Pushing the Boundaries of Brain Injury Research

As the helicopter landed on St. Mike’s helipad, a team of doctors raced to get Jane into emergency surgery after a motorcycle crash sent her careening headfirst into a guardrail.

In Canada, every three minutes, someone like Jane experiences a brain injury.

Fortunately, Jane survived and walked back into her life several months later. But brain injuries are among the toughest and most complicated medical challenges clinicians are faced with. They can be hard to diagnose, and even harder to treat. But St. Michael’s clinicians and scientists specialize in tough challenges, and stop at nothing to provide the best care for their patients, whether that means racing across the city on New Year’s Eve to save the life of a man in a coma, or pushing the boundaries of research to find the answers to the many questions raised by brain injuries like concussion.

“Head injury is very important at St. Mike’s—it’s huge,” says Dr. Andrew Baker, chief of Critical Care, medical director of the Trauma and Neurosurgery program and director of a brain injury lab at the Keenan Research Centre for Biomedical Science. “We’re dealing with it in so many ways: in the lab, in imaging and biomarker research, in the Emergency department, in our Head Injury Clinic and in our Trauma and Neurosurgery program.”

St. Michael’s Head Injury Clinic is one of the largest in the province, seeing more than 2,000 patients a year. “It’s well known because it focuses on a comprehensive way to manage symptoms,” says Dr. Baker. “They often get patients who are really struggling with the persistent effects of concussion and more serious head injuries. There’s not a single solution, but they’re addressing patient issues and they do a marvelous job. And they’re doing research projects around early education and symptom control.”

Many patients are referred from the Trauma and Neurosurgery program, says Alicja Michalak, the clinic’s coordinator, for follow-up treatments. But increasingly, the clinic deals with concussion. “There are not nearly enough concussion services in Ontario,” says Michalak. “So we decided to do something about it.”

The clinic developed a concussion stream, with patients coming mostly from the Emergency Department. “Emergency is so busy, and we wanted to help with the flow of patients,” says Michalak. “If they don’t get the right care at the right time, the symptoms can become chronic, and we don’t want that, because it’s so much harder to help them. So we set up a triage process, and it’s been working beautifully. They are quickly discharged to our clinic, where they can be seen by specialists.” The clinic’s multidisciplinary team includes physicians, social workers and physiatrists (rehab physicians). And patient education is a big part of their work.

Michalak says many acute concussion symptoms subside after one to two weeks. “We’re looking for the symptoms that linger and cause problems when they want to go back to work or school,” she says. “We also flag patients who have had several concussions, because they’re at high risk of prolonged recovery. And anyone with depression, anxiety or mental illness. We have many students, and going back to school can be challenging. We don’t want them to lose their education.”

When it comes to research at St. Michael’s, Dr. Baker is most excited about a new program that aims to look at the effects of concussions right after they happen. “We want to discover opportunities for therapeutics by understanding the early pathophysiology,” he explains. “Early is important because after several days other factors interfere, like whether they’ve rested, their health status before the injury, and what they’ve done since it happened. We want to look at the core of the problem, and if you can capture that right after it happens, there’s a better chance of understanding it before the picture gets complicated. So we have a research coordinator embedded in the Emergency department, and we’re enrolling patients. It’s hard to have patients volunteer within 24 hours of their concussion to go straight to the MRI. But for the first time we’re able to document the ultra-early changes in blood flow in the brain.

”That is exciting, because we’ll combine biomarkers, clinical factors, patient factors and this imaging and put it all together. It’s a really special thing, and we’re thrilled about it.”

Dr. Baker also points to the work being done by Dr. Tom Schweizer, director of the Neuroscience Research program and interim director of the Keenan Research Centre. He uses advanced neuro imaging to learn what areas of the brain are serving particular functions. “I’m interested in the things that make us uniquely human, like language, the ability to multi-task and make decisions—things we do on a day-to-day basis and tend to take for granted,” he says.

“If there’s an injury to a part of the brain, some of those things can just shut down,” he adds. “And that fascinates me, how everything is connected and how elaborate that organ is. It’s shocking. In fact, I’m surprised more things don’t go wrong.”

Dr. Schweizer experienced a full-on eureka moment when he realized that driving a car is key to investigating how the brain works. “It’s visual, motor, decision-making–nearly every skill you can think of,” he says. “And you can see how important it is to people if the first thing that comes out of their mouth after neurosurgery is, ‘When will I get my licence back?’ And there are really no tools to help a physician decide that.”

So Dr. Schweizer and his team got to work building a driving simulator that could fit into an MRI machine.

“It took a long time, but we now have one of the first simulators with steering wheel, pedals, accelerator and brake that is fully embedded into an MRI,” he says. “So patients can drive, and we can see what areas of the brain light up. It’s amazing. Elderly people are most susceptible to having an accident making a left-hand turn at a busy intersection. Why is that? Well, at that moment the entire brain lights up. You’re looking at the light, oncoming traffic, pedestrians and what’s behind you, and you have to take in all that information in one moment and make a good decision. So you can see that if you have any slight injury, or early aspects of dementia, the system isn’t fully intact, and it gets exposed.”

Dr. Schweizer’s team is also scanning the brains of university athletes who have suffered concussion to see what happens to them over time. “Most people recover from concussion within a couple of weeks, but some take months,” he says. “We’ve developed new imaging protocols to see what’s happening, so we can identify that cohort and make sure they don’t return to the field of play too soon.”

The athletes are great for that research, as they are all about the same age, fit and academically oriented, but Dr. Schweizer wants to make his research more relevant to the real world by studying patients at the Head Injury Clinic. “They see a huge volume of patients,” he says. “We’re focusing on those 55 and older, to see what happens to their brains. We’ll use what we’ve learned from the athletes’ brains and the new imaging parameters we’ve developed, apply it to that cohort and see what happens.”

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