The topic of traumatic brain injuries (or TBI) has been rife in the press this year, with new guidelines, studies, initiatives and related advances in imaging equipment regularly popping up.

And it's no wonder: This is a major public health problem. The Centers for Disease Control and Prevention (CDC) estimate that every year, at least 3.8 million TBIs occur either as an isolated incident or along with other injuries. Additionally, TBI is a contributing factor to a third of all injury-related deaths in the United States. More than three-quarters of the TBIs that occur are concussions or other forms of mild TBI, many of which may go undiagnosed.

There are several reasons for this surge in interest, Dr. Thomas Hammeke, professor of psychiatry and behavioral medicine at the Medical College of Wisconsin, told DOTmed News.

These include: The revival of a previous diagnosis of dementia pugilistica (a neurodegenerative disease seen in boxers), renamed Chronic Traumatic Encephalopathy, raising the question of whether this syndrome can be attributed to multiple mild head injuries; and the NFL's acknowledgement of potential issues related to brain concussions.

"Perhaps precipitated by a lawsuit from retired players," said Hammeke.

Further, brain concussions seen in soldiers who fought or are still fighting in Iraq and Afghanistan have been identified from blasts as the "signature injury" from OEF/OIF operations, making this a priority interest in the military, according to Hammeke.

Research, diagnosis and treatment
Several big players in the medical imaging market have focused their efforts on this topic.

Most recently, Carestream Health has entered into a partnership with the Buffalo Bills, focusing on the need for new technology to help address key concerns in sports medicine, particularly those related to head injuries including: early diagnosis and accurate assessment of injured areas; development of medical standards that indicate if an athlete can return to play; and research that can assist in early diagnosis of long-term degenerative medical conditions in the head and brain.

The agreement builds on plans between Carestream and Johns Hopkins University for research and development of new systems for imaging of TBI to help improve the diagnosis and treatment of head injuries.

"[TBI] is clearly an area that can greatly benefit from advances in medical imaging technology," Jim Burns, Director, X-ray Solutions Advanced Development and Strategy for Carestream Health, told DOTmed News. "There is plenty of research underway to extend current imaging modalities, such as conventional CT and MRI."

Companies like Carestream are also developing new technologies, such as CBCT, to better diagnose and manage TBI.

"New diagnostic imaging technology may help improve the diagnosis and treatment of head injuries," Burns said. "With the prevalence and severity of TBI being a major concern in the medical community, our work can lead to create a system capable of detecting TBI at the point of care to more confidently diagnose brain injuries."

Meanwhile, in March, GE and the NFL announced the Head Health Initiative, a four-year, $60 million collaboration to speed diagnosis and improve treatment for mild traumatic brain injury. Guided by health care experts, the goal of the research and innovation program is to improve the safety of athletes, military members and society overall. In addition the NFL, GE and sporting apparel company Under Armour launched a two-year open innovation challenge to invest up to $20 million in research and technology to better understand, diagnose and protect against mild traumatic brain injury.

On the whole, there are several new imaging techniques being used on patients with concussions, according to Hammeke.

Diffusion tensor imaging holds promise for identifying white matter abnormalities that might be linked with brain concussion; while susceptibility-weighted imaging has promise in identifying microscopic traces of hemorrhage that can be associated with brain concussion, he said. Further, resting and activated functional MRI scans have promise in showing subtle residuals in functional abnormalities that may persist beyond any structural abnormalities.

"New technologies in brain imaging now enable better study of structural and functional changes in the brain associated with concussion," Hammeke said.

New findings
A new study, published in the September issue of the Journal of the International Neuropsychological Society, documents irregular brain activity within the first 24 hours of a concussive injury, as well as an increased level of brain activity weeks later. For the first time, the study, lead by Hammeke, found that the brain may compensate for the injury during recovery time. By utilizing functional MRI, decreased activity in select regions of the right hemisphere of the brain were highlighted, suggesting the poor cognitive performance of concussion patients is related to the underactivation of attentional brain circuits.

"There is a notion that, after a brain concussion, the brain is particularly vulnerable to the effects of a second concussion, which may disrupt the healing process of the first concussion," said Hammeke. "Defining this window of vulnerability after a concussion will be important to establishing effective public policies for managing concussions in sports, the military and general civilian circumstances."

This "window" has been broken down into varying time frames according to age and the severity of the injury, by new draft guidelines from the National Institute for Health and Care Excellence (NICE).

Children and adults with a potentially serious or life-threatening head injury should be administered a CT brain scan within one hour, while others should be scanned within four to eight hours of their injury depending on the injury, the new guidelines state. Currently, NICE suggests a time frame of eight hours for anyone to be scanned.

The new head injury guidelines are subject to review and are expected to be published in January 2014.

Guidelines are tightening in the sports world too. Because of recent evidence and attention given to brain concussions in sports, the NFL now mandates following a protocol of evaluation and treatment following any suspected brain concussion. For example, the NFL used to simply rely on the team physician to clear a player to return to the game. While the NFL has not fully solidified its protocol as yet, they have adopted a policy of requiring at least two professionals to provide clearance, one of whom is not affiliated with the team. Also, it is unlikely that any NFL players will continue to be released for play on the same day concussion occurs.

Preventive measures
A TBI can occur on the athletic field, battlefield, on the playground, in a car accident or even at home. And anyone involved in a physical work activity is at high risk of injury.

"The single most hazardous thing we do is get in an automobile," said Hammeke. "In football, there are strategies associated with avoiding head-to-head contact that will reduce concussions."

Wearing the proper protective headgear when playing contact sports is an obvious but important preventative measure, said Carestream's Burns. This is also true when working around the house or in a job that demands proper head protection.

"For example, if you are pruning a tree at home, wearing a hardhat is a smart choice," Burns said.

Although recent studies have uncovered more information about the effects of concussions on the brain, and there have been advances in imaging techniques for diagnosing and treating TBIs, vigilance for hazardous situations is optimal. Even with all of these efforts, considerable mystery still surrounds the total impact of a concussion on the brain and the prime way to treat it.