1. C35 Developing a Standard for Imaging in Patients with Mild Traumatic Brain Injuries

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3. Table of Contents Mild Traumatic Brain Injuries Description Causes
Health Impacts
Current Treatments
Detection
Magnetic Resonance Imaging
Description
How it Works
Purpose
Advantages
Disadvantages
Specialized Imaging
Imaging in Mild Traumatic Brain Injuries
Current Protocols
Current Issues
Proposed Solutions

4. Abstract
Procedures and care following mild traumatic brain injuries, such as concussions, are varied and ineffective
Protocols across the board are necessary to ensure patient safety and reduce the risk of long term damage
We chose this topic because of the unclear standards that are in place to treat mild traumatic brain injuries, or mTBIs. To fix this, this presentation goes over the modality of choice to reap the most benefits to ensure patient safety and reduce the risk of long term damage.

5. Objectives Understand how mTBI’s affect the brain
Identify the types of imaging used for mTBI’s
Recognize the importance of imaging for mTBI’s
Create a standard practice for treatment of mTBI
The objectives for this presentation will be to understand how mild traumatic brain injuries affect the brain, identify the types of imaging used for mTBIs, recognize the importance for imaging for mTBIs, and to create a standard practice for treatment of mTBIs

6. Mild Traumatic Brain Injury
“A pathophysiologic disturbance in neurologic function characterized by clinical symptoms induced by biomechanical forces.” 1
Description of
Mild Traumatic Brain Injury

7. Clinical Symptoms Headache Confusion Nausea Vomiting
Signs and symptoms of concussion. Queensland Brain Institute. Published May 16, Accessed November 28, 2018.
Clinical Symptoms
Headache
Confusion
Nausea
Vomiting
Lack of coordination
Ringing in the ears
Sensitivity to light
Drowsiness
Fatigue

8. Mild Traumatic Brain Injury
Direct Blow
Any direct contact to the head that causes the brain to move back and forth against the skull
Head to head contact
Head to object contact
Indirect Blow
Anything that forces the head to rotate quickly
Whiplash
Causes of
Mild Traumatic Brain Injury

9. Health Impacts Short Term Effects 3 Somatic complaints
Pain
Fatigue
Weakness
Impaired cognition
Mood changes
Sleep disturbances
Loss of consciousness
Long Term Effects 4
Decreased processing speed
Attention deficits
Decreased memory
Loss of productivity
Increased risk factors: 5
Depression
Memory problems
Dementia
Alzheimer’s disease
Parkinson’s disease
CTE
Cerebrovascular diseases
Short term effects: impaired cognition, mood changes, sleep disturbances, loss of consciousness, somatic changes
Long term: Decreased processing speed, loss of focus, impaired memory, decreased productivity
Increased risk factors: depression, memory problems, dementia, Alzheimer’s disease, Parkinson’s disease, CTE, Cerebrovascular diseases

10. Current Treatments Guidelines: 6
Limiting physical and cognitive activity
Reducing exposure to symptom-aggravating stimuli
“For more chronic symptoms, the standing recommendation for treatment of post-concussion conditions is a symptom-based approach” 6

11. Detection Initial Assessment (Performed by parents, coaches, peers)
Detection of signs
Pupillary dilation test
Determining need for further assessment
Further Assessment (Performed by medical professionals)
Sport Concussion Assessment Tool 3
Medical Imaging

12. Magnetic Resonance Imaging
Description of
An advanced imaging modality that uses radiofrequency and high powered magnets to produce images
Magnetic Resonance Imaging
Magnetic Resonance Imaging is an advanced modality that uses radiofrequency and high powered magnets to produce images. These components are essential to achieve its detailed images of soft tissues.

13. Magnetic Resonance Imaging
Purpose of
Visualization of soft tissue in detail
Evaluate structural abnormalities and injuries
Diagnose diseases and disorders
Magnetic Resonance Imaging
The main purpose of MRI is to visualize the soft tissue in detail. This helps radiologists evaluate structural abnormalities, injuries, and helps doctors diagnose diseases and disorders. This is all due to the complex science behind MRI.

14. How does an MRI scan work? 8
How it Works
How does an MRI scan work? 8
The body contains hydrogen protons
Hydrogen protons are present in different concentrations based on the types of tissues
Magnets in MRI align hydrogen protons
MRI measures the signal produced when the hydrogen protons relax to realign to their normal state
To achieve detailed and diagnostic quality images, the magnets present in MRI scanners align the hydrogen protons that are present throughout the body. These hydrogen protons relax at different rates based on the types of tissues they are in like muscle, fat, and bone. The scanner measures the signal produced when the hydrogens relax to realign to their normal state.

15. Magnetic Resonance Imaging
Advantages 9,10
Provides long term prognostic information
Different techniques
More sensitive
Injuries are better detected
Disadvantages 9
Not as widely available as CT
Requires longer acquisition times
Higher sensitivity to patient motion
According to Useche, MR imaging is more sensitive (93%–98%) than CT (18%–56%) in detecting acute and chronic extra-axial traumatic collections and hemorrhagic and nonhemorrhagic contusions” 9. All types and stages of intracranial hemorrhage, including subdural and epidural hematomas, subarachnoid hemorrhage (SAH), contusions (particularly those adjacent to bony surfaces), axonal injury, and brainstem lesions, are also better detected” 9. MRI also has specialized imaging.

16. Specialized Magnetic Resonance Imaging
Functional MRI
Diffusion Tensor Imaging
Specialized Magnetic Resonance Imaging
Functional MRI, or fMRI, and Diffusion Tensor Imaging, abbreviates as DTI are very valuable when imaging head injuries.

17. fMRI Utilizes the blood flow to the brain to assess brain activity.
fMRI is a powerful tool to assess brain activity in concussed patients.
Di Battista AP, Churchill N, Schweizer TA, et al. Blood biomarkers are associated with brain function and blood flow following sport concussion. J Neuroimmunol. 2018;319:1-8. Available from: Pub Med with Full Text, Accessed October 31, 2018
Functional MRI is a powerful to assess brain activity in concussed patients by utilizing the blood flow to the brain. The different colors indicate the differences in connectivity with the warmer colors showing increased connectivity and the cooler colors showing a decrease in connectivity.

18. DTI
Specialized imaging that estimates the location, orientation, and gives measurement of the brain’s white matter tracts.
“MR imaging technique that uses magnetic gradients to measure water diffusion in the brain, and in turn, brain microstructure” 13
“Provides a highly sensitive window into tissue microstructure and changes in white matter, greatly improving understanding of the pathophysiology of mTBI.” 13
RESOLVE. Siemens Healthineers Global. Published Accessed November 28, 2018
Diffusion Tensor Imaging on the other hand estimates the the network of the brain’s white matter tracts. According to Weber, that this technique measures the water diffusion in the brain to estimate the location, orientation, and also gives measurements of the the white matter tracts. Weber also states that DTI allocates a “high sensitive window into [the] tissue microstructure and changes in white matter, greatly improving [the] understanding of the pathophysiology of mTBIs.

19. Imaging in mTBI’s “Computed Tomography is primary for TBIs...4
Current Protocols
CT Advantages: 9
Widely available
Rapid evaluation
Compatible with medical and life support devices
No screening
Not imaging based
Mainly palliative care, based on symptoms and signs
Less stimuli prevents symptoms from worsening

20. Imaging in mTBI’s
...but does not provide long term prognostic information.” 4
CT Disadvantages: 9
Ionizing radiation
Increased efforts to reduce the amount of non indicated scans
No long term prognostic information
Current Issues
CT disadvantages: Ionizing radiation, no long term prognostic information, increased efforts to reduce the amount of non indicated scans

21. Imaging in mTBI’s Initial assessment: Further assessment: More Issues
Some patients may have little to no signs
Many patients do not seek further assessment
Further assessment:
Decreased use of non-indicated scans for mTBI’s
Many patients are non-indicated
Follow up treatment and preventative measures are often not taken
Lack of proper diagnosis can lead to severe long term effects
More Issues
“It is presently unknown whether these subjective measures [symptom based] are associated with reliable, objective measures of brain physiology” 3

22. Imaging in mTBI’s Proposed Solutions
mTBI protocols should include imaging
Diagnose patients with varied signs and symptoms
Prevent long-term effects
Provide a diagnosis-based approach vs. symptom-based approach
Imaging in mTBI’s
Proposed Solutions
In light of the benefits of imaging, mTBI protocols should imaging. This will help to diagnose patients with varied signs and symptoms, prevent long-term effects, and more importantly provide a diagnosis-based approach.

23. Conclusions MRI is superior to CT when imaging for mTBI’s
MRI scans soft tissue with better detail
Provides long-term prognostic information
Allows for specialized imaging
Does not have Ionizing radiation
Compared to CT, MRI scans soft tissue with much greater detail. It presents long-term prognostic information, allows for specialized imaging, and is not ionizing.

24. Bibliography
1. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24): Available from: Pub Med with Full Text, Accessed October 31, 2018
2. Signs and symptoms of concussion. Queensland Brain Institute. symptoms-concussion. Published May 16, Accessed November 28, 2018.
3. Churchill NW, Hutchison MG, Graham SJ, Schweizer TA. Connectomic markers of symptom severity in sport-related concussion: Whole-brain analysis of resting-state fMRI. Neuroimage Clin. 2018;18: Available from: Pub Med with Full Text, Accessed October 31, 2018
4. Wu X, Kirov II, Gonen O, Ge Y, Grossman RI, Lui YW. MR Imaging Applications in Mild Traumatic Brain Injury: An Imaging Update. Radiology. 2016;279: Available from: Pub Med with Full Text, Accessed October 31, 2018
5. Hasan KM, Keser Z, Schulz PE, Wilde EA. Multimodal Advanced Imaging for Concussion. Neuroimaging Clin N Am. 2018;28: Available from: Pub Med with Full Text, Accessed October 31, 2018
6. Wing BH, Tucker BJ, Fong AK, Allen MD. Developing the Standard of Care for Post-Concussion Treatment: Neuroimaging- Guided Rehabilitation of Neurovascular Coupling. Open Neuroimag J. 2017;11: Available from: Pub Med with Full Text, Accessed October 31, 2018

25. Bibliography
7. Simple Sideline Evaluation For Concussion. Sideline Sports Doc. Published September 4, Accessed November 28, 2018
8. gov NIBIB. How Does an MRI Scan Work? YouTube. Published April 16, Accessed November 28, 2018
9. Useche JN, Bermudez S. Conventional Computed Tomography and Magnetic Resonance in Brain Concussion. Neuroimaging Clin N Am. 2018;28: Available from: Pub Med with Full Text, Accessed October 31, 2018
10. Functional magnetic resonance imaging. NeuroImage. magnetic-resonance-imaging. Published Accessed November 28, 2018
11. Di Battista AP, Churchill N, Schweizer TA, et al. Blood biomarkers are associated with brain function and blood flow following sport concussion. J Neuroimmunol. 2018;319:1-8. Available from: Pub Med with Full Text, Accessed October 31, 2018
12. RESOLVE. Siemens Healthineers Global. upgrades/clinical-applications/syngo-resolve. Published Accessed November 28, 2018
13. Weber AM, Torres C, Rauscher A. Imaging the Role of Myelin in Concussion. Neuroimaging Clin N Am. 2018;28: Available from: Pub Med with Full Text, Accessed October 31, 2018

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