Traumatic brain injury: progress and challenges in prevention, clinical care, and research

Abstract

This Commission covers a range of topics that need to be addressed to confront the global burden of TBI and reduce its effects on individuals and society: epidemiology (section 1); health economics (section 2); prevention (section 3); systems of care (section 4); clinical management (section 5); characterisation of TBI (section 6); outcome assessment (section 7); prognosis (section 8); and new directions for acquiring and implementing evidence (section 9).Table 1 summarises key messages from the Commission and provides recommendations to advance clinical care and research in TBI.We must increase awareness of the scale of the challenge posed by TBI.If we are to tackle the individual and societal burden of TBI, these efforts need to go beyond a clinical and research audience and address the public, politicians, and other stakeholders.We need to develop and implement policies for better prevention and systems of care in order to improve outcomes for individuals with TBI.We also need a commitment to substantial long-term investment in TBI research across a range of disciplines to determine best practice and facilitate individualised management strategies.A combination of innovative research methods and global collaboration, and ways to effectively translate progress in basic and clinical research into clinical practice and public health policy, will be vital for progress in the field. Key messages Assess responses in three domainsEye (score range 1-4) Motor (score range 1-6) Verbal (score range 1-5) Add scores from the three components to give a sum score (3-15) GCS 13-15: mild TBI GCS 9-12: moderate TBI GCS 3-8: severe TBI Panel 2: Definitions of traumatic brain injuryWorld Health Organization definition 39 "...an acute brain injury resulting from mechanical energy to the head from external physical forces", excluding manifestations relating to "drugs, alcohol, medications, caused by other injuries or treatment for other injuries (eg, systemic injuries, facial injuries or intubation), caused by other problems (eg, psychological trauma, language barrier or coexisting medical conditions) or caused by penetrating craniocerebral injury."This broad definition of traumatic brain injury (TBI) is widely used, but some ambiguity exists as to what constitutes "an acute brain injury".Furthermore, the definition focuses on mild TBI, and therefore excludes patients with penetrating craniocerebral injury.American Congress of Rehabilitation Medicine definition 40 "A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following:(1) any period of loss of consciousness; (2) any loss of memory for events immediately before or after the accident; (3) any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused); and (4) focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following: loss of consciousness of approximately 30 minutes or less; after 30 minutes, an initial Glasgow Coma Scale score of 13-15; and posttraumatic amnesia (PTA) not greater than 24 hours."This definition is specific to mild TBI and excludes patients with more severe TBI, which conflicts with the concept that the severity of TBI lies along a continuum.Note that the term "concussion" is often used synonymously with "mild TBI".41 See figure 2 for classification of clinical severity with the Glasgow Coma Scale. National Institute of Neurological Disorders and Stroke definition1 "TBI is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force."This statement acknowledges potential confounders to TBI diagnosis, and suggests that symptomatology, imaging findings, details of the incident, and wider context should all be taken into account to inform diagnosis.1