Heading Toward the Future

The ACR Head Injury Institute works to advance the study of traumatic brain injury and bring the latest technology into the clinical arena.

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January 2015

Much attention has been devoted to traumatic brain injury (TBI) in the news lately. Millions of Americans have watched as athletes ranging from little league players to professional snowboarders step out of competition to be imaged for concussions. This increased awareness of the tragic long-term effects of head trauma puts radiology front and center in the push to understand and treat TBI.

What's Trending

Looking beyond athletics, medical and lay media have recently turned their attention to the consequences of repeated TBI impacts on soldiers. Body armor has improved tremendously over the years, and as a result has saved many lives. But that doesn't mean those who survive the initial blast come out unharmed, says Alexander M. Norbash, MD, MHCM, FACR, chief of the department of radiology at Boston University School of Medicine and chair of the ACR Head Injury Institute™ (HII). Often, these individuals receive concussive head trauma, which results in symptoms ranging from headaches to severe memory loss. These issues, combined with the high incidence of suicide among soldiers following duty, are causing physicians to reexamine how the brain functions following injury, says Norbash. It seems the brain could be affected by these injuries much more than anyone had previously realized.

With this heightened emphasis on TBI, physicians, patients, and researchers alike look forward to new technologies, innovative therapies, and a better understanding of how TBI impacts the brain and quality of life, says James R. Stone, MD, PhD, associate professor of radiology and medical imaging at the University of Virginia School of Medicine. Stone is currently leading a study on breachers, military service members who have expertise in working with explosives to gain entry through fortified structures. These soldiers may be exposed to large numbers of low-level blasts over the course of a career. The relationship between repetitive low-level blast exposure and cumulative neurological injury is presently an area of high interest for the military.

Both Norbash and Stone agree that imaging is going to become increasingly involved in the management of TBI. "Currently, imaging plays a somewhat limited role in the management of TBI and is largely used to diagnose more severe forms of injury or exclude specific conditions that may require neurosurgical intervention. However, neuroimaging will likely play a more significant role in addressing milder forms of this condition as experimental imaging methods are validated and moved into clinical workflows," says Stone. Approximately 1.7 million individuals per year are affected by TBI. The significant number of patients combined with new imaging technology such as diffusion tensor imaging (DTI) will most likely result in rapid evolution in the diagnosis and treatment of TBI, says Stone — as well as new opportunities for radiologists to be involved.

Obstacles Ahead

Technology is rapidly evolving, but there are plenty of obstacles to overcome concerning imaging and TBI, says Max H. Wintermark, MD, chief of neuroradiology at Stanford University. One of the main obstacles that physicians face with understanding the effects of TBI is the limitation of technology.

Currently, radiologists use CT scans and MRI to diagnose TBI and head trauma. Problematically, however, mild TBI is often undetectable on these scans. And although new technologies such as DTI and resting state functional MRI seem promising, they are not yet ready to be used in a clinical setting, says Wintermark. "We don't completely understand the difference in variation in these tests," he says. Although radiologists can pinpoint differences between brains with and without TBI, they don't necessarily know that brain trauma is the cause of those differences. "A whole variety of risk factors could also be creating these differences, such as smoking or age. For instance, when an older TBI patient demonstrates DTI changes, it is difficult to determine if the variations we're seeing are a result of TBI or just a result of the brain aging," he adds. Solving the issue of characterizing "normal" brain scans will require a large dataset of imaging, one acquired from individuals without a history of TBI or other neurologic disorders, that lets physicians examine a variety of risk factors, says Stone. Creating that will take a large collaborative effort, however, one that spans specialties.

Clarion Call

 With so much work to be done, how can radiology support better care in the clinical study and practice related to TBI? "Two of the ACR's strengths are standardization and communication, and those are the areas we think radiologists can really leverage in this field," says Norbash. To that end, the HII aims to ensure that when referring practitioners are seeing a concussive or subconcussive patient, they recognize the appropriate tests and sequences of actions for diagnosing and treating the patient. "At the same time, while we are standardizing imaging protocols, we want to make sure the right terminology and report structure is being utilized," Norbash says. "If the correct terminology is used in reports, and if we ensure that the necessary relevant findings are included or excluded through standardized report structure as determined by experts, we can help ensure appropriate thought is given to the examination and that the right diagnoses are being made."

The HII jumpstarted this effort by publishing two new white papers detailing the current research on TBI imaging technologies and laying out what is currently understood about the practice of imaging in head injury patients. The papers also make imaging recommendations for potential TBI across different practice settings and give supporting evidence for those recommendations, which will be aligned with the ACR Appropriateness Criteria®. "The white papers are designed to help radiologists and referring physicians alike," says Wintermark. You can access the JACR® paper at http://bit.ly/JACRTBI and the American Journal of Neuroradiology white paper at http://bit.ly/AJNTBI.

Digital Solutions

The ACR and the HII are also conceptualizing the dataset mentioned by Stone and the HII Working Group. In May 2014, the HII held a one-day workshop whose goal was to define the requirements needed to create and maintain such a database. The HII is working closely with ACR Informatics to develop the infrastructure for the project. The HII plans to publish a "research road map" that will also describe the different steps that doctors from a variety of specialties must take in order to use DTI and other new imaging technologies for TBI patients in a clinical setting.

One of the ways radiologists can help is to pay attention to the latest news about TBI and convey new advances in imaging to their referring clinicians and the other specialists, says Wintermark. He also encourages radiologists to support organizations that are seeking to find solutions to TBI's technological problems, noting that the HII and the ACR are becoming increasingly involved in providing education on standards and recommendations for things such as imaging assessments of TBI. "Radiologists must take the lead on advancing the national standard for imaging's vital role in diagnosing head injuries and caring for our patients," says Wintermark. For more information on the HII, visit http://bit.ly/ACRHII.

TBI at ACR 2015TM

Looking for more information on TBI and the ACR Head Injury Institute™ (HII)? At ACR 2015, the HII will present two continuing education sessions, "Traumatic Brain Injury: Current Practice and Research Horizons" and "Traumatic Brain Injury Patient: What the Radiologist Needs to Know." Alexander M. Norbash, MD, MHCM, FACR, chair of the HII and chief of the department of radiology at Boston University School of Medicine, says, "These sessions are going to focus not only on the state-of-the-art technologies involved in TBI and the HII, but the practical aspects as well." For more information about these sessions, visit http://bit.ly/ResearchHorizons and http://bit.ly/TBINeedtoKnow.

By Meghan Edwards, copywriter for the ACR Bulletin


1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention. http://1.usa.gov/11WxHHp. Published 2010.Accessed October 10, 2014.
2. "Severe Traumatic Brain Injury." Centers for Disease Control and Prevention. http://1.usa.gov/1vL4RaS. Updated March 2014 . Accessed October 12, 2014.
3. "Traumatic Brain Injury." The Mayo Clinic. http://mayocl.in/1uUV4wU. Updated 2014. Accessed October 12, 2014.
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