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.
See more videos with Dr. David Wright.
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.
Posted on BrainLine October 25, 2012.
David Wright, MD is a tenured associate professor in the Department of Emergency Medicine, Emory University, and the director of the division of Emergency Neurosciences.
Produced by Victoria Tilney McDonough, Ashley Gilleland, Justin Rhodes, and Erica Queen, BrainLine.