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San Francisco Chronicle​

UCSF team's method for assessing brain injuries could transform concussion care

A team of neurologists led by UCSF scientists has developed a new scale for assessing damage caused by brain trauma that could overhaul the field of concussion medicine and help doctors better treat patients with both the least and most severe injuries, including those who are comatose and considered near-death. Health providers have been using the Glasgow Coma Scale to assess brain injuries for more than 50 years. The tool assigns patients a score based on their physical presentation, including how alert they are, whether they can speak clearly and how they respond to pain, and that score determines if their injury is mild, moderate or severe. But experts in neurology have long said that it is a blunt instrument for assessing complex injuries. The new tool, described in a paper published Tuesday in the journal Lancet Neurology, uses the Glasgow Coma Scale along with other descriptors — including head scans, blood tests and the patient's own background — to quickly produce a more nuanced and, neurologists say, accurate analysis of a brain injury. 'Mild, moderate and severe doesn't work for any disease,' said Dr. Geoff Manley, chief of neurosurgery at San Francisco General Hospital and lead author of the new paper. 'We need to characterize these patients better. Our hope is that changing the framework of how we describe these patients can hopefully change the culture.' Worldwide, head injuries are among the most common causes of disability and death. Nearly 50 million people sustain a brain injury each year, and in the United States about 70,000 people die annually from head wounds. And increasingly, concussions and other so-called minor head injuries are understood to be potentially disastrous for some people. Such injuries have become the hallmark of modern warfare, and are of mounting concern in sports like football and soccer. The new framework will provide 'more granularity and allow us to have more thoughtful conversations with our patients,' said Dr. Cathra Halabi, director of UCSF's neurorecovery clinic. 'We're in a very exciting time where there's a confluence of pretty rapid advances in neuroscience and rapid advances in technology,' Halabi said. 'And we're now at a point where we can leverage that and focus on our patients and what is going to serve them best.' The Glasgow Coma Scale lumps patients broadly into mild, moderate and severe categories, with 'mild' fitting those who are able to talk normally and understand where they are and what's going on, and 'severe' including those who are comatose or otherwise nonresponsive. But those categories don't capture the complexity of injury, especially at the mild and severe ends of the spectrum. In fact, some patients with so-called minor head wounds suffer debilitating symptoms months after their injuries, including difficulty concentrating, chronic headaches, insomnia, and depression and anxiety. Meanwhile, some coma patients considered near-death based on the Glasgow Coma Scale — including people whose families were advised to remove them from life support — are able to make a near-full recovery. 'These terms weren't doing patients any favors,' said Manley, who has experience treating both the least and most severe cases, including the 2002 case of a San Francisco police officer who fully recovered from an injury that had him in a coma. 'We were quite nihilistic' about the severe cases, Manley said, but anecdotal experience and, later, research studies found that some of those patients weren't as bad off as they appeared and could recover — if not completely, then enough to have some independence. At the same time, 'we didn't pay much attention to these people with mild traumatic brain injury,' Manley said. 'I was following up with people in the emergency department who were like, 'You said I was stable but it's been three months and I'm not back at work.'' The new scale, called the CBI-M framework, takes clinical, blood biomarker and imaging results into account, along with modifiers such as the patient's mental health, pre-existing conditions, housing status and other social determinants of health. The framework will still rely on the Glasgow Coma Scale — that's the clinical element of CBI-M — but the other factors should give a more robust sense of how injured patients are and their prognosis. For example, a patient who hit his head in a car accident may show up in the emergency room fairly alert and with a high score on the Glasgow Coma Scale, suggesting a mild brain injury. If that coma scale is the only tool used — which is often the case — that patient may be sent home within hours. But a blood test may show high biomarker levels, suggesting a more serious injury, which would then prompt doctors to do a brain scan, which could show a blood clot or bleeding. In addition, the patient may have substance abuse issues that may interfere with recovery and should be taken into consideration. So that patient may stay overnight, or be referred to another clinic for follow-up care. On the other end of the spectrum, a comatose patient with a very low Glasgow Coma Scale, suggesting a very poor prognosis, but who also has low biomarker levels, no alarming signs on a brain scan and no modifying issues that could impede recovery may wake up and do well. 'The old way of categorizing brain injury was a very blunt, crude way,' said Dr. Anthony DiGiorgio, a UCSF neurosurgeon who was not involved in the Lancet paper. 'This tool makes us able to hedge on one side or the other and help manage expectations. It's a lot easier for me to figure out how to triage a patient.' The new tool also should be applied to research into head injuries, which has been frustratingly slow and stilted, Manley said. There are no drugs specifically to treat head injuries, and neurologists say that's at least in part because scientists have struggled to stratify patients in a way that makes testing effective. The 'mild,' 'moderate' and 'severe' head injury clusters that scientists have used to study therapies aren't very homogenous, as demonstrated by biomarker results, head scans and practical outcomes. Drugs to treat mild injury may have failed, for example, because 'mild' includes a broad array of symptoms and manifestations — maybe those drugs worked on some people with mild injury but not others. 'We've had numerous unsuccessful drug trials, and I think a large part of that is because of the heterogenous nature of brain injury,' DiGiorgio said. 'Maybe down the line we can get some useful clinical trials out of this framework.' Rolling out the new brain injury tool will likely take 10 years at least, Manley and others said. San Francisco General Hospital already uses aspects of the new tool, including taking patients' background into consideration when evaluating head injuries. And Manley said the tool already is being used in some clinical trials. Sean Sanford, 43, has firsthand experience on both ends of the brain injury spectrum, including a prolonged recovery from what seemed like a mild skateboarding accident eight years ago. He was just 20 for the first injury, which occurred in a car accident in his hometown of Grass Valley (Nevada County). He was in a coma for weeks, and his outlook was grim; his family was told he might not wake up. But he managed to fully recover. The second injury was 15 years later, when Sanford was skating with some friends in Glen Park. He hit his head on a ledge and knocked himself out. He came around after a few seconds, but his friends took him to the emergency room when he was behaving oddly and couldn't seem to remember where he was or what he was doing. At San Francisco General Hospital, he was told it was probably a minor head injury, but doctors decided to do a brain scan just in case — Sanford was rushed into surgery when the scan showed a skull fracture and bleeding. His friends and wife were told that if he 'had gone home and gone to sleep, he wouldn't have woken up,' Sanford recalled. The recovery from that injury has been rougher than the first time around, for reasons that aren't entirely clear. Sanford developed a seizure disorder and is on medication for that now. He had to take time off college, though he's since graduated and is working toward his master's degree in creative writing. 'The insomnia is still a thing. And I get anxiety,' Sanford said of the lingering symptoms. He struggles with short-term memory and concentration. 'Sometimes I feel like the subjects in my brain are just like a pinball bouncing around.' But he's also grateful both for the care he got and for the awareness of the nature of his injury. He said it would be incredibly frustrating to deal with the ongoing symptoms if he'd been told his was a 'mild' injury and left on his own. But he's had follow-up care, including therapy to manage his anxiety, and his family and friends too have been supportive. 'One of the big things they told me that I have to keep reminding myself is it's going to be a long road to recovery,' Sanford said. 'Don't get discouraged. Don't feel like you're broken. But it will be years, if not decades, before you even feel normal again, and you might never feel normal again.'