Mild Traumatic Brain Injury Grant L. Iverson, Ph.D. Professor, Department of Physical Medicine and Rehabilitation, Harvard Medical School; Director, MassGeneral Hospital for Children™ Sport Concussion Program; & Associate Director of the Traumatic Brain Injury Program, Home Base, Red Sox Foundation and Massachusetts General Hospital Trondheim, Norway May 4, 2017
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Mild Traumatic Brain Injury
Grant L. Iverson, Ph.D.
Professor, Department of Physical Medicine and Rehabilitation,
Harvard Medical School;
Director, MassGeneral Hospital for Children™ Sport Concussion Program; &
Associate Director of the Traumatic Brain Injury Program,
Home Base, Red Sox Foundation and Massachusetts General Hospital
Trondheim, Norway
May 4, 2017
Funding Disclosure • US Department of Defense (grants)
• Canadian Institute of Health Research (grants)
• Lundbeck Canada (grant)
• AstraZeneca Canada (grant)
• ImPACT Applications, Inc. (unrestricted philanthropic support)
• CNS Vital Signs
• Psychological Assessment Resources, Inc.
• Tampere University Hospital
• Alcohol Beverage Medical Research Council
• Rehabilitation Research and Development (RR&D) Service of the US Department of Veterans Affairs
• Defense and Veterans Brain Injury Center (former independent contractor; HJF/GD)
• Mooney-Reed Charitable Foundation (unrestricted philanthropic support)
• INTRuST Posttraumatic Stress Disorder and Traumatic Brain Injury Clinical Consortium funded by the Department of Defense Psychological Health/Traumatic Brain Injury Research Program (X81XWH-07-CC-CSDoD)
• Football Players Health Study, Harvard University (NFLPA Funding)
Other Disclosures
• Speaker honorariums and travel expenses for
conferences and meetings
• Independent practice in forensic
neuropsychology, including athletes
Traumatic brain injuries occur on a broad
continuum of severity, from very mild injuries to
catastrophic injuries resulting in death or severe
disability.
Continuum of TBI Severity
Approximately 90% of all injuries
Very mild/transient Uncomplicated mild Complicated mild Moderate Severe Catastrophic
Moderate-Severe TBI
• Can result in:
– widespread damage to the structure and function of
the brain
– permanent changes in physical functioning,
cognition, emotional functioning, behavior, and
personality
– permanent disability from work
• Outcome is variable, however, ranging from very good
to very poor.
Susceptibility Weighted Imaging
(SWI)
• SWI exploits differences in magnetic
susceptibility between tissues, and is sensitive
to microhemorrhages.
• SWI is very sensitive to bleeding in the
GM/WM boundaries, making it is possible to
see very small lesions.
Why is White Matter
Vulnerable?
1. Anatomy
2. Physics & Forces
Mild Traumatic Brain Injuries
are Not Created Equally
Spectrum of MTBI
Extremely Mild Structural Damage
(Transient) (Permanent)
Continuum of Pathophysiology
Minor Major Neurometablic & Neurometabolic Pathoanatomical
Review of 50 DTI Studies in MTBI (Wäljas et al., 2014)
Findings Yes No Not
Reported
Abnormal White Matter 88% 12% ---
Correlated with:
Return to Work 0% 2% 98%
Post-Concussion Symptoms 12% 6% 82%
Cognitive Functioning 54% 8% 38%
Mental Health Problems 6% 8% 86%
DTI is interesting and has advanced
knowledge in TBI.
Remember, however, white matter
abnormalities are present in many
conditions—even in healthy adults.
And many of these conditions are present before injury or sometimes in
the years after injury.
ADHD
Learning Disability/Dyslexia
Depression
Hypertension
Non-Traumatic TMJ Disorder
Migraine
Marijuana & Alcohol Abuse in
Adolescents
More Bad News for Smokers
These data suggest that smoking affects the microstructural
integrity of cerebral white matter and support previous data
that smoking is associated with impaired cognition.
CONCLUSIONS: We document lower cognitive
performance and reductions in brain structural integrity
among adolescents with Metabolic Syndrome, thus
suggesting that even relatively short-term impairments in
metabolism, in the absence of clinically manifest vascular
disease, may give rise to brain complications.
Isolated White Matter Hyperintensities
in Healthy Adults
Examining DTI in a Civilian
Biopsychosocial Outcome from
MTBI Study
Prospective Study of One Year
Outcome from Civilian MTBI
Tampere, Finland
Recruited from the Emergency Department
Imaging and Clinical Assessment at 3-4 Weeks
Clinical Assessment at 1 Year
Wäljas M, Iverson GL, Lange RT, Hakulinen U, Dastidar P, Huhtala H, Liimatainen S, Hartikainen K, Öhman J. A prospective biopsychosocial study of the persistent post-concussion symptoms following mild traumatic brain injury. J Neurotrauma. 2015 Apr 15;32(8):534-47.
Prospective Outcome Study on MTBI
(N = 126 at one month and 103 at one year) Wäljas et al. (2015)
ICD-10 Mild Post-Concussion Syndrome
• MTBI One Month: 59% MTBI One Year: 38%
• Healthy Controls: 31%
Abnormal Structural MRI and/or DTI
• Abnormal structural MRI = 12.1%
• Diffusion Tensor Imaging (DTI): Multifocal areas
of unusual white matter
– MTBI Group = 50.7%
– Healthy Controls =12.4%
Predictors of the Post-Concussion
Syndrome
• One Month: pre-injury mental health problems
and bodily injuries.
• Being symptomatic at one month was a
significant predictor of being symptomatic at
one year.
• Depression was significantly related to PCS at
both one month and one year.
• Structural MRI abnormalities and
microstructural white matter findings (DTI)
were not significantly associated with greater
post-concussion symptom reporting, and they
were not significant predictors of PCS at one-
month or one-year following injury.
Participants and Procedures
• 62 adults with MTBIs
• 31 complicated and 31 uncomplicated
• Neurocognitive testing (many tests)
• Symptom Ratings
– British Columbia Postconcussion Symptom Inventory
– Beck Depression Inventory-Second Edition
– Beck Anxiety Inventory
• DTI on a 3T MRI scanner approximately 6-8
weeks post injury.
Reduced FA in body and genu of the corpus callosum and the
left frontal corona radiata and
Increased radial diffusivity in genu of the corpus callosum
and left frontal corona radiata
No Significant Differences
• Symptoms
• Broad range of neuropsychological tests
Depression and the
Post-Concussion Syndrome
Civilians who sustain an MTBI are at substantially
increased risk for experiencing depression in the
first year following injury.
The etiology of depression is likely individualized
and multifactorial.
Post-concussion-like symptoms can be mimicked or
magnified by traumatic stress, anxiety, pain, depression,
sleep disturbance, and social psychological factors at any
point in the recovery trajectory.
Individuals who are symptomatic at 3-6 months are
at considerable risk for being symptomatic at 1-2
years post injury.
Factors Affecting Recovery Time
• General health
• Previous concussions / neurological problems
• Pre-injury mental health problems
• Mechanism of Injury: MVA vs. Sports
• Acute Psychological Distress in the first few days
• Severity of concussion symptoms in the first week