TBI Patient Outcomes Could Improve with Earlier MRI

When it comes to neurological injury, time is brain. That makes the findings from a new study published this week that much more valuable – using advanced MRI within 72 hours of a mild traumatic brain injury (TBI) could translate to better patient outcomes.

In a March 18 article published in JAMA Network Open, investigators from the University of Cambridge in the United Kingdom revealed that performing MRI scans earlier can pick up the white matter injuries that accompany the signs and symptoms of a mild TBI. Making those identifications as early as possible can help providers pinpoint which patients are more likely to have worse outcomes, necessitating more timely intervention.

“Imaging may, thus, document the evolution of pathology, thereby highlighting windows for therapy,” said the team led by Sophie Richter, Wellcome Trust PhD Fellow and specialty registrar in emergency medicine at Cambridge. “In addition, imaging can provide prognostic information to help select patients for clinical follow-up or interventional trials.”

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There is a conundrum with TBI, though, Richter’s team said. Between 70 percent and 90 percent of the 3 million TBI cases reported annually are considered to be mild, but the categorization may not reflect the true severity in a significant number of instances. In fact, they pointed out, between 30 percent-to-50 percent of patients have persistent symptoms that linger after six months, creating work-related and personal problems.

Consequently, Richter’s team launched a study to examine whether particular neuroanatomical substrates exist with mild TBI, and if so, how they change over time. They also wanted to know the optimal time to conduct an MRI so providers can best predict patient outcomes.

As a result, said a team led by Elie Massaad, M.D., postdoctoral research fellow in neurosurgery at Massachusetts General Hospital, this study shows that MRI is capable of evaluating people with mild TBI.

“Advanced MRI methods have shown promise for improved prognostication in mild TBI,” said Massaad’s team in an accompanying editorial. “The study…provides further evidence that there is an association between structural changes detected on diffusion tensor imaging…and symptom severity and persistence.”

To reach that goal, Richter’s team evaluated data from 104 control participants and 81 patients who presented to the hospital within 24 hours of sustaining a mild TBI, such as a fall from a height (26 percent of patients) or a ground-level fall (23 percent of cases). These patients had their first MRI scan within 72 hours of injury and a second within two-to-three weeks. Injury severity was measured with Glasgow coma scores – scores between 13 and 15 indicated mild TBI with 79 percent of patients scoring 15.

By using volumetric T1-weighted, volumetric FLAIR, T2-weighted, susceptibility-weighted imaging, and diffusion tensor imaging (DTI), the team determined reduced white matter volume in patients with injuries compared to the control participants between the first and second MRIs occurred most often. This outcome, they said, pointed to new, potentially progressive, pathology.

According to their analysis, patients with mild TBI had, on average, 231.5 cm³ cerebral white brain matter on the first MRI, but 229.8 cm³ on the second. The team also determined, with an area under the curve of 0.87 compared with 0.75, that the recovery-MRI findings association was closer on the first scan than the second with the initial MRI also having both higher positive and negative predictive values.

These results, they said, showed that earlier MRI scans are more closely linked with patient outcomes.

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