In the next 5-10 years, we could see revolutionary changes to the way brain injury is treated, diagnosed, managed, and understood as an overall disease process.
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There are a lot of gaps, and there are a lot of challenges
in traumatic brain injury research.
I think if I had to say,
the biggest gap is we have no treatment.
We don't have any intervention
that improves functional outcome
after traumatic brain injury,
and that slows down that secondary neurotoxic cascade.
That's our biggest gap,
but that's hampered by another really big gap,
actually, 2,
if I had to put them on a scale of
elephants in the room in hugeness.
The first one
is the way we define
traumatic brain injury.
The Glasgow Coma Scale has served us well
over the last 20 or 30 years,
since Glasgow, since it was developed
by Graham and others,
but it is a very crude scale.
What does the Glasgow Coma Scale measure?
It measures how the patient is reacting
to the environment
which has absolutely zero
link with what's going on in the brain
at a structural or functional level.
There is no link from
the Glasgow Coma Scale to pathophysiology.
Imagine if we treated breast cancer
this way, or cancer in general.
I would say, "Oh, you have a moderate cancer,
let's try this treatment,"
or "Your cancer is severe." Okay?
With no understanding that it was
breast cancer,
GI cancer,
sarcoma,
and then tried to manage that
or tried to do research on that or tried to treat it.
So, our problem with being able to
have a pathophysiologic
definition and
a classification system
that we can use early on
in the management of patients
has been a real hindrance to the field.
The other side is
treatment.
A traumatic brain injury patient
is cared for by
EMS/pre-hospital care,
emergency physicians,
trauma surgeons,
neurosurgeons,
neurointensivists,
rehab specialists,
and on and on.
Every single one of those people
are trained differently
and have different opinions about management,
because there is limited data
on how to manage these patients,
which creates a huge amount
of variability
in the management of a traumatic brain injury patient,
depending on where you go.
It really does matter
where you go for your TBI care,
because the difference in mortality
of a severe patient in 1 place
compared to another can be anywhere from
25% to 65%.
That is a huge difference
of the same patient.
Now you try to find a drug
that's going to improve mortality by 10% or 15%,
which is actually very large improvement,
and you've got a signal noise
of 45% or 50%.
Is that drug ever going to be able to show that it works?
No, so we have a problem in the US
and globally when we're doing
clinical trials,
and we go multicenter.
All of a sudden, the signal noise
for outcome
gets huge, and so we have a real problem,
both from the standpoint of controlling
and standardizing management
across all these different sites.
Despite the fact that we've had guidelines
for management for over 15 years,
there's still only about a 65% adoptance
within the US of those guidelines,
and even then within individual centers
people adopt them at a varying degree.
So, we've got 2 really big problems.
One at the beginning in defining the injury
and the pathology and 1 at the end,
or in the middle, managing these patients
so that our clinical trials have a chance to work.
Fingers crossed, prayers answered.
We are
on a revolutionary,
hopefully, transformative path for head injury.
Maybe next 5, next 10 years,
we'll have a number of treatments available.
We'll have better diagnostic capabilities
and a better understanding
of the disease process altogether.
Produced by Victoria Tilney McDonough, Ashley Gilleland, Justin Rhodes, and Erica Queen, BrainLine.
David Wright, MD, FACEP is a tenured associate professor in the Department of Emergency Medicine at Emory University, and the director of the division of Emergency Neurosciences. The Emergency Neurosciences program is dedicated to finding novel therapies for the treatment of rapidly evolving neurological conditions, including traumatic brain injury, stroke, status epilepticus, spinal cord injury and others.
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