Harvard Humanitarian Initiative, Harvard University, and T.H. Chan School of Public Health, Cambridge, MA 02138, USA.
Woodrow Wilson International Center for Scholars, Washington, DC 20004-30217, USA.
Mil Med. 2022 Jul 1;187(7-8):e933-e937. doi: 10.1093/milmed/usab373.
In this report, we discuss the controversy of the diverse traumatic brain injury (TBI) categorization and taxonomy and the need to develop a new multidimensional and multidisciplinary categorization system that can be an aid in improved diagnostic and prognostic outcomes. Of interest, the heterogeneity of TBI marks the major obstacle to develop effective therapeutic interventions. Currently, the Glasgow Coma Scale has been utilized to guide in the prognosis and clinical management of TBI; it does not encompass the pathophysiological mechanisms leading to neurological deficits that can impede therapeutic interventions and consequently the failure of clinical trials. An unfortunate gap exists between advances in TBI research and existing U.S. Department of Defense (DoD) definitions, categorization, and management. Part I illustrates a unique posterior-focused TBI case report that does not fit any existing TBI definitions. Part II summarizes new animal-based TBI research that supports the case report as a legitimate TBI category. Part III critiques existing TBI criteria and their controversies.
Current DoD definitions and decision-making protocols based on concussion time alone are reviewed and compared to the myriad of additional TBI definitions that further illustrate the marked differences in definitions, especially in mild TBIs.
The DoD definitions are not consistent with what academic research and science bring to the debate. With increasing world conflicts and wars, evaluators are not prepared to accept, evaluate, and properly manage those TBIs that are not associated with immediate levels of unconsciousness alone as the prime determinant of diagnosis and long-term severity. Despite comprehensive research, current understanding among decision-makers of progressive pathology of non-hemispheric TBIs remains limited, inconsistent, and confusing.
This dilemma requires a multidisciplinary, science/medicine-led panel to actively reassess TBI criteria that take into consideration the latest research including non-cerebral hemispheric injuries. We recommend that DoD/Veterans Affairs establish a commission to regularly review the academic-related scientific evidence and incorporate these findings in a timely fashion into their operational definitions. This would guarantee that recognition, diagnosis, and follow-up of all TBIs are properly understood, managed, and documented.
在本报告中，我们讨论了外伤性脑损伤（TBI）分类和分类学的争议，以及需要开发一种新的多维和多学科分类系统，以帮助改善诊断和预后结果。有趣的是，TBI 的异质性标志着开发有效治疗干预措施的主要障碍。目前，格拉斯哥昏迷量表（Glasgow Coma Scale）已用于指导 TBI 的预后和临床管理；它不包括导致神经功能缺损的病理生理机制，这些机制会阻碍治疗干预措施的实施，从而导致临床试验失败。TBI 研究的进展与美国国防部（DoD）现有的定义、分类和管理之间存在不幸的差距。第一部分说明了一个不适合任何现有 TBI 定义的独特的后部聚焦 TBI 病例报告。第二部分总结了新的基于动物的 TBI 研究，这些研究支持将该病例报告作为一个合法的 TBI 类别。第三部分批评了现有的 TBI 标准及其争议。
审查并比较了基于脑震荡时间的现行 DoD 定义和决策方案，以及进一步说明了定义差异很大的许多其他 TBI 定义，尤其是在轻度 TBI 方面。
DoD 的定义与学术研究和科学带来的争议不一致。随着世界冲突和战争的增加，评估者还没有准备好接受、评估和正确管理那些不仅仅与即刻的无意识水平相关的 TBI，因为这是诊断和长期严重程度的主要决定因素。尽管进行了全面的研究，但决策者对非半球性 TBI 的进行性病理的理解仍然有限、不一致且令人困惑。
这种困境需要一个多学科、以科学/医学为导向的小组来积极重新评估 TBI 标准，这些标准要考虑到最新的研究，包括非大脑半球损伤。我们建议国防部/退伍军人事务部成立一个委员会，定期审查与学术相关的科学证据，并及时将这些发现纳入其业务定义。这将确保所有 TBI 的识别、诊断和随访得到正确的理解、管理和记录。
