Assessing the Severity of Traumatic Brain Injury—Time for a Change?

Journal of Clinical Medicine Review Assessing the Severity of Traumatic Brain Injury—Time for a Change? Olli Tenovuo 1,2,*, Ramon Diaz-Arrastia 3, Lee E. Goldstein 4, David J. Sharp 5,6, Joukje van der Naalt 7 and Nathan D. Zasler 8,9 1 Division of Clinical Neurosciences, Turku Brain Injury Centre, Turku University Hospital, 20521 Turku, Finland 2 Department of Neurology, Institute of Clinical Medicine, University of Turku, 20500 Turku, Finland 3 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; [email protected] 4 Alzheimer’s Disease Research Center, College of Engineering, Boston University School of Medicine, Boston, MA 02118, USA; [email protected] 5 Clinical, cognitive and computational neuroimaging laboratory (C3NL), Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, W12 0NN, UK; [email protected] 6 UK Dementia Research Institute Care Research and Technology Centre, Imperial College London and the University of Surrey, London, W12 0NN UK 7 Department of Neurology, University of Groningen, University Medical Center Groningen, 9713 GZ Groning-en, The Netherlands; [email protected] 8 Concussion Care Centre of Virginia and Tree of Life, Richmond, VA 23233, USA; [email protected] 9 Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA 23284, USA * Correspondence: olli.tenovuo@tyks.fi; Tel.: +358-50-438-3802 Abstract: Traumatic brain injury (TBI) has been described to be man’s most complex disease, in man’s most complex organ. Despite this vast complexity, variability, and individuality, we still classify the severity of TBI based on non-specific, often unreliable, and pathophysiologically poorly understood measures. Current classifications are primarily based on clinical evaluations, which are non-specific Citation: Tenovuo, O.; Diaz-Arrastia, R.; and poorly predictive of long-term disability. Brain imaging results have also been used, yet there are Goldstein, L.E.; Sharp, D.J.; multiple ways of doing brain imaging, at different timepoints in this very dynamic injury. Severity van der Naalt, J.; Zasler, N.D. itself is a vague concept. All prediction models based on combining variables that can be assessed Assessing the Severity of Traumatic during the acute phase have reached only modest predictive values for later outcome. Yet, these Brain Injury—Time for a Change? J. Clin. Med. 2021, 10, 148. https:// early labels of severity often determine how the patient is treated by the healthcare system at large. doi.org/10.3390/jcm10010148 This opinion paper examines the problems and provides caveats regarding the use of current severity labels and the many practical and scientific issues that arise from doing so. The objective of this Received: 5 December 2020 paper is to show the causes and consequences of current practice and propose a new approach based Accepted: 30 December 2020 on risk classification. A new approach based on multimodal quantifiable data (including imaging Published: 4 January 2021 and biomarkers) and risk-labels would be of benefit both for the patients and for TBI clinical research and should be a priority for international efforts in the field. Publisher’s Note: MDPI stays neu- tral with regard to jurisdictional clai- Keywords: traumatic brain injury; severity; assessment; outcome ms in published maps and institutio- nal affiliations. 1. Introduction Copyright: © 2021 by the authors. Li- Traumatic brain injuries (TBIs) are among the most common maladies affecting hu- censee MDPI, Basel, Switzerland. manity. Grading injury severity is an early step in management and is a first step towards This article is an open access article prognosis and targeted therapies. Fields of medicine as diverse as cardiology and oncology distributed under the terms and con- use grading schema, such as NYHA-congestive heart failure grading scale in cardiology ditions of the Creative Commons At- and staging scales in many cancers. Grading based exclusively on clinical features, in the tribution (CC BY) license (https:// absence of imaging or molecular biomarkers, provides suboptimal prognostic informa- creativecommons.org/licenses/by/ tion and is inadequate for identifying patients likely to benefit from specific therapies [1]. 4.0/). J. Clin. Med. 2021, 10, 148. https://doi.org/10.3390/jcm10010148 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 148 2 of 12 Grading scales that focus exclusively on clinical features may not capture disease endophe- notypes or differentiate underlying disease mechanisms. Progress in clinical management has often been made when grading scales have incorporated measurable biomarkers di- rectly related to the underlying pathophysiology, such as for choosing treatment options for gliomas or breast cancer based on biomarkers. TBI has been historically classified as mild, moderate, and severe, based exclusively on clinical features such as the level of consciousness or duration of post-traumatic am- nesia (PTA) [2]. The introduction of computerized tomography (CT) almost 40 years ago revolutionized the management of TBI, but primarily for the small subset (< 5%) of patients with TBI who require neurosurgical interventions. Over 90% of patients who sustain TBIs are classified in the mild end of the spectrum, including those injuries labeled as concussions. While most patients with a single mild TBI (mTBI) fully recover, some do not [3], leading to potentially prolonged suffering, impaired quality of life, and increased risk of post-traumatic sequelae. Because mTBI is so common, the cumulative social burden from mTBI approaches that arising from moderate to severe TBI [4], with treatment costs higher than those of more severe cases [5]. For decades, the cause of prolonged symptoms after mTBIs/concussions have been a subject of debate. This scientific confusion is reflected by the fact that mTBI has been defined more than 40 different ways in the scientific literature [6]. The situation is even more confusing for concussion, where there are no official or internationally agreed definitions [7]. The concept of concussion as a benign transient incident has prevailed until our times, and still strongly influences public opinion. However, recent work shows that even concussions can have long-lasting effects [8]. The inability to define concussion makes its use in clinical decision-making and research very problematic. There have been arguments made for classifying concussion as a type of mTBI [9]; yet, this position is not true in all guideline documents and, in practice, clinicians tend to use the terms mTBI and concussion synonymously. Studies in patients with “concussion” greatly overlap with studies in patients with mTBI, further confusing the field. In clinical reality, the ICD-10 diagnosis S06.0 (Commotio cerebri) is frequently used for patients with CT-negative TBI irrespective of the other clinical severity indices. These issues are of broad relevance as concerns about chronic traumatic encephalopathy (CTE) and other long-term sequelae of repetitive neurotrauma have spurred high-profile awareness campaigns, media discussions, and public health policies. In this discussion it often forgotten, that CTE seems to be more related to a large number of subconcussive impacts, than to the presence of a clearly demarcated TBI history. In this paper, we will point out how the current tools for assessing the severity of TBI are far from ideal, and current methods of classifying severity include numerous sources of error. We will discuss how assigning seemingly definitive severity labels to patients following TBI often leads to confusion and problems for patients, families, caretakers, and health care systems. For neurotrauma research, these problems have the potential to lead to study variability and inconsistency of results. Finally, we will propose a new approach for classifying TBIs and what will be needed to build a new and better classification. 2. TBI Severity: What Does It Really Mean? TBI severity can be assessed from several viewpoints (Table1) and varies depending on who is making the evaluation. Available measures of biological injury are not cur- rently used when assessing severity. Judgments about severity are context dependent, often subjective, and are influenced by the reference point and experience of the assessor. For example, a patient with life-threatening TBI surviving the critical early phase may recover to independent daily life, showing only mild deficits in the eyes of the neuro- surgeon, but severe cognitive deficits assessed by the neuropsychologist, and profound emotional/personality changes by the family. This creates challenges, as outcomes after TBI are so variable. Injuries judged as severe in the acute setting may show full recovery, whereas those thought to be mild can lead to disabling consequences. We fully acknowledge J. Clin. Med. 2021, 10, 148 3 of 12 that subjective views on outcome are not in any way specific to TBI, but simultaneously point out that few medical conditions are classified using such vaguely defined severity labels as in TBI. More importantly, because the whole concept of ’severity´ is so ill-defined, multifaceted and subjective, it should be abandoned and replaced with more appropriate descriptors, as discussed below. Table 1. Different viewpoints on TBI severity. Acute risk of death/mortality Quantifying brain biomarker efflux Risk/need for neurosurgical measures Level/intensity of treatment needed (home, ED 1, ward, ICU 2) Duration of hospital

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