Advanced MRI scans help identify one in three concussion patients with ‘hidden disease’

Advanced MRI scans help identify one in three concussion patients with 'hidden disease'

Whole-brain diffusion tensor tractography in a peer control group and two serial patients approximately two days, six weeks, and one year after severe traumatic brain injury. By: Newcombe et al. Neurorehab Neuro Repair 2016;30(1):49-62. Credit: Virginia Newcombe/University of Cambridge

Offering a type of brain scan known as diffusion tensor imaging MRI to concussion patients could help identify the one in three people who experience persistent symptoms that can change their lives, according to Cambridge researchers.

Around one in 200 people in Europe suffer a concussion each year. In the UK, more than 1 million people present to emergency departments each year with a recent head injury. It is the most common type of brain injury worldwide.

When a patient in the UK presents to an emergency department with a head injury, they are assessed according to the NICE guidelines for head injuries. Depending on their symptoms, they may be referred for a CT scan, which looks for brain damage including bruising, bleeding and swelling.

However, CT scans identify abnormalities in less than one in ten concussion patients, but 30-40% of patients discharged from the emergency department after a scan experience significant symptoms that can last for years and can be potentially life-changing. These include severe fatigue, poor memory, headaches and mental health problems (including anxiety, depression and post-traumatic stress).

Dr Virginia Newcombe, from the University of Cambridge’s Department of Medicine and an Intensive Care and Emergency physician at Addenbrooke’s Hospital, Cambridge, said: “Most patients with head injuries are given a note to take home telling them what symptoms of concussion to look out for and to seek help from their GP if symptoms get worse.

“The problem is that the nature of concussions means that patients and their GPs often fail to recognise that their symptoms are severe enough to require further investigation. Patients describe it as a ‘hidden illness’, unlike, say, breaking a bone. Without objective evidence of a brain injury, such as a scan, these patients often feel that their symptoms are being ignored or dismissed when they seek help.”

In a study published today in eClinical MedicineDr. Newcombe and colleagues show that an advanced form of MRI known as diffusion tensor imaging (DTI) can significantly improve existing prognostic models for concussed patients who have normal CT scans of the brain.

DTI measures how water molecules move through tissue, providing detailed images of the pathways, known as white matter tracts, that connect different parts of the brain. Standard MRI scanners can be modified to measure this data, which can be used to calculate a DTI “score” based on how many different brain regions show abnormalities.

Dr. Newcombe and colleagues examined data from more than 1,000 patients who took part in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study between December 2014 and December 2017. Thirty-eight percent of patients had an incomplete recovery, meaning their symptoms were still present three months after discharge.

The team assigned DTI scores to the 153 patients who had undergone DTI scanning. This significantly improved the accuracy of the prognosis; while the current clinical model would correctly predict that a patient would have a worse outcome in 69 out of 100 cases, DTI increased this to 82 out of 100 cases.

The researchers also looked at blood biomarkers (proteins released into the blood as a result of head injury) to see if any of these could improve the accuracy of the prognosis. While the biomarkers alone were not enough, levels of two specific proteins (glial fibrillary acidic protein (GFAP) within the first 12 hours and neurofilament light (NFL) between 12 and 24 hours after injury) were useful in identifying which patients might benefit from a DTI scan.

Dr Newcombe said: “Concussion is the most common neurological condition in adults, but health services do not have the resources to routinely bring every patient back for follow-up. That’s why we need a way to identify those patients who are most at risk of persistent symptoms.

“Current methods of assessing someone’s prognosis after a head injury are not good enough, but the use of DTI—which in theory should be possible for any center with an MRI scanner—could help us make much more accurate assessments. Given that concussion symptoms can have a significant impact on someone’s life, this is urgently needed.”

The team plans to look at blood biomarkers in more detail, to see if they can identify new ways to provide even simpler, more practical predictors. They will also explore ways to bring DTI into clinical practice.

Dr Sophie Richter, NIHR clinical lecturer in emergency medicine and first author of the study from Cambridge, added: “We want to see if there is a way to integrate the different types of information obtained when a patient presents to hospital with a brain injury – assessment of symptoms, blood tests and brain scans, for example – to improve our assessment of a patient’s injury and prognosis.”

More information:
Predicting recovery in patients with mild traumatic brain injury and normal CT using serum biomarkers and diffusion tensor imaging (CENTER-TBI): an observational cohort study, Eclinical medicine (2024). DOI: 10.1016/j.eclinm.2024.102751

Provided by the University of Cambridge


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