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After more than half a century, assessment of acute traumatic brain injury (TBI) is getting a makeover.<\/p>\n
A newly proposed framework expands assessment of acute TBI beyond the Glasgow Coma Scale (GCS) to include biomarkers, CT and MRI scans, and \u201cmodifiers\u201d such as other medical conditions and how the injury occurred.<\/p>\n
\u201cMultiple factors prompted this initiative. First was a growing consensus among clinicians, researchers, and patients alike around the need for an improved system for the characterization of TBI,\u201d co-senior author Michael McCrea, PhD, co-director of the Center for Neurotrauma Research at the Medical College of Wisconsin in Milwaukee, told Medscape Medical News<\/em>.<\/p>\n \u201cSecond, was the recognition that a multidimensional framework could better guide individualized treatments that give TBI patients the best chance of survival, recovery, and return to life function.\u201d<\/p>\n \u201cFinally, this movement is now enabled by decades of progress in translational research that informed the components of a multidimensional framework for classification of TBI,\u201d he added.<\/p>\n The proposed framework was published<\/a> online on May 20 in The Lancet Neurology<\/em>.<\/p>\n Since 1974, the clinical TBI severity has been classified according to the GCS sum score as mild, moderate, or severe, based largely on a patient\u2019s level of consciousness.<\/p>\n Given its limitations, in 2022, the US National Institute of Neurological Disorders and Stroke (NINDS) launched an international initiative to develop a multidimensional classification system for acute TBI.<\/p>\n The so-called \u201cCBI-M framework\u201d is made up of four pillars \u2014 clinical, biomarker, imaging, and modifiers \u2014 and was developed by TBI experts, implementation scientists, people with lived experience, and partners from 14 countries.<\/p>\n The clinical pillar retains the full GCS total score as a central element of assessment, measuring consciousness along with pupil reactivity as an indication of brain function. The framework recommends including the scale\u2019s responses to eye, verbal, and motor commands or stimuli, as well as the presence of amnesia and symptoms such as headache, dizziness, and sensitivity to noise.<\/p>\n The clinical pillar \u201cshould be assessed as first priority in all patients. Research has shown that the elements of this pillar are highly predictive of injury severity and patient outcome,\u201d co-senior author Andrew Maas, MD, PhD, emeritus professor of neurosurgery, University of Antwerp, Antwerp, Belgium, said in a news release.<\/p>\n The second pillar uses blood-based biomarkers to provide objective indicators of tissue damage. Measurement of one or more of the following three biomarkers is recommended in the first 24 hours after injury: Glial fibrillary acidic protein, ubiquitin C-terminal hydrolase L1, or S100 calcium-binding protein B.<\/p>\n The working group noted that this recommendation was based on the diagnostic and prognostic utility of these biomarkers demonstrated in acute care settings. Low levels of each of the three biomarkers accurately indicate a very low risk for traumatic intracranial injury on head CT scans and can be used to rule out the need for CT imaging.<\/p>\n The third pillar of the CBI-M framework is neuroimaging, which offers a \u201cgreat source\u201d of information about the type and extent of brain injury, the authors reported.<\/p>\n This pillar focuses on CT, the most widely used imaging modality within the first 24 h of injury, but recognizes that MRI is more sensitive than CT and can provide additional information while acknowledging certain practicalities around its use in the acute phase.<\/p>\n The final pillar in the CBI-M framework is \u201cmodifiers,\u201d which includes assessment of injury-related factors (how the injury happened) and patient- and society-related factors (such as medications, healthcare access, prior TBI, substance abuse, and living circumstances).<\/p>\n \u201cThis pillar summarizes the factors that research tells us need to be considered when we interpret a patient\u2019s clinical, blood biomarker, and neuroimaging exams,\u201d co-first author Kristen Dams-O\u2019Connor, PhD, professor in the Department of Rehabilitation and Human Performance and Department of Neurology, and director of the Brain Injury Research Center at the Icahn School of Medicine at Mount Sinai in New York City, said in the release.<\/p>\n \u201cOne example is a patient with underlying cognitive impairment who may require acute monitoring for risk of clinical deterioration, regardless of findings on the initial clinical exam,\u201d she said.<\/p>\n The proposed framework is being phased in at trauma centers on a trial basis. It will be refined and validated before it is fully implemented.<\/p>\nBusiness Beyond Level of Consciousness<\/strong><\/h2>\n
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