The Journal of Neurotrauma - 5

EXPERT PANEL DISCUSSION
looked at that, those people would meet some sort of
diagnostic criteria, then, for having a TBI, because
even if we roll back to a more clinical assessment, such
as the ACRM, they did meet the ACRM criteria with
that. They simply did not have a positive head CT or
positive MRI, but they had an elevated GFAP.
So I think that as these tests roll out and they become
more widely available, we will find that some of those
patients who do not come into the hospital and do not
have an injury that would bring them to a level 1
trauma center in fact may have an elevated GFAP.
This brings us back to the diagnosis versus prognosis. I suspect that if you had done a GFAP test or one
of these other biomarkers after one time when I fell off
a ladder hanging up holiday lights at my house, it
might have been elevated. The question is, what were
the long-lasting effects of that?
This is another thing that we need to tease out.
Simply having these elevated blood-based biomarkers may be indicative of an injury, but may or may not
be indicative of long-term issues. So what I would say
is that as we look, we probably will find injuries in
these populations that you are referring to, Dr. Marion. I think that the more sensitive these biomarkers
become and as we begin to understand them more, we
will also begin to reveal more injuries than we could
have before.
The real questions are, that when these injuries happen, what are the consequences, and what is it about the
person who has this injury that may predict those consequences? That is, what does the person bring to the
injury? And conversely, what does the injury bring to the
person? I think these are all questions that need to be
worked out in the future. But I think sometimes we put
the cart before the horse, so to speak, and we quickly
jump to prognosis when in fact we still have not worked
out the whole diagnostic model yet, which is, I think, the
focus primarily of this conversation today.
Dr. Marion: Dr. Bazarian, does the timing of
concussion diagnosis matter? Does that impact
outcomes?
Dr. Bazarian: I think it has potential to impact outcomes, particularly when the implication of missing it
involves sending someone back to an activity where
they could get hit again. I am thinking about sports as
well as Military activities.
In sports, the implications of not making a diagnosis
would impact someone possibly getting hit again, and
two concussions back to back mean that the outcome
would be worse. A delay in that diagnosis could potentially mean a prolonged outcome for an athlete.
For a war fighter, the concern is that if the diagnosis
is missed early the performance of the war fighter
would be somehow impaired, which would put not
ª 2020 by MARY ANN LIEBERT, INC.

only them at risk, but the people that they were
working with at risk as well. So, yes, making that diagnosis early is important.
There is an emerging thought that the earlier
this diagnosis is made, the earlier people get to treatment and the less likely they are to suffer prolonged
symptoms, but I think it is a fairly nascent idea. I do not
really know that it has been established. But I think
that there is some convergence of low-level evidence
suggesting that early diagnosis is the key to early
treatment and reducing prolonged recovery.
Dr. Marion: There is a recent article about that.6
Dr. McCrea, what are your thoughts about that?
Does timing of a diagnosis effect outcomes?
Dr. McCrea: For certain, and some of the work that
Dr. Barzarian was referring to has implications not
only in both sport and Military, but in civilian brain
injury.
There have been a couple studies from the
Concussion Assessment, Research, and Education
(CARE) Consortium indicating that there is a subgroup of athletes who never report their injuries at all,
and then there is another subgroup that plays a sort of
wait-and-see game. They are injured on Saturday
afternoon in a football game. They feel lousy, but
they elect to sleep on it, and if they still feel lousy on
Monday, they come to the training room and report
the injury. That actually turns out to be a very sizable
percentage of athletes, and I suspect there is a similar
scenario in the Military.
We found that those late reporters, who are not
immediately engaging in formal evaluation and treatment by an expert, end up with longer recovery time,
and on average, they return to play about three days
later than athletes who report their injury immediately
and engage in expert evaluation and treatment with a
trained clinician.
That starts to be the currency that athletes and
Military Service Members can understand. We can
talk to them all day about the hazards, but they are
not really interested in that. If we talk to them about
how late reporting comes with certain risks, but also
might be detrimental to your eventual return to play
time, then they start to listen to that dialogue a bit
more and might be more inclined the next time to
come forward immediately for evaluation and
treatment by an expert.
Dr. Marion: Thank you, Dr. McCrea. We have established a rationale for early and hopefully the
objective and correct diagnosis of this problem.
Dr. Puccio, from your perspective, what are the
most promising technologies for the objective diagnosis of concussion?
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