Traumatic Brain Injury (TBI): Advanced Neuroimaging. Jamie Hutchison Professor of Pediatrics, University of Toronto. CCCF, Toronto November 10, 2013

Transcription

1 Traumatic Brain Injury (TBI): Advanced Neuroimaging Jamie Hutchison Professor of Pediatrics, University of Toronto CCCF, Toronto November 10, 2013

2 Conflicts of Interest Patent on CT tool PI Anne-Marie Guerguerian Patent Electroencephalography synchrony imaging tool Vera Nenadovic and Jose-Luis Perez-Velasquez

3 Question 1 How many people use CT scan for diagnosis and management of TBI in the ICU? Yes raise your hands

4 Question 2 How many people use MRI for diagnosis and management of TBI in the ICU? Yes - raise your hands

5 Question 3 How many people use other neuroimaging technologies (e.g. PET scan or other novel imaging technologies) for diagnosis and management of TBI in the ICU? Yes Raise your hands

6 Classification of TBI in the Critical Care Unit Current classification Mild (GCS=13-15), moderate (GCS=9-12) and severe (GCS=3-8) This classification is based on the paper by Sir Graham Teasdale from Glasgow in the 1970s A new classification system is needed linking neuroimaging and other acute parameters to how the brain functions during recovery Rationale: For prognosis and implementation of novel therapies

7 Geoff Manley, UCSF

8 The CT Scan Tool The tool Quantifies Brain Injury It will be integrating into clinical care to enhance the utility of the CT scan Anne-Marie Guerguerian

9 International TBI Research Network Have invested in TBI research during recent meetings in Brussels and Vancouver $$$ are committed between the European Union, the National Institutes of Health (NIH-US) and the Canadian Institutes of Health The NIH Common Data Elements provide a template for collaboration in neuroimaging research TRACK-TBI - Geoff Manley $20 million (US) CENTRE-TBI Andrew Mass and David Menon $30 million Euros CIHR Team Grants in Mild TBI in Children and Youth

10 Magnetic Resonance Imaging Structural MRI (MRI) Diffusion-weighted Imaging (water) Susceptibility weighted Imaging (Hemoglobin) Diffusion Tensor Imaging fmri MR Spectroscopy

11 6 year old male 11 year old male GCS=12 GCS=3 Struck by bicycle ATV collision

12 Brian Levine et al. Quantified MRI and cognition in TBI with diffuse and focal damage. Neuroimage: Clinical, 2013

13 Diffuse axonal injury 10 year old male, GCS=13, TBI Susceptibility- CT T2-weighted MRI weighted MRI Beauchamp et al., 2011, Journal of Neurotrauma.

14 Attention and TBI study Case report form Recruit Day 5 3 Months 6 Months 12 Months Injury BRIEF MRI BRIEF Helena Frndova

15 August 2011: Recruitment for Attention and Traumatic Brain Injury Study 140 Total screened Total enrolled ONF Sample (n=60) Toronto London Start CHEO, Ste Justine, McMaster start 0 D F A J A O D F A J A O D F A J A August 2011: Complete recruitment

16 Results: Baseline characteristics (N=58) Parameter Value Age 12.4 ± 3.6 Male 41 (71%) Severity of injury (Glasgow coma scale) Mild 14/53 (27%) Moderate 11/53 (22%) Severe 27/53 (51%) Other Injuries Spinal cord injury 9 (16%) Thoracic 19 (33%) Cardiovascular 1 (1.7%) Abdominal 8 (14%) Genito-urinary 1 (1.7%) Major fracture 24 (41%) Other injuries 25 (43%)

17 Cognitive changes following TBI Deficits in executive function 1 Ability to plan, carry out, and evaluate behaviour Supported by frontal lobes Particularly vulnerable to injury 2 Problems: Maureen Dennis MRI is more sensitive for detecting injury but is not part of routine care Lack of longitudinal data to predict & characterize course of executive dysfunction 1 Brookshire, Levin, Song, & Zhang (2004); Mandalis, Kinsella, Ong, & Anderson (2007) 2 Bigler (2007)

18 Study Question Does presence of frontal lobe diffuse axonal injury predict executive dysfunction?

19 Methods Frontal lobe injury: structural MRI within 5 days of injury (n=25) Diffuse Axonal Injury (DAI): scattered, small hemorrhagic and/or non-hemorrhagic lesions; 3 separate foci of signal abnormality 13 participants had evidence of frontal DAI 12 participants had no evidence of frontal DAI Executive function: parent reports/standardized questionnaire Behaviour Rating Inventory of Executive Function (BRIEF) 3,4 4 time-points: Pre- injury (baseline); 3, 6, and 12 months postinjury 3 Gioia et al. 2000, 4 Guy et al. 2004

20 Behaviour Rating Inventory of Executive Function (BRIEF) 1. Initiate: Begin activity; generate ideas 2. Working Memory: Hold information in mind 3. Plan/Organize: Anticipate future events; develop step to implement plan 4. Organize Materials: Clean room 5. Monitor: Assess own performance 6. Inhibit: Control impulses; stop behavior 7. Shift: Move from one activity/situation to another; problem-solve; flexibly 8. Emotional Control: Modulate emotional responses appropriately

21 At Risk P=0.08

22 At Risk P=0.01

23 Effect of hyperventilation on cerebral blood flow in patients with TBI PET Scans Coles et al. Crit Care Med 2002

24 31 yo man 7 days post-tbi CT Scan PET scans PaCO2 (mmhg) HypoBV (ml) Coles et al. Crit Care Med 2002

25 Respiratory Support: Normoventilation Hyperventilation : Historical management more harm than good??? CBF pre- hyperventilation CBF post-hyperventilation Originally adapted from research by Skippen et al. (1997) Critical Care Medicine, 25

26 Focal EEG Synchrony F7 FP1 O1 C4 L R Vera Nenadovic Channel 1

27 Conclusions A new classification system for TBI using advanced neuroimaging will improve diagnosis, risk stratification and facilitate earlier interventions during recovery This will lead to better designed trials and improved quality-of-life for patients with TBI

28 Acknowledgements ATBI study coordinators Judy Van Huyse and Sumaira Hussain Co-principal Investigators Russell Schachar Co-investigators Maureen Dennis, Anne-Marie Guerguerian, Vera Nenadovic, Helena Frndova, Miriam Beauchamp, Dean Ferguson, and site investigators CCCTG and CCCTBG - John Marshall, Deborah Cook and Brent Winston Funding ONF, Eli Lily, SickKids and CIHR