Eye tracking to help determine concussion severity

Using an eye-tracking method may help spot concussions and help determine their severity.

A new eye-tracking method might help determine the severity of concussions, researchers report.They said the simple approach can be used in emergency departments and, perhaps one day, on the sidelines at sporting events.

"Concussion is a condition that has been plagued by the lack of an objective diagnostic tool, which in turn has helped drive confusion and fears among those affected and their families," said lead investigator Dr. Uzma Samadani. She is an assistant professor in the departments of neurosurgery, neuroscience and physiology at NYU Langone Medical Center in New York City.

"Our new eye-tracking methodology may be the missing piece to help better diagnose concussion severity, enable testing of diagnostics and therapeutics, and help assess recovery, such as when a patient can safely return to work following a head injury," she explained in an NYU news release.

According to researchers, it's believed that up to 90 percent of patients with concussions or blast injuries have eye movement problems. But the current method of assessing eye movement is asking a patient to track a doctor's finger, Samadani said.

The new method was originally developed by Samadani and her colleagues to assess eye movement in U.S. military personnel believed to have concussion or other types of brain injuries.

The researchers compared 75 trauma injury patients and a control group of 64 healthy people. The movements of the participants' pupils were tracked while they watched a music video for a few minutes.

Thirteen trauma patients who hit their heads and had CT scans showing new brain damage, and 39 trauma patients who hit their heads and had normal CT scans, were much less able to coordinate their eye movements than trauma patients who hadn't hit their heads and those in the control group.

The more severe the concussion, the worse a patient's eye movement problems, according to the study. Results were published online Jan. 29 in the Journal of Neurotrauma.

Dr. M. Sean Grady, chair of the neurosurgery department at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, said, "The importance of this study is that it establishes a reliable test and a 'biological' marker for detecting concussion." He was not involved in the study.

"Since concussion can occur without loss of consciousness, this can be particularly important in sideline evaluations in athletics or in military settings where individuals are highly motivated to return to activity and may minimize their symptoms. More work is needed to establish its sensitivity and specificity, but it is very promising," Grady said.

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$1 billion spent on brain scans each year for headache sufferers

A study shows that $1 billion is spent each year on brain scans for those who suffer from headaches when most of the scans may be unnecessary.

One in eight visits to a a doctor for a headache or migraine end up with the patient going for a brain scan, at a total cost of about $1 billion a year, a new study finds. 

And many of those MRI and CT scans -- and costs -- are probably unnecessary, given the very low odds that serious issues lurk in the patients' brains.

In fact, several national guidelines for doctors specifically discourage scanning the brains of patients who complain of headache and migraine. But the new study shows the rate of brain scans for headache has risen, not fallen, since guidelines for doctors came out. This may mean that patient demand for scans drives much of the cost.

The researchers suggest that better education of the public, and insurance plan designs that ask patients to pay part of the cost based on the likely value of the scan for them, may be needed to reduce unnecessary use and spending.

The research, published in JAMA Internal Medicine by a team from the U-M Department of Neurology, uses national data on headache-related doctor visits and neuroimaging scans by people over age 18, and calculates estimated total costs across multiple years.

In all, 51.1 million headache-related patient visits occurred between 2007 and 2010 -- nearly half of them related to migraine. The vast majority were by people under the age of 65, and more than three-quarters of the patients were women. In those same four years, 12.4 percent of these visits resulted in a brain MRI or CT.

The researchers estimated the total cost of the four years' worth of scans at $3.9 billion, based on typical Medicare payments to doctors for imaging.

"This is a conservative cost estimate based on what Medicare would pay for these tests. CTs and MRIs are commonly ordered for headache and migraine, and increasing over time, despite the fact that there are rare circumstances where imaging should be used," says Brian Callaghan, M.D., M.S., the U-M neurologist who led the team performing the study.

"Lots of guidelines say we shouldn't do this -- including ones from neurology and radiology groups -- but yet we still do it a lot. This is a source of tremendous cost in health care without a lot of evidence to justify the cost," he notes.

A billion dollars' worth of reassurance?

Doctors might order a CT or MRI scan for a headache or migraine to put patients' minds at ease about fears that a malignant brain tumor, aneurysm, arteriovenous malformation or other issue might be causing their symptoms.

And even if the patient doesn't meet the conditions that guidelines say can benefit most from brain imaging -- for instance, someone with an abnormal neurological exam or a known cancer -- doctors might order a scan at a patient's request to protect themselves legally.

But past research shows that only 1 percent to 3 percent of scans of patients with repeated headaches find that a growth or blood vessel problem in the brain is to blame. And many of the issues that scans spot turn out not to pose a serious threat -- or may not require treatment right away.

"There's solid research showing that the number of times you find serious issues on these scans in headache patients is about the same as that for a randomly chosen group of non-headache patients," he says. "And a lot of the things we find on such scans aren't necessarily something we will do something about."

Callaghan notes that the current study, based on data from the Centers for Disease Control & Prevention's National Ambulatory Care Medical Survey, couldn't detect which scans met guidelines and which didn't.

But the fact that 14.7 percent of people who saw a doctor for headache or migraine in 2010 went on to have a brain scan would not be expected if guidelines were being followed, he says. The team is working on further research into the appropriateness of the scans ordered for patients.

He also notes that the $1 billion a year estimate doesn't include other costs, including follow-up tests and any treatment that might be ordered if a scan finds something. And, CT imaging comes with a radiation exposure that itself carries risks, while MRI scans are more costly and have a higher chance of finding things that turn out to be of no concern.

"But doctors typically don't consider costs, and patients usually aren't paying directly for these scans," he notes. "Insurers may require prior authorizations but still cover the scans if they are ordered." In fact, he and his colleagues last year published a study showing that the cost of medical imaging ordered by neurologists cost more than the cost of all visits to neurologists added together.

The bottom line for headache patients who think they might want to have a brain scan, says Callaghan: if the doctor treating your headache doesn't think you need a scan, don't push them.

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Causes of headaches in children

This article discusses the many possible causes of headaches in children ranging from normal to serious causes.

Children’s headaches can be related to ailments, from allergies to ear infections to sinus problems, and most of the time they don’t indicate a dangerous illness.

But for many parents, the shadow of a terrible diagnosis lurks in the corner of the darkened room where a headachy child is lying with a cool cloth on her brow.

Sometimes, children with headaches need neuroimaging — brain CTs or MRIs. But recently several large studies have raised concerns about CT scans done on children because the radiation from these scans can increase the risk of eventually developing cancer, though that overall risk is still very small.

Doctors are being asked to follow guidelines for judicious use of these scans, but many parents remain unaware of the risks and guidelines. A study in the journal Pediatrics looked at a huge group of children who each saw a doctor at least twice with headaches but had no injury or trauma. More than 25 percent of those children got CT scans, the researchers found.

Children who brought their aching heads into emergency rooms were more likely to get scans than children visiting their regular doctors or neurology clinics.

“However, even outside the emergency room, the use of CT scans was quite high,” said Andrea DeVries, a director of research at HealthCore, a subsidiary of the insurer WellPoint, and the lead author of the study. About two-thirds of the children who received CT scans did not visit an emergency room, she noted.

Who does need neuroimaging? Doctors worry about a severe headache that gets worse, and about any abnormalities on the physical exam or changes that suggest a pathology in the brain. These changes can range from disturbances in gait or eye movements to confusion and lethargy.

Though nausea and vomiting commonly go along with migraines, vomiting can also indicate increased pressure in the brain. It can be a danger sign in a child who has recently had a concussion.

Symptoms like these quickly push a headache into the realm of a neurological emergency. Headaches that wake children from sleep or occur on just one side also may be cause for concern.

For children whose headaches don’t fit a clear migraine pattern, an eye exam is an important diagnostic step, said Dr. Andrew Lee, a neuro-ophthalmologist at the Methodist Hospital in Houston. An exam is also critical if parents have noticed any crossing of the eyes.

In serious situations, the eye exam may reveal signs of increased pressure in the brain. On a more mundane level, an exam may find that a child’s headache is caused by eye strain.

“The mother and father might not notice till reading age, third grade or fourth grade,” Lee said. Headaches that come on at that age, and are made worse by homework or reading, can be treated with glasses to correct poor vision and exercises to strengthen the eye movements.

And then there’s concussion. A 2012 study that looked at children who had head trauma found that three months after their injuries, many reported headaches. Most of the time, these children improve, but some will have headaches for months, and a very small percentage may have them for more than a year.

Heidi Blume, a pediatric neurologist at Seattle Children’s Hospital and lead author of the study, invoked a “SMART” mnemonic for helping children deal with their recurrent headaches. S is for sleep, she said, and getting enough of it. M is for not skipping meals and drinking enough to be properly hydrated. A is for physical activity, because too much or too little can lead to headaches, and R is for relaxation. T is for triggers to avoid, like cigarette smoke or particular foods.

Children can take painkillers (acetaminophen, ibuprofen and others; children should not take aspirin). Those with migraines may also benefit from preventive medicines. Counseling and biofeedback are important: Headaches can be triggered by stress, and living with chronic pain can cause depression. One goal in headache clinics is getting children back to school and helping them navigate regular activities while still avoiding their triggers.

“Many, many kids will outgrow their bad headaches,” said Dr. Daniel Bonthius, professor of pediatrics and neurology at the University of Iowa. “Exactly why they got the headaches and exactly why they go away, modern medicine doesn’t really understand.”

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MRIs Show Signs of Brain Injuries Missed in CT Scans

MRIs can show signs of traumatic brain injuries that cannot be seen in CT scans. 

The second best test is a history and exam by a specialist. 

The most sensitive test is a parent saying that their child is not right. JR

Hospital MRIs may be better at predicting long-term outcomes for people with mild traumatic brain injuries than CT scans, the standard technique for evaluating such injuries in the emergency room, according to a clinical trial led by researchers at the University of California, San Francisco (UCSF) and the San Francisco General Hospital and Trauma Center (SFGH).

Published this month in the journalAnnals of Neurology, the study was led by UCSF neuroradiologist Esther Yuh, MD, PhD and followed 135 people treated for mild traumatic brain injuries over the past two years at one of three urban hospitals with level-one trauma centers: SFGH, the University of Pittsburgh Medical Center and University Medical Center Brackenridge in Austin, Texas as part of a study called NIH-funded TRACK-TBI (Transforming Research and Clinical Knowledge in Traumatic Brain Injury).

All 135 patients with mild traumatic brain injuries received CT scans when they were first admitted, and all were given MRIs about a week later. Most of them (99) had no detectable signs of injury on a CT scan, but more than a quarter (27/99) who had a "normal" CT scans also had detectable spots on their MRI scans called "focal lesions," which are signs of microscopic bleeding in the brain.

Spotting these focal lesions helped the doctors predict whether the patients were likely to suffer persistent neurological problems. About 15 percent of people who have mild traumatic brain injuries do suffer long-term neurological consequences, but doctors currently have no definitive way of predicting whether any one patient will or not.

"This work raises questions of how we're currently managing patients via CT scan," said senior author on the study Geoff Manley, MD, PhD, the chief of neurosurgery at SFGH and vice-chair of the Department of Neurological Surgery at UCSF. "Having a normal CT scan doesn't, in fact, say you're normal," he added.

Better Precision Tools Needed for Head Injuries, Doctors Say

At least 1.7 million Americans seek medical attention every year for acute head injuries, and three quarters of them have mild traumatic brain injuries -- which generally do not involve skull fractures, comas or severe bleeding in the brain but have a variety of more mild symptoms, such as temporary loss of consciousness, vomiting or amnesia.

The U.S. Centers for Disease Control and Prevention (CDC) estimates that far more mild traumatic brain injuries may occur each year in the United States but the true number is unknown because only injuries severe enough to bring someone to an emergency room are counted.

Most of those who do show up at emergency rooms are treated and released without being admitted to the hospital. In general, most people with mild traumatic brain injuries recover fully, but about one in six go on to develop persistent, sometimes permanent disability.

The problem, Manley said, is that there is no way to tell which patients are going to have the poor long-term outcomes. Some socioeconomic indicators can help predict prolonged disability, but until now there have been no proven imaging features, or blood tests for predicting how well or how fast a patient will recover. Nor is there a consensus on how to treat mild traumatic brain injuries.

"The treatment's all over the place -- if you're getting treatment at all," Manley said.

The new work is an important step towards defining a more quantitative way of assessing patients with mild traumatic brain injuries and developing more precision medical tools to detect, monitor and treat them, he added.

If doctors knew which patients were at risk of greater disabilities, they could be followed more closely. Being able to identify patients at risk of long-term consequences would also speed the development of new therapeutics because it would allow doctors to identify patients who would benefit the most from treatment and improve their ability to test potential new drugs in clinical trials.

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Surprising Child Concussion Myths and Facts

Suppose your son or daughter has just been brought home from an athletic field with a concussion, complains of being tired and wants to go to sleep. Should you let that happen?

"There was a time when it was considered life-threatening to let someone suffering from a concussion to fall asleep," said Chris Hummel, a certified athletic trainer and clinical associate professor in Ithaca College's Department of Exercise and Sport Sciences. "But current research shows that sleeping is actually the best thing for a concussed player. Getting physical and mental rest helps an athlete recover from a concussion. But athletes should not be left alone the first night and should be seen by the sports medicine staff the next day."

Concussion management, Hummel added, is very complicated and should only be undertaken by athletic trainers, sports medicine physicians and others with specialized concussion training. Still, it's important for coaches, parents and athletes to know the difference between fact and fiction when applied to concussion basics.

Fictions

•A normal CT scan rules out a concussion. "A concussion results from a neuro-metabolic event brought on by the trauma," Hummel said. "Simply put, there is an imbalance of the needed chemicals or fuel that helps the brain function when an athlete is concussed. That's not a structural injury, so a CT scan won't pick it up. CT scans can only view structural damage."

•A player who has been knocked unconscious will suffer a worse concussion than a player who didn't lose consciousness. "A player doesn't have to be knocked out to sustain a serious concussion," Hummel said. "In some cases, individuals who are knocked out may suffer less severe trauma. In either case, the severity of the concussion might not be known for days or weeks."

•Male athletes sustain more concussions than female ones. "Male athletes sustain concussions at similar rates as female ones," Hummel said. "However, recent studies have shown that symptoms might vary by gender, as males with concussions experience more physiological issues such as balance problems while females experience more psychosocial issues such as fatigue or low energy."

•A grade-one concussion is less serious than one that's a grade-three. "We used to grade concussions during the initial diagnosis, but we no longer do that because we now know it's difficult to accurately assess the severity of a concussion right away," Hummel said. "We have to wait and see how the symptoms resolve over time before we can determine how significant the concussion is or is not."

•The harder someone is hit, the worse the concussion. "It doesn't always take a big hit to produce a concussion," Hummel said. "Any contact to the head or body that causes rapid head movement can cause a concussion. It's also important to point out that several lower impacts over time might be more serious than a single collision of great force. For example, offensive linemen in football, who experience contact on almost every play, could be more at risk for permanent brain damage than a wide receiver who absorbs a single hard hit once or twice a game."

•Athletes can soldier through a concussion. "No," Hummel said. "Typically, it takes one to two weeks for concussion symptoms to resolve and for the brain to begin operating back at full capacity. Just because an athlete states his or her head has cleared, it's no indication that he or she should go back into the game. It is not safe to go back on the field the same day after experiencing concussion-like symptoms."

•Concussions are the same for adults and adolescents."Adolescent brains are still developing," Hummel said. "The effects of a concussion on young athletes are more dynamic than on mature ones and may take longer to recover from."

•Helmets prevent concussions. "Helmets are designed to prevent skull fractures, not concussions," Hummel said. "If a helmet is fitted properly, it might reduce the risk or severity of concussions, but no one helmet is capable of preventing a concussion, yet!"

Facts

•An athlete who has had one concussion is more likely to have another than an athlete who hasn't been concussed."Once an athlete has experienced one concussion, the threshold for sustaining another concussion can be diminished. Also, if a player sustains another blow before he or she is fully recovered, the resultant symptoms can be worsened and result in a prolonged recovery. There is also a rare phenomenon called Second Impact Syndrome that can cause impaired brain blood flow or even death if an athlete suffers another trauma before fully recovering."

•Concussions should be treated and managed on an individual basis. "The brain is an incredibly complex organ, and so are the neurochemical processes that govern it," Hummel said. "No two concussions are exactly alike anymore than the brains of any two individuals are identical. Concussion management begins by obtaining individual baseline (pre-injury) testing for each athlete. Once a concussion occurs you will then know what is 'normal' for that athlete. Once the athlete has become symptom-free and is back to his or her baseline test scores, a progressive return to play plan should be followed. This progression should consist of rest, light exercise, noncontact drills and then full practice before returning to game competition. Each level of recovery should take 24 hours. An athlete has to continue being symptom-free to proceed to the next level."

•If you suspect a student-athlete of having a concussion, assume it's a concussion. "If an athlete describes having a headache or dizziness, shows signs of balance problems, or difficulty remembering, assume that player is concussed and have him or her evaluated by an athletic trainer or a physician trained in sports medicine," Hummel said.

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