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Emerging technology improves ability to see ‘invisible’ wounds

As well as providing high-resolution clinical imaging capabilities, the 3T Magnetic Resonance Imaging (MRI) scanner used at the NICoE provides researchers access to cutting-edge image acquisition methods, such as multiband diffusion tensor imaging (DTI) and echo planar imaging (EPI) sequences. (Photo courtesy of NICoE) As well as providing high-resolution clinical imaging capabilities, the 3T Magnetic Resonance Imaging (MRI) scanner used at the NICoE provides researchers access to cutting-edge image acquisition methods, such as multiband diffusion tensor imaging (DTI) and echo planar imaging (EPI) sequences. (Photo courtesy of NICoE)

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The active lifestyle of servicemembers can increase the possibility for concussion or mild TBI because recreation often involves vigorous activities or contact sports, and training can include rigorous physical activity. Deployments also can put warfighters in hazardous situations such as near blasts.

Statistics compiled by the Department of Defense show that servicemembers – both deployed and nondeployed – sustained more than 315,000 mild Tramatic Brain injuries, or mTBI, from the year 2000 through the first quarter of 2018. A recent study of brain injuries in the military republished by the National Institutes of Health noted that the absence of external damage to the head can lead servicemembers to believe they should feel fine. But they don’t.

Fortunately, most mTBI sufferers recover fully under the supervision of a health care professional using a protocol such as the Progressive Return to Activity.

For some, however, symptoms may persist, and can include mood changes, headaches, sleeplessness, and trouble concentrating. With the damage seemingly “invisible,” current methods of looking at bone, blood vessels, and soft tissues in the brain often can’t find a physical cause of these lingering problems. These testing methods include magnetic resonance imaging, known as MRI, or computed tomography X-ray, commonly called CT scans. But a special type of MRI called diffusion tensor imaging or DTI, takes a different approach to examining the brain for traumatic injury. This technology, still in its infancy, may one day serve as a powerful tool for understanding concussions at the molecular level.

“Diffusion tensor imaging is really a way of looking at the connections in the brain,” said Dr. Louis French, deputy director for operations at the National Intrepid Center of Excellence, or NICoE, at Walter Reed National Military Medical Center in Bethesda, Maryland. “Rather than focus solely on the structures there, DTI examines the connections and communication between the various parts of the brain.”

DTI works by observing the flow of water molecules along nerve fibers called axons in the brain, looking for signs of disruption, French explained. Those fibers usually direct water to flow through the brain in one direction, along one of many such channels. In the case of TBI, say after a blast concussion, those fibers and pathways can be deformed or distorted and may even be torn or structurally malformed, causing the water that was flowing along one axis to seep out into other spaces, which can be measured through DTI.

French has been using DTI as one of many evaluation tools in a 15-year, congressionally mandated study of servicemembers with mild to severe TBI. He said most have had multiple concussions or multiple exposures to potentially concussive events. “In that population, we’re really interested in the cumulative brain changes associated with those exposures,” he said. In addition to the study group, researchers also have two control groups: individuals with no injuries and individuals with bodily injuries that don’t involve the head or brain.

DTI is helping to increase understanding of TBI as a process, not an event, French said. “The neuro-imaging that we do, including the MRI with diffusion tensor, enables us to look at the relationship of the changes in the brain as the person recovers.”

“This is a way we can point out to people that, yes, we can see here on the computer screen physically the origin of your complaints,” said French, explaining that the data is objective evidence of subjective complaints.

DTI is available at NICoE, but not widely used across the MHS, partly due to some MRI units unable to run the required software. Additionally, not all MTFs have experts able to evaluate the data produced by DTI. French says the technology is constantly being refined and improved upon, but currently it’s so technically challenging and time consuming, it’s not available for regular use.

He said the MHS is at the forefront of TBI research and care, with abilities that are equal to, or better than, any in the civilian sector. “This isn’t just about treating problems but also understanding wellness,” he added. “We are interested in protecting servicemembers across their lifespan. We want to understand what happens to people when they go through the process of training and deployment and then re-acclamation to society, and this is all part of that effort.”

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