On the ever-changing horizon of developments in the imaging of brain injuries, one approach recently generated international interest. It was not the launch of another piece of sophisticated new imaging technology kit, but a simple blood test.

It was developed in the US working with injured veterans via the Department of Defence (DoD) and researchers from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Network using the principle of measuring biomarkers. The test measures two types of proteins, GFAP and UCH-L1, that are released from the brain and into the blood when the brain is injured.

A strength of the test, called the i-STAT® Alinity® system, is in its simplicity and utility: it is contained in a hand-held device, providing results within minutes. Trials are ongoing to see how the accuracy of the blood test system compares with results from CT scans; it is a promising but unproven addition to the brain injury assessment methods.

The assessment of brain injury is an area where the weaknesses of currently available imaging technology are widely recognised. In UK hospitals, if a scan is considered necessary when a patient presents to A&E, this will be a CT scan to help determine the extent of the injury, risk of complications and whether surgery may be required.

CT stands for computerised tomography (CT), using x-rays and a computer to create detailed images of the inside of the body. CT is the main imaging tool of hospital emergency departments; it is effective at identifying fractures and severe bleeds and is useful in the first 48 hours after an injury.

However, CT is less effective at showing damage within the brain where they may not be bleeding, such as injuries to microscopic nerve fibres. Research shows CT scans will miss a large number of mild Traumatic Brain Injuries (mTBI): an estimated 80 to 90 per cent of injuries will not be visible on standard CT imaging. Equally, the injury may produce damage within the brain which continues to take place after the initial time of presentation at an emergency department in hospital.

Here, MRI (magnetic resonance imaging) can be helpful and is often used to help explain enduring symptoms when the CT scan is clear. MRI is an area of rapid development, with variations in weight, diffusion and the enhancement of image quality improving the ability of scans to detect damage and changes at a microscopic level.

The range of technology introduced in recent years is broad, encompassing terms such as MR spectroscopy, Diffusion Weight imaging (DWI), Diffusion Tensor Imaging (DTI) / Diffusion Kurtosis Imaging (DKI), perfusion imaging, PET/SPECT, and magnetoencephalography (MEG).

Of course, for the affected individual and their family, this is very challenging to understand and navigate. Patients are heavily dependent upon the NHS services available within their area and the imaging available to services where they receive care. But for some, it can be valuable to explore other imaging options and second opinions.

We can help, advise and signpost families to specialist MRI imaging which may not be available within their local service, but could play an essential role in establishing a full and precise diagnosis. Although there is still some progress to be made, imaging technology in brain injuries is rapidly developing and particularly for individuals living with difficult symptoms without an accurate diagnosis, imaging can be essential in developing a more effective, targeted treatment plan.

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Every three minutes, a patient attends a UK hospital after suffering a head injury. Traditionally, the much greater proportion of these patients were male.

This picture seems to be changing, however, according to figures collated by Headway, the UK brain injury association, which shows a 24 per cent increase in hospital admissions among females since 2005.

The reason for this increase is not fully understood. Certainly, the last decade has seen an increase in female participation in contact sports such as football and rugby and sports such as cycling, which also present elevated head injury risk. But the connection remains hypothetical, without a body of research evidence.

Where better understood is how concussion seems to affect women differently to men. Women appear to be more at risk of concussion, more likely to experience the most severe effects of concussion and take longer to recover from concussion, studies have shown.

Tracey Covassin of Michigan State University in the US has been a leading researcher in the field of female concussion, finding in ball sports, females were almost twice as likely to suffer a concussion as male players. Different symptoms were reported: male concussions were more likely to produce amnesia, while females reported prolonged headaches, mental fatigue and difficulties with concentration and mood changes.

Another study of young sportspeople found on average, females took 76 days to recover from a concussion, compared with 50 days for males. Another study has shown differences in cognitive impairment measured after a concussion.

Three theories have been put forward to explain these gender differences. One focuses on the physiology of female necks, emphasising the way injuries can be caused as much by the sudden jerking of the head as much as being the impact of a specific blow. As such, male necks, with a wider average circumference and muscle density are better able to mitigate sudden force and its effect than female necks.

The second theory focuses on how female brains are thought to have slightly faster metabolisms than male brains, with greater blood flow to the head. Therefore, if a head injury momentarily disrupts that supply of glucose and oxygen, it has the potential to cause greater damage.

The third theory considers different hormone levels during the menstrual cycle. One study found injuries during the follicular phase (after menstruation and before ovulation) were less associated with symptoms enduring beyond a month, while an injury during the luteal phase (after ovulation and before menstruation) resulted in more severe and lasting symptoms.

Head injuries can temporarily disrupt the production of various hormones, including progesterone. During the luteal phase progesterone levels are highest, and the researchers suggest the sudden dramatic fall in progesterone due to head injury throws the brain off balance and contributes to the worse and longer lasting symptoms. In the follicular phase, by contrast, progesterone levels are already lower; the drop in progesterone is therefore less dramatic.

There have been some concerns about the effect of emphasising gender differences in concussion: whether this might contribute to male sportsmen feeling their concussion is less serious, exacerbating male tendencies to underplay symptoms and return to activities too soon. Equally, there have been concerns about how differences could work against female participation in sport more generally, which has many recognised health benefits.

The American football player Brittni Souder, who retired from the sport due to a number of concussions, seems to strike a positive balance, working with young players to raise awareness of concussion for females and how to mitigate risks, while also advocating for participation in football.

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