James' World 2

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Fifteen years ago I slipped on a wet patio deck and fell backward, slamming the back of my skull into a pillar. I saw stars and briefly felt nauseated. But I picked myself up, checked that I wasn’t bleeding, and went about my day. The back of my head was sore for a few days, but there weren’t any lingering effects, and I didn’t see a doctor.

Still, those symptoms I did have might have been signs of a concussion, the common term for a mild traumatic brain injury (TBI). Such injuries are a lot more common than you might think and may cause long-term problems. When more than 600 average middle-aged people in the U.K. and Ireland were asked careful questions about past incidents in which they might have hit their heads, a full third turned out to have suffered a TBI of some kind. And nearly three million people in the U.S. are officially diagnosed with a TBI every year in emergency departments and hospitals. About 75 to 80 percent of their injuries are described as mild.

But “mild,” it turns out, can have consequences years later for many people. For example, in 2023 the multicenter TRACK-TBI study revealed that out of more than 1,200 people, 33 percent of those with mild TBI and 30 percent of those with moderate or severe TBI showed deterioration one to seven years after injury. Complaints can include problems sleeping, headaches, and memory and psychiatric issues. Long term, a TBI can lead to dementia, and it may also trigger several types of cardiovascular disease.

“What we need to do is pay more attention to what happens in the months and years after injury.” —David Sharp Imperial College London

Doctors have misunderstood or mis­diagnosed these problems because of an old way of looking at and thinking about concussions. For 50 years physicians have relied on symptoms they observe, such as loss of consciousness and motor or verbal changes, and on patient reports to classify traumatic brain injury as mild, moderate or severe. But this system isn’t very accurate at predicting either short- or long-term outcomes.

Experts have been pushing for change for several years. A 2022 National Academies report listed reclassification of these three grades, based on stronger evidence, as its first recommendation. “We know these terms are not accurate; they’re not precise. In fact, they can actually be problematic for patients,” says Nsini Umoh, who is the TBI program director at the National Institute of Neurological Disorders and Stroke (NINDS).

Now the field is doing something about the problem. After a January 2024 meeting hosted by NINDS, experts are proposing a new system of diagnosis and classification that provides neuro­bio­log­i­c­al detail instead of a vague term such as “mild.” Called the CBI-M model, it includes clinical symptoms (C), blood-based biomarkers (B), imaging (I), and modifiers (M). The last item includes social determinants of health, such as access to care.

If doctors use this model, they will have to approach concussions and their treatment differently. Breast cancer patients, for instance, are not told that

their cancer is mild or severe but are informed of the exact size of the tumor, whether it is estrogen-receptor-positive, and so on. People with a potential TBI could get that level of detail. Under the proposed guidelines, they will get a TBI score on a scale based on their responsiveness to a clinician’s questions (as they do today), as well as blood biomarker results and possibly imaging results. The biomarkers are proteins released in the brain in response to injury; new technology can measure concentrations of these proteins in the bloodstream. The U.S. Food and Drug Administration has approved two tests, for the proteins GFAP and UCHL1, that can predict whether intracranial lesions are present in the brain and whether a CT scan is warranted to confirm them.

Someone with no visible changes in imaging and low blood biomarkers would be told that their recovery prognosis was good. Someone with more worrisome indicators might be told to follow up with specialists over months or even years. Physicians would adjust these risk assessments based on modifiers—for example, a person with a history of mental health issues is at higher risk than someone without.

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