Head Trauma Breakthroughs

Army veteran Joe Montanari sits before an array of computer screens in an exam room at the Virginia Commonwealth University Medical Center. He sports a T-shirt, long beard and full sleeves of tattoos – also, headphones, a microphone and a sensor-equipped headband. When prompted, he reads aloud from a screen and answers related questions. Later, it’s simple math problems.

What’s going on? The 40-something suffered a series of mild traumatic brain injuries, commonly known as concussions, while serving in the Iraq War around 2002. He’s one of 2,300 participants in a new study seeking to understand later-in-life effects and develop related treatments.

The tests help measure cognitive response and brain activity, says Dr. David Cifu, who directs VCU’s Center for Rehabilitation Sciences and Engineering and is leading the five-year, $50 million study. Combined with blood biomarkers and other biological assessments, the data helps researchers map patients’ brains and home in on potential anatomical problem areas.

STUDYING HEAD TRAUMA

Spearheaded by VCU, the study began in 2019 and is a partnership between the U.S. Department of Defense, 30 universities, 12 military treatment facilities and 15 Veterans Affairs medical centers. It is the largest and most comprehensive of its kind ever conducted.

Cifu says its goal is essentially threefold. First comes studying the long-term effects of repeat concussions and head trauma. Second, standardizing diagnostic techniques. Third, trials for drugs that could slow or prevent the development of later-in-life conditions – like dementia, Parkinson’s, chronic pain and more.

“The past 10 years have brought some really promising drugs,” says neurologist Randy Merchant, M.D., who spent nearly 40 years studying traumatic brain injuries as a VCU professor and director of the Virginia Neuroscience Institute. “But until now, we haven’t been able to conduct clinical trials that are large enough, or targeted enough, to reliably test their efficacy.”

“Studies like the one being led by Dr. Cifu are going to revolutionize treatment around these injuries,” says Merchant, 68. “And it’s going to happen very, very soon.”

MUCH-NEEDED PROGRESS

Merchant doesn’t use the word “revolution” lightly. He helped pioneer traumatic brain injury science in the U.S. and was among the first to study pharmaceuticals aimed at curbing later-in-life issues. He calls the road to today’s breakthroughs a long battle.

“When I was starting out, our assessment tools were, by today’s standards, incredibly primitive,” says Merchant, who joined the VCU faculty around 1980.

Back then, doctors were limited to conducting physical exams looking for telltale symptoms like improperly dilated pupils. Questions like “What day of the week is it?” looked for trauma-induced cognitive dysfunction. Diagnosis was essentially subjective.

Beyond surgical intervention for acute injuries, “All you could do was prescribe rest and follow-up assessments,” says Merchant. The majority of patients got better on their own. But a small percentage didn’t. What’s more, symptoms reemerged unpredictably.

Some reported impaired balance within a few weeks. Others felt great for six months, then got sudden bouts of vertigo. Others were beset by chronic headaches a year later. What was going on?

“Basically, we were in the dark,” says Merchant. That changed as technology like CT scans and MRIs became commercially available in the 1980s and were improved in the 1990s. “The technology gave us the ability to look directly at the brains of head trauma patients.”

CONCUSSION TRAUMA

A better picture of concussions emerged. For starters, they accounted for more than 80 percent of all reported head injuries. And neurologists now understood their anatomical effects.

“Concussions involve a disruption in the normal function of the brain caused by a sudden force, bump or blow to the head that forces the brain to rapidly accelerate and then decelerate,” explains Merchant. In a nutshell, the bursts of movement stretch brain tissues beyond their capacity, causing nearly imperceptible separations and tears. Improper healing or repeat traumas can lead to short-term cognitive dysfunction and issues later in life.

Longitudinal studies of such patients in the late-2000s showed increased likelihood of developing diseases like Parkinson’s and dementia – for instance, according to the Alzheimer’s Association, older adults “with a history of moderate brain injury had a 2.3 times greater risk of developing Alzheimer’s than seniors with no history of head injury.” Understanding the risks brought better methods for detecting symptoms earlier.

“A lot of times, later-in-life problems start with [loved ones] noticing subtle shifts in behavior,” says Merchant. A husband tears up during sitcoms when he never did before. Perpetually good-natured Mom gets angry for no apparent reason during phone calls.

Still, doctors wanted to do better.

“The question became, can we identify markers that will tell us if a person is likely not to heal on their own?” says Merchant. And what about tests to detect anatomical abnormalities related to concussions suffered 10, 20, 30 years in the past?

Such markers could identify patients at risk for neurodegenerative disorders and help them seek preventive measures.

HOPE FOR THE FUTURE

Advances in blood testing and understanding around brain function have, in recent years, led to major breakthroughs. Cifu and other doctors have developed increasingly sophisticated methods of isolating and detecting proteins that enter the bloodstream after a concussion, as well as those that stem from past injuries.

The discoveries have enabled neurologists to better assess anatomical damage and develop specifically targeted drugs. Merchant calls them “the Holy Grail of traumatic brain injury science.”

“This is what we’ve all been working toward and dreaming about for the past 30-40 years,” he says. “This is going to help countless people all around the world … These drugs have the potential to extend lives and drastically improve the quality of later years.”

The good news? They’re likely to be available within the next five years or so.

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Eric J. Wallace is a freelance journalist whose work has appeared in more than 50 local, regional and national media outlets. He is a contributing editor for Gastro Obscura.