Guest post from Brent R. O’Neill, MD
University of Colorado, Children’s Hospital Colorado
A retired pro-linebacker, an army general, a cable news personality, and a neurosurgeon walk into a bar . . .
Actually, on May 1, 2016, they walked into Chicago’s McCormick Place for the Opening Ceremonies of the 84th AANS Annual Scientific Meeting. The topic tackled, attacked, interrogated and dissected by such a distinguished and diverse panel was, of course, concussion — a subject that has seen an explosion in scientific and media attention over the past decade.
The format was a panel discussion moderated by neurosurgeon and CNN chief medical correspondent Dr. Sanjay Gupta. The panelists represented diverse groups interested in concussion. Jeff Miller, the senior vice president of health and safety for the National Football League (NFL), and Mike Singletary, a long-time Chicago Bears linebacker and NFL Hall-of-Famer, in representing the contact sports arena.
Retired General Peter W. Chiarelli and Geoffrey Ling, MD, PhD, Col. (Ret) represented the military perspective. In recent years, Gen. Chiarelli has taken his military concussion work to the private sector, now serving as CEO of One Mind, a company devoted to benefiting individuals with brain injury and illness through research and advocacy. Col. Ling, a neurocritical care physician with 27 years of army service, also shared his experience, including his work at the Defense Advanced Research Projects Agency (DARPA).
Discussing the perspective of the neuroscience community were Walter J. Koroshetz, MD — director of the National Institute of Neurological Disorders and Stroke (NINDS) — and Russell R. Lonser, MD, FAANS — former chief of the surgical neurology branch at NINDS and current chair of neurosurgery at The Ohio State University Wexner Medical Center.
H. Hunt Batjer, MD, FAANS, AANS president, introduced the panel and framed the discussion. He started with a few well-accepted facts:
- First, traumatic brain injury (TBI) is a BIG problem;
- TBI is the leading cause of death and disability among those under 45-years old;
- Five million Americans currently suffer from TBI-related disability;
- TBI costs the U.S. economy $76 billion per year; and
- Sports-related TBI, the vast majority of which are concussions, afflicts 3.8 million individuals each year.
Dr. Batjer also addressed the science related to chronic traumatic encephalopathy (CTE). He noted that CTE can be reliably diagnosed by a collection of phosphorylated tau protein in the perivascular spaces at the depths of sulci on autopsy, but beyond that, there are many unanswered questions.
Early in the event, Singletary described his experience of a concussion from a blindside hit delivered by his former teammate William “Refrigerator” Perry in the 1985 Super Bowl. “It was frustrating and like a blur.”
That comment could aptly describe the state of concussion care today — frustrating for the lack of any established therapy and consensus definition, while at the same time, the media, courts and public opinion play fast and loose with the facts.
The military men on the panel expressed frustration at the lack of progress on the issue. Gen. Chiarelli and One Mind have worked for two years to institute mandatory screening and distribution of concussion information in civilian emergency departments — with little success. In contrast, when he was in the military, he was able to devise a full concussion protocol for the army and to implement it in the front-lines of two war zones in the space of one month.
Col. Ling echoed this frustration, extolling the need for leadership and focus in the scientific community and calling for a scientific strategy to be “targeted, targeted targeted” — a line that drew the most exuberant applause of the evening.
Dr. Koroshetz provided a counterweight to these impassioned pleas. He coolly explained the methodical strategy by which the NINDS is attempting to unravel the challenges of CTE:
- How to diagnose CTE pre-morbidly (tau positron emission tomography, or PET, scans look promising but still need work);
- Assessing with a prospective cohort the relationship between severity of symptoms, types of symptoms and severity of pathology; and
- Study of patient-specific risk factors that can lead to risk-avoidance interventions.
To the NIH approach, Col. Ling added the NFL’s crowd-sourcing efforts and reported the results of two material science challenges. One — which asked the question “Can you come up with a better way to diagnose concussion?” — garnered 400 submissions. The second challenge aimed to devise concussion mitigating football equipment and yielded over 500 responses, including a start-up helmet company in Seattle and an impact-absorbing artificial turf company in Detroit. All of which serves as a testament, according to Ling, to the societal interest in sports and the ability to leverage that for a cause.
The conversation ranged widely across many topics including:
- Treating acute concussion;
- Teaching proper tackling;
- Implementing military policy;
- Football helmet design; and
- Funding for NIH research.
The night ended on a moment of consensus with all panelists agreeing that they would allow their children to participate in sports that carry a risk of concussion citing the known benefits of team sports. The panel also emphasized the importance of neurosurgery to continue to lead the way in the areas of prevention, treatment and understanding of concussion.