as General Peter Chiarelli the vice
chief of staff of the US Army told us
about the most difficult phone call he’d
ever had to make is in his entire life
he had to call the mother of a young man
who’d been killed in Iraq this young
man’s convoy had been obliterated by a
u.s. airstrike that had struck the wrong
location and Corelli had to call this
young man’s mother to explain why that
happened what had happened was that a
radio operator about a hundred miles
away in another part of Iraq had called
in the coordinates for the airstrike
wrong this young man this radio operator
had been concussed four times in the
previous week and he was so badly
injured that he was vomiting in the back
of his battered MRAP as he was calling
in the numbers but he told his
commanding officers he was good to go
because that’s what you did everybody
knew that concussions were something you
shrugged off except that he wasn’t good
to go and that young man’s mother was on
her way to Dover to pick up her son’s
possessions and a flag so my name is
Dave Brody I’m a neurologist at
Washington University in st. Louis I’m
not in the army and I never was so what
was I doing in that briefing room in
Bethesda listening to General Corelli
well it started because I had met an
army colonel named Stephen flirty and
flirty and I had a common enemy we were
on the same side in a vigorous
scientific debate that had really
important policy implications what had
happened was that an army psychiatrist
named Charles Hogge had published a
paper stating that all of the
consequences of concussive traumatic
brain injury were actually due to
post-traumatic stress disorder and that
not to a concussion itself and they had
been published in the New England
Journal of Medicine and it picked up by
the New York Times and had gotten a lot
of attention
but flirty was the chief of trauma at
launch tool Regional Medical Center in
launch tool Germany which was the main
triage point for the wars in Iraq and
Afghanistan and he’d seen hundreds
sometimes maybe thousands of US service
members who had been evacuated and
ambulances that look like this on their
way back from wartime and too flirty the
psychiatrist’s view just didn’t hold
true I didn’t know very much about
military concussive traumatic brain
injury at the time but my gut feeling
was that flirty was right but to make
policy decisions takes more than just
gut feelings it takes data and I had an
idea that I told clarity about for how
we could get some the idea involved a
new MRI technique called diffusion
tensor imaging which involves tracking
the brain’s water tracking the movement
of the brain’s water with an MRI scanner
we didn’t invent diffusion tensor
imaging at Washington University but
we’ve got to be the first ones to use it
in military concussive traumatic brain
injury patients because of the
connection that we made with Colonel
Flaherty so let me tell you a little bit
about diffusion tensor imaging and why
it works the most vulnerable part of the
brain is called the axons these are long
wires that transmit information from one
part of the brain to the other and the
axons are like celery they’ve got a long
direction and shorter directions and so
if you imagine water diffusing in celery
it diffuses really fast up and down this
celery and much more slowly across wise
in the celery or in and out of the
celery but after injury the brains axons
become like celery soup same color as
celery may smell like celery but quite
disrupted and now the water is going to
diffuse pretty much the same in all
directions so we could use diffusion
tensor imaging to detect the difference
between celery and celery soup in the
brain so we did that we brought our
scanners technology to launch tool
Regional Medical Center in launch tool
Germany it just took reprogramming the
scanners the hardware that they had was
fine
and we did our study the smartest move I
make the most fortunate choice I made
that day was bringing with me a genius
this is Christine McDonald she was a
postdoctoral fellow in my lab and she
was technically very solid but she was a
true genius when it came to
interpersonal relations she got the
injured servicemembers she understood
they were scared lonely had been
evacuated from Iraq or Afghanistan all
the way out to Germany separated from
the men and women with whom they had
lived trained ate slept and sometimes
even died forming bonds that were closer
than even those of their own families in
many cases Christine told these
servicemembers this is not about you
this is about the people that are still
out there and about helping them in the
future and they got that 80% of them
agreed to participate in our research
study and two-thirds of them still
followed up with us even a year later
she’s still tracking them now five years
after so we did our study and what do we
find well the first part of the brain we
looked at was called the cingulum the
cingulum is a highway of brain wiring
that starts in the front and wraps all
the way around the back and goes deep
inside the brain with conventional MRI
scans the cingulum looks like this looks
very similar in the control subject
versus the traumatic brain injury
subject you really can’t see any
difference the control subjects by the
way were US military personnel who’d
been evacuated from Iraq and Afghanistan
for other reasons but did not have any
brain injury so there was no difference
these injuries were invisible to
conventional MRI but when we used
diffusion tensor imaging we could see
right away that in the control subject
there’s a really bright green you can
see that bright green up and down the
middle
that means this is like celery this part
of the brain has very fast water
diffusion up and down and much slower
right and left and in and out in
contrast though the traumatic brain
injury subject the cingulum bundle is
not quite as bright green the arrows
indicate the part of the brain that
we’re going to analyze quantity
beautifully let me show you how that
looks in the control subject there’s
high anisotropy in the left cingulum and
in the right cingulum anisotropy is the
word that means directional asymmetry
not the same in all directions that
means fast up-and-down and slow or right
and left like a normal stalk of celery
but the control the traumatic brain
injury subject had lower and I saw
trophy and now what was invisible is now
quite clear it’s quite a bit lower in
the traumatic brain injury subject
compared with the control let me show
you another example this is a part of
the brain called the middle cerebellar
peduncle which is in the back part of
the brain especially vulnerable to blast
injuries you don’t see any difference
between the two scans and the control
and the traumatic brain injury subject
on a conventional MRI scans another
invisible injury but here’s how the
control subject looks with diffusion
tensor imaging again there’s this
beautiful bright green areas across the
sides of this middle cerebellar peduncle
and in the traumatic brain injury
subject it’s dramatically reduced it’s
really ragged there’s much less bright
green here’s the area that we’re going
to analyze quantitatively on both sides
and here’s the data in the control
subject there’s high and isotropy in the
left and right middle cerebellar
peduncle
and in the traumatic brain injury
subject it’s wiped out
there’s no anti there’s hardly any anti
satrapy at all this is one is not subtle
at all once we had to fusion tensor
imaging to look at it here’s a third
example this is the orbital frontal
white matter this is important part of
the brain right up in the front part of
the brain that’s involved in emotional
regulation and decision-making processes
here’s how it looks in a control and a
traumatic brain injury patient and
conventional MRI scan no different can’t
see anything wrong here in the control
subject there’s very bright green it’s
very beautifully intact and a traumatic
brain injury subject it’s not quite
right it’s reduced anisotropy here’s the
data hi in a control subject not as high
in the traumatic brain injury subject
you guys get the idea so by the time we
finished this study we were able to
detect clear abnormalities in 18 out of
63 US military personnel only one had
any of
at all on conventional imaging
technology anything that we had prior
and none of the controls had any
abnormalities at all
so we reported our data in scientific
meetings and we published it in the New
England Journal of Medicine and the New
York Times picked it up in media outlets
around the world so our side Flaherty
and I with McDonald and the Army
psychiatrist Holmes had a pretty equal
opportunity to present our work to the
people that made the important decisions
and in the end the decision was made and
the decision came out in a document that
was really rather bland looking and this
is called a directive type memorandum
but it established policy for over a
million US service members around the
world for how concussion would be
handled and this directive type
memorandum was the new beginning after
the directive type memorandum a radio
operator who’d been concussed would not
have been told he was good to go or get
back to work or shake it off he would
have been treated in a warrior recovery
center like this one in Kandahar
Afghanistan which I visited in 2011 and
at that warrior Recovery Center he’d be
treated with by people who were well
educated about concussion and he’d have
scheduled sleep and powerful yet safe
non narcotic pain medications he’d get
education about concussion strict
regulation of caffeine use acupuncture
and physical therapy if necessary and be
treated in an environment where stigma
was not an issue so most importantly
he’d be returned to duty only after
passing objective performance
evaluations typically 12 to 14 days
after a concussive event so what now the
wars in Iraq and Afghanistan are largely
over for the US military but we need to
keep going our new technology coming out
of Washington University is now so much
better than what we had in 2007 to 2009
but I’m almost embarrassed to look at
those old images in those days and it’s
a good thing too because we need to do
better we need to be able to get 63 out
of 63 why does this matter to
you this matters to you because if your
son or daughter has a concussion playing
soccer or football or if you have a car
accident or a fall or an assault or any
of the slings and arrows about rageous
fortune that affect us in our daily
lives that can cause concussion we need
to be able to detect it so that we can
treat it appropriately in the future
just as in all of history
war has led to advances in trauma care
helicopter ambulances and blood banks
ready for to give trans youth
transfusions we hope that this
technology that we’re learning about
from visualizing the invisible wounds of
war in Iraq and Afghanistan will
translate to improve concussion care in
our world in our civilian world and for
every one of you and your families thank
you [Applause]