Download Are TBIs being diagnosed accurately?

Are TBIs being diagnosed accurately?
Medical advances over the past few decades have improved diagnosis of TBI. Nevertheless,
many factors make diagnosis tricky.
Around 1975, hospitals began installing a new kind of machine for a diagnostic procedure called
X-ray computerized tomography — the now familiar CT scan. A computer hooked to an X-ray
machine gathers data from multiple scans of a patient's head, then assembles a three-dimensional
image that can distinguish between brain tissue and blood in the brain by the different ways in
which the two materials block the X-ray beams. CT scanners in emergency rooms can reveal
deadly brain bleeding in some patients before irreversible damage occurs, for example.
Some organizations have instituted programs to improve diagnosis for high-risk groups, such as
athletes and service members.
The National College Athletic Association (NCAA) now bases sideline scrutiny of potential
TBIs on widely accepted medical standards. Coaches are advised not to rely on their own
judgment of whether a player is concussed but to get a clinician's evaluation.
The military is going further. In 2008 the Pentagon mandated “baseline predeployment
neurocognitive testing” for all service members to give medics an assessment of each person's
normal, noninjured brain and facilitate later TBI diagnosis. Brains are ultra-complex and highly
individual, so it helps to know how an individual's normal brain functions before declaring that a
bomb blast, for example, has indeed created abnormalities that point to a TBI.
Using in-depth interviews along with CT scans, clinicians can accurately diagnose TBIs and
differentiate them from other conditions, such as post-traumatic stress disorder (PTSD), an
anxiety disorder that can also result from a bad accident or other trauma, says Robert Sbordone, a
neuropsychologist in Laguna Hills, Calif., and longtime scholar in the field. For one thing, an
accident victim with PTSD but no TBI will remember the accident clearly, but a TBI sufferer
won't, he says. “I ask, ‘What happened when you first got into the car? What was the weather?’”
— questions that can establish whether there's a period for which the patient has no memories.
Diagnosing mild TBIs in service members can be difficult because the military's tendency to
maintain a stiff upper lip in the face of physical challenges makes many reluctant to discuss
symptoms, says Rodney Vanderploeg, supervisory psychologist for neuropsychology and
polytrauma at the James A. Haley Veterans' Hospital, in Tampa. To correctly diagnose and heal,
both patients and clinicians “need patience and to be open, honest and forthright,” he says. “That
takes trust and time,” elements that the VA has tried to build into its TBI care system, he says.
Despite progress, diagnosis of milder TBIs remains spotty, however.
“There's no question that we're not capturing all the injuries,” says Alisa Gean, a professor of
radiology, neurology and neurosurgery at the University of California, San Francisco.
In one study, for example, trauma centers missed mild TBIs in “over half” of patients, says
Ronald Ruff, a clinical neuropsychologist and rehabilitation psychologist in San Francisco.
Many TBI patients come to the hospital with multiple injuries, and if a patient answers “I'm fine”
to doctors' cursory questioning about concussion, physicians may dismiss the TBI possibility and
get busy treating injuries that seem more pressing, such as a spinal-cord injury, Ruff says.
TBI symptoms can be slow-developing and thus easily missed in trauma care, says Sbordone.
Some emergency rooms lack CT scanners, and sometimes “a scan comes back normal” in the
early going, if bleeding in the brain is slow, he says.
An accurate diagnosis can hinge on a patient interview, but “we know that patients can look and
feel normal and say they're back to their baselines when they're not,” says Gean.
There's no “simple lab test” that provides a sure diagnosis or distinguishes TBI from PTSD, for
example, says David Cifu, national program director for physical medicine and rehabilitation
(PMR) services at the VA and a professor of PMR at Virginia Commonwealth University, in
Richmond. For this reason, the VA uses a team of clinicians from different specialties, including
neurology and psychology, he says.
Clinical tools currently available don't give a clear picture of TBIs' many possible nuances, and
few emergency-room personnel are TBI specialists.
One standard tool, the Glasgow Coma Scale, classifies TBIs as mild, moderate or severe based
on emergency personnel's assessments of patients' behaviors, such as whether and how often
they blink, for example, says Connors at the Brain Injury Association of America. “But that
initial score doesn't take into account the cascade of secondary injuries” that occur in the hours
and days after a TBI and doesn't even distinguish between wounds in which an object penetrates
the brain and so-called “closed-head” injuries, she says.
“I've seen some people with [bad] Glasgow Coma Scale [ratings] do very well and people [who
rate as only ‘mildly’ injured on the] scale do very badly,” says Brent Masel, president of
Transitional Learning Center, a rehabilitation center in Galveston, Texas, and national medical
director for the BIAA. “As of yet, we have no good way of surely categorizing” TBIs, so “all we
can do is be vigilant” about how patients' conditions develop.
“With TBI, the trauma can be of different magnitudes and can come from the front, from the
back or side of the head. So there's not really a predictable pattern” that imaging machines, such
as CT scans and MRI machines, can pick up, as there is with most other brain ills, such as
multiple sclerosis or stroke, says Michael Weiner, a professor of medicine, radiology and
psychiatry at the University of California, San Francisco, and director of the VA's Center for
Imaging of Neurodegenerative Diseases.
Furthermore, scientists now know that psychological problems such as PTSD can change the
brain in much the same way that TBIs can. As a result, “it is often unclear if a service member,”
for example, “is suffering primarily from biological damage … or a psychological injury,” says
the advocacy group Iraq and Afghanistan Veterans of America (IAVA).