Traumatic Brain Injury Diagnostic Challenges & Emerging Tools

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Traumatic Brain Injury Diagnostic Challenges
Emerging Tools

• Julie C. Chapman, PsyD

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VA/DOD Definition of TBI

• A traumatically induced structural injury AND/OR
• physiologic disruption of brain function
• as a result of an external force
• that is indicated by new onset or worsening of
• at least one of the following clinical signs
• immediately following the event

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VA/DOD Definition of TBI

• At least one of the following clinical signs
  immediately following the event
• Any period of loss of consciousness
• Any loss of memory for events immediately before
  or after injury
• Any alteration in mental state at the time of
  injury
• Neurologic deficits
• Intracranial lesion

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How is TBI Diagnosed?

• 2nd Level TBI Evaluation
• Interview
• Physical Examination
• Neurobehavioral Symptom Inventory
• TBI is often retrospectively diagnosed

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Severity of Injury

• Three 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)
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Diagnostic Challenges

• Diagnostic criteria is based largely upon patient
  self-report, particularly in mild TBI.
• Possible threats to diagnostic accuracy
• Recall bias
• Cognitive difficulties
• Other factors

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Diagnostic Challenges

• Overlap of symptoms in co-morbid conditions
• Hoge et al. Study
• Schneiderman et al. Study
• RAND Study

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Symptom Overlap

• TBI

• PTSD

• Insomnia
• Memory Problems
• Poor concentration
• Depression
• Anxiety
• Irritability
• Headache
• Dizziness
• Fatigue
• Noise/light intolerance

• Insomnia
• Memory problems
• Poor concentration
• Depression
• Anxiety
• Irritability
• Re-experiencing
• Avoidance
• Emotional numbing

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Seeking Objective Markers

• Biomarkers
• Brain Imaging
• Neurobehavioral Measures

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Biomarkers

• S-100B
• Calcium binding protein found in astroglial and
  Schwann cells
• Sensitive 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 Imaging

• Measures 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 Imaging

• Lipton 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) Study

• Sample of OEF/OIF Veterans and Controls with
• No prior TBI (even mild)
• No current or recent or chronic substance abuse
  or dependence
• All OEF/OIF Veterans have
• Mild TBI from blast exposure and/or
• Combat-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 Measures

• Heitger et al. 2009 Antisaccades and visual
  tracking more impaired in patients with
  post-concussive syndrome at avg of 140 days
  post-injury than controls
• Wortzel 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 Diagnostics

• Patient Self-Report

Objective Diagnostic Markers
GESTALT
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All Hands on Deck
Epidemiology
Laboratory Science
Clinical Science
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Integrative Diagnostics
Clinical Algorithms
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Markers for the Identification, Norming
Differentiation (MIND) of TBI and PTSD

• Principal 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
  n800)
• Veterans with TBI
• Veterans with PTSD
• Veterans with both TBI and PTSD
• Veterans with neither TBI nor PTSD

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Phase One AimsMIND Study

• Aim 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 Study

• Aim 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 Study

• Aim 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 Us

• ADDRESS
• Veterans Affairs Medical Center
• MS 127
• Washington, DC 20422
• PHONE [phone]
• EMAIL Julie.Chapman_at_va.gov
• VISIT OUR WEBSITE
• www.warrelatedillness.va.gov/dc/