Trauma centres will begin testing a new approach for assessing traumatic brain injury (TBI) – that is hoped will ensure more accurate diagnoses and facilitate more appropriate treatment and follow-up for patients.
The new framework, which was developed by a coalition of experts and patients from 14 countries and spearheaded by the National Institutes of Health, expands the assessment beyond immediate clinical symptoms.
Added criteria includes biomarkers, CT and MRI scans, as well as factors such as other medical conditions and the circumstances surrounding the trauma.
The framework appears in Lancet Neurology.
For 51 years, trauma centres have used the Glasgow Coma Scale to assess patients with TBI, roughly dividing them into mild, moderate and severe categories.
This was based solely on their level of consciousness and a handful of other clinical symptoms.
That diagnosis determined the level of care patients received in the emergency department and afterwards.
For severe cases, it also influenced the guidance doctors gave the patients’ families, including recommendations around the removal of life support. Yet, doctors have long understood that these tests did not tell the whole story.
Corresponding author Geoffrey Manley, professor of neurosurgery at UC San Francisco and a member of the UCSF Weill Institute for Neurosciences, said: ‘There are patients diagnosed with concussion whose symptoms are dismissed and receive no follow-up because it’s “only” concussion, and they go on to live with debilitating symptoms that destroy their quality of life.
‘On the other hand, there are patients diagnosed with “severe” TBI, leading full lives, whose families had to consider removing life-sustaining treatment.’
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, said: ‘The proposed framework marks a major step forward. We will be much better equipped to match patients to treatments that give them the best chance of survival, recovery, and return to normal life function.’
The framework was led 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 on improving TBI characterisation.
The clinical pillar retains the Glasgow Coma Scale’s total score as a central element of the assessment, measuring consciousness along with pupil reactivity as an indication of brain function.
The framework recommends including the scale’s responses to eye, verbal and motor commands or stimuli, presence of amnesia and symptoms like headache, dizziness and noise sensitivity.
The second pillar of the framework uses blood biomarkers to provide clear indicators of tissue damage, helping to overcome the limitations of clinical assessments.
Geoffrey Manley said: ‘These biomarkers are crucial in clinical trials.’
Low levels of these biomarkers can help identify which patients don’t need CT scans, reducing unnecessary radiation exposure and healthcare costs.
For those with more severe injuries, CT and MRI scans are crucial for detecting issues such as blood clots and lesions. The framework also examines how the injury occurred and any pre-existing health conditions.
Dr Kristen Dams-O’Connor said: ‘One example is a patient with underlying cognitive impairment who may require acute monitoring for risk of clinical deterioration.’
This framework is being tested at trauma centres before full implementation.
