Traumatic Brain Injury Diagnostic Challenges & - PowerPoint Presentation

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Traumatic Brain Injury Diagnostic Challenges &Emerging Tools

Julie C. Chapman, PsyD

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VA/DOD Definition of TBIA traumatically induced structural injury AND/ORphysiologic disruption of brain function as a result of an external force

that is indicated by new onset or worsening ofat least one of the following clinical signs immediately following the event

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VA/DOD Definition of TBIAt least one of the following clinical signs immediately following the event:Any period of loss of consciousnessAny loss of memory for events immediately before or after injuryAny alteration in mental state at the time of injury

Neurologic deficitsIntracranial lesion

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How is TBI Diagnosed?2nd Level TBI Evaluation:InterviewPhysical ExaminationNeurobehavioral Symptom InventoryTBI is often retrospectively diagnosed

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Severity of InjuryThree main indices:Duration of Loss of Consciousness (LOC) or Alteration of Consciousness (AOC)Post-Traumatic Amnesia (PTA)Glasgow Coma Scale (GCS)

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Severity of Injury (VA/DOD)

Criteria

Mild

Moderate

Severe

LOC

0 - 30

mins

31

mins

- 24 hrs

>24 hours

AOC

Moment - 24 hrs

>24 hours. Severity based on other criteria

PTA

0 - 1 Day

2 – 7 Days

>7 Days

GCS

13 - 15

9 – 12

<9

Structural

Imaging

Normal

Normal or Abnormal

Normal or Abnormal

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Diagnostic ChallengesDiagnostic criteria is based largely upon patient self-report, particularly in mild TBI. Possible threats to diagnostic accuracy:Recall biasCognitive difficulties

Other factors

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Diagnostic ChallengesOverlap of symptoms in co-morbid conditions:Hoge et al. StudySchneiderman et al. Study

RAND Study

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Symptom OverlapTBIInsomnia

Memory ProblemsPoor concentrationDepressionAnxiety

Irritability

Headache

Dizziness

Fatigue

Noise/light intolerance

PTSD

Insomnia

Memory problems

Poor concentration

Depression

Anxiety

Irritability

Re-experiencing

Avoidance

Emotional numbing

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Seeking Objective MarkersBiomarkersBrain ImagingNeurobehavioral Measures

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BiomarkersS-100BCalcium binding protein found in astroglial and Schwann cellsSensitive but not specific for brain injury

Others:GFAP = Glial

Fibrillary

Acidic Protein

MBP = Myelin Basic Protein

NSE= Neuron Specific

Enolase

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Diffusion Tensor ImagingMeasures the movement of water molecules in neurons.Diffusion is an intrinsic physical process independent of the MR effect & magnetic field.White matter tracts can be visualized and estimated in vivo.

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Diffusion Tensor ImagingLipton et al. 2009 - 20 pts (2 wks post mTBI), 20 matched controls. Reduced FA in frontal WM correlated with executive function tests (IntegNeuro

: CPT & EMT).Niogi et al. 2008 - 43 patients (16.9

mths

post

mTBI

) and 23 controls.

Attentional

control correlated with FA in L corona

radiata

. Memory performance correlated with FA in

uncinate

fasciculus.

Rutgers et al. 2008 - 21 patients (5.5

mths

post

mTBI

) and 11 controls.

mTBI

had reduced FA in cerebral lobar WM,

cingulum

and corpus

callosum

.

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Blast Injury Outcomes (BIO) StudySample of OEF/OIF Veterans and Controls with:No prior TBI (even mild)No current or recent or chronic substance abuse or dependenceAll OEF/OIF Veterans have

Mild TBI from blast exposure and/orCombat-related PTSD

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Blast Injury Outcomes (BIO) Study - Chapman

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Blast Injury Outcomes (BIO) Study-Chapman

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Neurobehavioral MeasuresHeitger et al. 2009: Antisaccades and visual tracking more impaired in patients with post-concussive syndrome at avg

of 140 days post-injury than controlsWortzel et al. 2009: Presence of frontal release signs plus

paratonia

predicted cognitive and functional impairment in a acute TBI.

Chapman et al. 2010: Presence of visual tracking, frontal release signs and

antisaccades

predicted

mTBI

versus No TBI group.

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Integrative DiagnosticsPatient Self-Report

Objective Diagnostic Markers

GESTALT

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All Hands on Deck

Epidemiology

Clinical Science

Laboratory Science

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Integrative Diagnostics

Clinical Algorithms

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Markers for the Identification, Norming & Differentiation (MIND) of TBI and PTSDPrincipal Investigator: Julie C. Chapman, PsyD

Study Chair and Co-PI: Aaron Schneiderman, PhD

Tri-WRIISC Study (DC, East Orange, Palo Alto)

Clinical Research Evaluation of OEF/OIF Veterans from the Epidemiological Study

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Markers for the Identification, Norming & Differentiation of TBI and PTSD (MIND)

Four groups of OEF/OIF Veterans studied (total n=800): Veterans with TBIVeterans with PTSD

Veterans with both TBI and PTSD

Veterans with neither TBI nor PTSD

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Phase One AimsMIND StudyAim 1: To validate the prevalence estimate of TBI and PTSD in OEF/OIF Veterans from the Epidemiological Study.Aim 2: To assess the effectiveness of VHA screening instruments for TBI and PTSD in OEF/OIF Veterans.

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Phase Two AimsMIND StudyAim 1: To identify sensitive & specific markers for both conditions from each measurement modality.

Aim 2: To develop prediction models for both conditions using multi-system, objective measures and patient self-report. Measures include:

Cognitive

Sensorimotor

Advanced

Neuroimaging

Sleep

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Phase Three AimsMIND StudyAim 1: To identify sensitive & specific markers for TBI from each measurement modality.Aim 2: To develop prediction models for TBI using multi-system, objective measures and patient self-report.

Measures include:Neuroendocrine

Sleep Medicine

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Contact UsADDRESS: Veterans Affairs Medical CenterMS 127Washington, DC 20422

PHONE: (202) 745-8249

EMAIL:

Julie.Chapman@va.gov

VISIT OUR WEBSITE:

www.warrelatedillness.va.gov/dc/