Saving hope and preventing traumatic brain injury

Saving hope and preventing traumatic brain injury

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By: Stanley Zhang, BM, CRA, Michael Cusimano, MD, MHPE, FRCSC, DABNS, PhD, FACS

Relative to its burden on society or the amount of research on HIV and cancer, traumatic brain injury (TBI) has not drawn the research attention it deserves. Recently, increased media attention has changed the amount of research devoted to understanding TBI, but there is still a long way to go to fully grasp the ramifications of this “silent epidemic.”

Types of TBI
TBI can be classified in many different ways. The commonest classification is based on severity, which ranks the extent of brain damage and symptoms manifested clinically (as measured by the level of the patient’s Glasgow Coma Score (GCS) shortly after injury) as mild, moderate, or severe.

Mild TBI is the most common, and fortunately, the extent of damage to the brain is usually limited. Symptoms may include headache, confusion, nausea, lightheadedness, dizziness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, a change in sleep patterns, behavioural or mood changes, and trouble with memory, concentration, attention, or thinking. The person may lose consciousness. If loss of consciousness is involved, the duration is often short—measured in seconds or minutes. A CT or MRI scan is usually negative and most patients can recover from mild TBI without any sequelae. A small number of these patients have prolonged disability, but it is not known exactly why these patients suffer with symptoms for so long. It is clear, however, that the likelihood of showing permanent neuro-cognitive effects, such as depression and personality change, is positively correlated with the number of mild TBI events experienced.

In moderate TBI, the patient often has impaired consciousness of a greater degree for a longer period of time. As recovery from injury progresses, symptoms similar to those seen in mild TBI can occur, but they usually are more severe and longer lasting. These patients usually have a positive CT or MRI scan. Furthermore, patients often have persisting sequelae that can be picked up on physical or neurocognitive assessments and often have persisting changes such as cognitive deficits or issues with impulse control.

Severe TBI is the least common and these patients, by definition, present in coma. These injuries are often the result of traffic trauma, severe falls, violence, or workplace injury. Violence can be both an antecedent to TBI as well as a consequence of TBI. Young men are particularly at risk of severe TBI and violence. Outcome from severe TBI often depends on a variety of factors, such as the level of the patient’s GCS, brainstem function, and age. Recovery back to baseline health is unlikely and death may occur.

Treatment and prevention of TBI

Significant research on brain injury relates to interventions administered after an event has occurred. One aspect of this work focuses on preventing secondary injury—such as progressive hemorrhage and ischemia—by providing rapid emergency responses and immediate surgery. Indeed, our modern medical systems are organized around the prevention of secondary events. Another component of TBI research deals with the rehabilitation of these patients to optimize their return into society. Neurosurgeons are involved primarily in the first component and in extending their findings to the rehab phase. However, most neurosurgeons realize that prevention of brain injury will inevitably have a better outcome than even the most ideal cures. This is exactly where Dr. Michael Cusimano believes we need to focus our energy: we need to intervene before the TBI event occurs.

In North America, neurosurgeons have recognized the importance of TBI prevention for 20 years and have formalized it through an organization called ThinkFirst / Pensez D’Abord. In Canada, Dr. Charles Tator and Dr. Michael Cusimano have been the most vocal proponents of TBI prevention. As a neurosurgeon and professor of Neurosurgery, Education and Public Health, and full IMS member, Dr. Cusimano also founded the Injury Prevention Research Office at St. Michael’s Hospital more than 15 years ago; education and knowledge translation are essential to injury prevention, and Dr. Cusimano sought to make it a focus of the Research Office (1-7). The goal of his research is to understand the “who,” “when,” “where,” “why,” and “how” of TBI at all severity levels, and to study the effectiveness of methods to prevent TBI (8-14).

Dr. Cusimano has published several works about TBI in ice hockey and other sports. He was once a “lone voice,” often ostracized by colleagues a decade ago, when his review of the literature concerning TBI in hockey called for a ban or at least major modifications regarding body checking in the sport. Since then, many papers have supported this stance. Last year, the National Hockey League instituted “Rule 48” which bans hits to the head, and many youth hockey leagues followed suit.

Dr. Cusimano currently leads a major CIHR-funded grant exploring the potential relationship between violent behaviour in Canadian society and TBI, and more specifically, the common modifiable risk factors of both. Investigators seek to develop and evaluate knowledge translation strategies to prevent TBI and violence, particularly in populations deemed most vulnerable. The project is undertaken by a multidisciplinary team of roughly 30 ambitious scientists in seven institutions across Canada and is centered at St. Michael’s Hospital in Toronto. Overall, the team is exploring the antecedents and upstream factors associated with TBI and violence in Canadian society to provide an evidence base for their prevention, influence knowledge translation into factors like public policy and engineering pertaining to injury prevention, and to set in motion further research to understand and correct the problem. In short, the research team aims to save hope and prevent TBI.

For more information on the above study—Traumatic Brain Injury and Violence: Reducing the risks, improving the outcomes—please visit: and

  1. Cooke DJ, Cusimano MD, Tator CH, Chipman ML. Evaluation of the Think First Canada Smart Hockey Brain and Spinal Cord Injury Presentation Video. Injury Prevention 2003;9:361-366.
  2. Isaac D, Cusimano MD, Mansfield E Chipman M, et al. Child Safety Education and the World Wide Web: An Evaluation of the Content and Quality of Online Resources. Injury Prevention 2004;10:59-61.
  3. Echlin PS; Cusimano MD. A prospective study of concussion education among two elite junior age ice-hockey teams: implications for sports concussion education. Neurosurgical Focus 2010; 29(5):E6.
  4. Cusimano MD; Kwok J. Skiers, Snowboarders, and Safety Helmets. JAMA 2010;303(7):661-662.
  5. Cusimano MD, Josse JM. The Effect of a Skiing/Snowboarding Safety Video on the Increase of Safety Knowledge in Canadian Youth–a Pilot Study. International Journal of Circumpolar Health 2006;65(5):385-388.
  6. Cusimano MD, Taback NA, McFaull SR, et al. Research Team in Traumatic Brain Injury and Violence: Effect of bodychecking on rate of injuries among minor hockey players. Open Med. 2011;5(1):e57-64.
  7. Cusimano MD, Chipman M, Glazier RH, et al. Geomatics in Injury Prevention: the science, the potential and the limitations. Injury Prevention 2007;13(1):51-56.
  8. Ray JG, Moineddin R, Bell CM, et al. Alcohol Sales and Risk of Serious Assault. PLOS Medicine 2008; 5:1-7.
  9. Cusimano MD, Mascarenhas AM, Manoranjan B. Spinal Cord Injuries Due to Diving: A Framework and Call for Prevention. Journal of Trauma Injury, Infection, and Critical Care 2008;65:1180-1185.
  10. Rinner C, Cinnamon J, Cusimano MD, et al. Online Map Design for Public Health Decision Makers. Cartographica 2009;44(4):291-302.
  11. Cinnamon J, Rinner C, Cusimano MD, et al. Evaluating Web-based Static, Animated, and Interactive Maps for Injury Prevention. Geospatial Health 2009;4(1):3-16.
  12. Cusimano MD, Marshall S, Rinner C, et al. Patterns of Urban Violent Injury: a spatio-temporal analysis. PLoS ONE 2010;5(1):e8669.
  13. Harris MA, Reynolds CC, Winters M, et al. The Bicyclists’ Injuries and the Cycling Environment study: a protocol to tackle methodological issues facing studies of bicycling safety. Injury Prevention 2011;17(5):e6.
  14. Cusimano MD, Luong WP, Faress A, et al. Evaluation of a Ski and Snowboard Injury Prevention Program. International Journal of Injury Control and Safety Promotion 2012 Jan 9. [Epub ahead of print]