/techniques (eg. CT, MRI, PET, SPECT, MEG, fMRI, DTI, DKI) for TBI?

Dr. Joyce Li from Einstein Healthcare Network, moderator for EinsteinTBII, elucidates:

"
Diagnosis

Imaging is not required for diagnosis of TBI, especially for minor head injury. CT is the initial imaging modality of choice during the first 24 hours after injury and is better than MR is identifying subarachnoid hemorrhage and fractures. Anatomic imaging with MRI is very sensitive for subtle pathology and intracranial TBI, especially 48-72 hours after injury. Intracranial blood products become more detectable over time on MR.

Identifying the mechanisms and extent of injury

The mechanism of injury is more of a clinical diagnosis. Although CT can identify a fair amount of clinically significant intracranial hemorrhage, it tends to underestimate the extent of TBI and CT findings may lag behind actual intracranial damage. MR 2-3 days after initial injury is more sensitive to intracranial blood products, with better identification of cortical contusions, microhemorrhage, and foci of shear injury/diffuse axonal injury. MRI is also better at evaluation of the brainstem and deep gray structures than CT. Some newer MR techniques such as magnetization transfer imaging, magnetoencephalography, and MR spectroscopy also show promise in increased sensitivity for extent of intracranial injury, but are not readily available in most centers. Functional MRI can demonstrate changes in regional brain activation in patient with mild TBI but no other imaging findings, but also has limited availability, especially in the acute setting.

Prognosis and clinical outcomes

Most of the acute management is administered based on clinical data and CT findings. MRI may offer a better understanding of the mechanisms of secondary injury in brain trauma and can lead to preventative or preemptive treatment in the acute setting. DTI can detect white matter abnormality and can measure structural integrity of tissue, therefore assess the degree of axonal injury and probability or meaningful recovery in a patient with DAI. MR spectroscopy with lower NAA to creatinine also is indicative of neural injury and correlate with poorer clinical outcome. Functional MRI found persistent changes in the brain activation patterns of mild TBI patient compared with controls when given various working memory tasks. PET and SPECT in the non-emergent setting in conjunction with anatomic imaging are useful in guiding long-term therapy by helping establish a patient’s long-term prognosis as they detect abnormality in cerebral blood flow and glucose metabolism respectively, which may be indicators of neuropsychologic deficits.

Treatment administration

CT and MR in the acute to early subacute setting remain the studies of choice for clinical decision making and treatment administration. Also, imaging helps in identifying mechanism of secondary injury in TBI and potentially identifying targets of new therapies. New targets of inflammatory cascades can be found which can cause further tissue damage with the help of neuroimaging such as PET, functional MR, MR spectroscopy, and SPECT can help the development of target therapy and measure the outcome of therapy such as measuring improvement in cerebral blood flow associated with hyperbaric oxygen therapy and herventilation therapy in TBI patients.

Treatment surveillance

CT remains important in the initial follow-ups of hemorrhage, fractures, cerebral edema, and infarct as well as complications. MRI in the subacute to chronic setting better detects chronic blood products. MR spectroscopy, PET, and SPECT can assess for recovery of mild TBI with improvement and normalization of NAA/Cr ratio, glucose-metabolism, and cerebral blood flow."

Thoughts?

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How do you clinically define reversibility and irreversibility in TBI?
How does this tie to the spectrum of the severity and types of brain injuries?

Dr. Michael Marino of MossRehab, moderator for EinsteinTBII explains:

"There are many factors that go into predicting outcome, which ties into reversibility, but overall our ability to predict long term outcome is poor. Often it is a matter of allowing the brain time to heal and following a patient clinically to track the rate of change. There are a few threshold values that can strongly predict long term outcome using the Glasgow Outcome Scale

Severe Disability on GOS is unlikely if:
-Time to follow commands is less than 2 weeks
-Duration of Post Traumatic Amnesia (PTA) is less than 2 months

Good Recovery on GOS is unlikely if:
-Time to follow commands is longer than 1 month
-Duration of PTA is greater than 3 months
-Age is greater than 65 years and patient has a Severe injury (based on GCS, duration of LOC, duration PTA)

The above information applies to traumatic injuries only and has little direct correlation to type of injury (i.e. SAH, SDH, EDH, DAI, etc.)."

Stay tuned. More to follow.
What is your clinical experience as it relates to the potential reversibility of the condition?

See TBI through the experience of a multi-talented teenager on this beautiful short.

From Underneath the Rubble This is the story of my experience of a traumatic brain injury. This is also a submission to the 2015 Neuro Film Festival, so wish me luck if you could! This...

Neurotrauma 2015 Final Abstract Deadline is TODAY

Imaging Evidence and Recommendations for Traumatic Brain Injury: Advanced Neuro- and... SUMMARY: Neuroimaging plays a critical role in the evaluation of patients with traumatic brain injury, with NCCT as the first-line of imaging for patients with traumatic brain injury and MR imaging being recommended in specific settings. Advanced neuroimaging techniques, including MR imaging DTI, bl…

A Decade of DTI in Traumatic Brain Injury: 10 Years and 100 Articles Later SUMMARY: The past decade has seen an increase in the number of articles reporting the use of DTI to detect brain abnormalities in patients with traumatic brain injury. DTI is well-suited to the interrogation of white matter microstructure, the most important location of pathology in TBI. Additionall…