Traumatic brain injury with neurosurgeon Gregory Hawryluk, MD, PhD

Many thanks to Gregory Hawryluk, MD, for joining me on this episode of The Art of Medicine with Dr. Andrew Wilner! Dr. Hawryluk is a neurosurgeon with a PhD in stem cell research. He is the Medical Director of the Brain Trauma Foundation.

As we began our 30-minute discussion, Dr. Hawryluk described his medical training as a neurosurgeon. He explained the origin and goals of the Brain Trauma Foundation. 

According to Dr. Hawryluk, the Brain Trauma Foundation's most significant contribution has been developing clinical practice evidence-based guidelines for traumatic brain injury. These guidelines have been associated with a 50% reduction in head injury mortality. Dr. Hawryluk suggested that the guidelines serve as a basis for individualized care that may lead to even greater benefits. The guidelines are available on the Brain Trauma Foundation's website.

We explored the definition of concussion and current approaches to management. Dr. Hawryluk explained that neuroimaging, such as CT and MRI, should be normal in a patient with concussion. He offered his opinion regarding the safety of participating in contact sports, which may result in concussions. We also broached the subject of chronic traumatic encephalopathy (CTE).

To learn more, please contact The Brain Trauma Foundation: https://braintrauma.org/

#concussion #CTE #traumatic brain injury #TBI

@braintraumafoundation

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Transcript

[Andrew Wilner, MD] (0:07 - 1:31)

Welcome to the Art of Medicine, the program that explores the arts, business, and clinical aspects of the practice of medicine. I'm your host, Dr. Andrew Willner. Today, I'm pleased to welcome Dr. Gregory Harluck. Dr. Harluck is a neurosurgeon and medical director of the Brain Trauma Foundation. I'm thrilled to have Dr. Harluck with us today to discuss traumatic brain injury, especially concussion, what it means, and what to do about it. Traumatic brain injury affects athletes, soldiers, people in motor vehicle, and many other types of accidents. I work at a level one trauma center in downtown Memphis, Tennessee. Unfortunately, not a day goes by I don't see a patient with a traumatic brain injury.

I'm looking forward to a meaningful and informative discussion in just a few moments. But first, a word from our sponsor, locumstory.com. Locumstory.com is a free, unbiased educational resource about locum tenens. It's not an agency. Locumstory answers your questions on their website, podcast, webinars, videos, and they even have a locums 101 crash course. Learn about locums and get insights from real-life physicians, PAs, and NPs at locumstory.com.

And now to my guest. Welcome, Dr. Gregory Harluck.

[Gregory Hawryluk, MD, PhD] (1:32 - 1:34)

Pleasure to be with you, sir.

[Andrew Wilner, MD] (1:34 - 1:47)

Thanks so much for joining me. Okay, so neurosurgeon, just give us a quick synopsis of how you get from, I don't know, idealistic college student to practicing neurosurgeon. How does that happen?

[Gregory Hawryluk, MD, PhD] (1:47 - 2:23)

Well, I basically stayed in school until I got to grade 42 or so. I think to do neurosurgery you really have to like school and learning because there's no fast way to get there. So really after medical school in Canada, at least at the time I went through, it was six years of residency training.

And I decided to make that longer with a five-year PhD. It's now become seven years, both in the U.S. and Canada. So an awful lot of training, but obviously we have a great privilege and we have to be well trained to do what we do.

[Andrew Wilner, MD] (2:24 - 2:32)

Right. You mentioned Canada. I actually trained at the Montreal Neurologic Institute at McGill for my neurology and epilepsy fellowship.

Where did you train?

[Gregory Hawryluk, MD, PhD] (2:33 - 2:45)

So I trained, med school was University of Alberta. My residency was University of Toronto. And my fellowship was at University of California, San Francisco, UCSF.

[Andrew Wilner, MD] (2:45 - 2:51)

All right. So now the Brain Trauma Foundation. Tell us about that.

[Gregory Hawryluk, MD, PhD] (2:52 - 5:11)

Yeah. So it's really an interesting story. So in fact, the origin story of the Brain Trauma Foundation is really documented in the movie Reversal of Fortune.

So it grew out of the Sunny von Buelow Coma Foundation. And I'll let people watch the movie to learn more about that. It involves Ellen Dershowitz, who over the last few years has been back in the media again.

So really, you know, there was a desire with the advancement of science in the 1980s to really learn more about the brain and coma. And the foundation shifted in its early years to be more focused on brain injuries. So the Sunny von Buelow Coma Foundation became the Brain Trauma Foundation.

Really, since its inception, it's been led by its founder, Dr. Jam Gajar. You could probably call him a bonafide Persian prince. His family ruled Iran about 200 years ago.

And it's really evolved over the years. So I think there's no question that its biggest contribution to medicine has been evidence-based guidelines. So, in fact, the guidelines that we published back in 1996, they were the very first clinical practice guidelines ever published by a surgical specialty.

And, you know, I guess the question is, why did that happen? I think, you know, it was really a rise of evidence-based medicine. But I think there's actually a lack of evidence in head injury.

So it actually made it relatively easy compared to other aspects of medicine. You know, there's a sort of limited pool of studies to work with. So our guidelines really had an important legacy.

So we've now done certainly over 15 full guideline projects. And when you think about each one of those takes over 30 people, about five years of work to do. That's a pretty substantial accomplishment.

But I think the thing that we're most proud of is that whenever it's been looked at, whether it's Eastern Europe, New York State, our guidelines have been associated with a 50% reduction in mortality. And the way I look at that is if you were to think of our guidelines as being like a pill, if you had a pill that reduced head injury mortality by 50%, that's probably a Nobel Prize. So I'm not claiming that we deserve one of those.

But I think, you know, we have achieved something very substantial for patients with head injuries.

[Andrew Wilner, MD] (5:11 - 5:55)

Yeah. And what that means is collating the science, understanding the science, and then spreading the science. You know, guidelines are a way of managing patients.

You know, no doctor wants to be told what to do. On the other hand, if a patient shows up with a severe head injury, you want to have a clear path. It's like, well, should I give antibiotics or not?

Should I intubate or not? Should I put his head up or head down? You know, there's a lot of decisions that need to be made.

And if you can benefit from thousands of other physicians who've been through that and figured out what works, that's what ends up in the guidelines.

[Gregory Hawryluk, MD, PhD] (5:56 - 6:55)

Yeah. You know, there's absolutely no question that the path that we tried to follow is, as you said, if we can figure out through evidence-based medicine what's best practice, if we can get more people doing that, how could people not get better? And that's actually been, you know, as I described, a very successful model.

You know, what's sort of funny is I sort of joke with people. I oversee the guidelines, but I don't always follow them. And the reason is that there's a lot of times where, you know, I think I might know better than the guidelines.

I think that the guidelines set a baseline standard. And, you know, for the average patient, the guidelines probably work very well. But I think on every patient there's reasons why they're a little bit different than the average.

So I think you need to see why your patient might benefit from care that's a little bit different. But, you know, our guidelines are, you know, they're not to be followed religiously. But they certainly do provide a pathway that we think, you know, helps patients to get the best possible care.

[Andrew Wilner, MD] (6:56 - 7:39)

Yeah, I was co-author of several American Academy neurology guidelines on epilepsy. And, you know, there's big committee meetings with all the people who know as much as anybody and have read a lot. And sort through the data and try and make some sense out of it.

I think the onus on the physician is if you do deviate from the guidelines, you need to justify that. In other words, the guidelines say this. Now, I don't have to follow the guidelines, but if you've got a good reason not to, that's okay.

But not willy-nilly. So I think guidelines got kind of a bad rap that, well, I have to do it this way. But, in fact, they're guidelines.

They're not rules and regulations. So all those guidelines are on your website, I presume.

[Gregory Hawryluk, MD, PhD] (7:40 - 8:27)

They sure are. And, you know, the other thing that I would say is that, you know, medicines, it evolves. And over the last 10 years, I think we've seen a huge upsurge in what we might call personalized medicine.

And guidelines might be viewed as inherently at odds with that idea. The idea that all people should be treated the same versus, you know, refining care in a more individualized fashion. So, you know, I think we certainly got an initial bump in outcomes by standardizing a high level of care.

And it may be that we're going to see even better outcomes by building off that with more individualized care. And in some ways it sort of seems like the pendulum is swinging back, but maybe it's not. But absolutely, I agree with you that, you know, I think we need to get that baseline care up and then refine from there.

[Andrew Wilner, MD] (8:28 - 8:46)

Well, you can imagine subsets of patients, right, that would be treated a little differently. Children, elderly, maybe women versus men, I don't know. But where there are differences in biology, there may be differences warranted in management.

Would you agree with that?

[Gregory Hawryluk, MD, PhD] (8:46 - 8:54)

I absolutely would. You know, one of the problems, for instance, in elderly patients is that a lot of times their brains are shrunken away from inside of the skull.

[Andrew Wilner, MD] (8:56 - 8:57)

Pleasant company accepted.

[Gregory Hawryluk, MD, PhD] (8:58 - 9:25)

Exactly. So, you know, that does a couple of things. One is that it gives you a little bit of a buffer zone.

So if you get some blood outside your brain, you can compensate a little bit better. But it can actually be a lot harder to put in things like neuromonitors into the brain. Because if the brain is separated from the inside of the skull, the monitors can bounce off and it doesn't work as well.

So you're absolutely right that you have to tailor your approach a little bit to the individual patient characteristics.

[Andrew Wilner, MD] (9:25 - 9:39)

All right. I want to talk about a very common injury. And it's not clear to me about the guidelines.

They seem to be shifting. So tell us first, what is a concussion?

[Gregory Hawryluk, MD, PhD] (9:40 - 10:20)

Oh, that's a hard question. So, you know, I could pick amongst the over 20 different definitions of concussion and tell you the one I like. But I guess what I would say is it continues to be a point of some controversy.

There are continual efforts to bring people together. The most recent definition that I saw was about a three-paragraph long definition. So the general gist, though, is it's going to be some sort of an energy transfer to the brain, some sort of an impulse.

It doesn't have to be a direct blow to the brain. You don't have to lose consciousness. But it's something that's going to lead to an alteration in brain function.

[Andrew Wilner, MD] (10:21 - 10:39)

So it's a relatively mild head injury where the skull isn't fractured. There's no bleeding in the brain. Would you agree with it?

It seems to me the old definition was that the CAT scan had to be normal to be a concussion. Do we still go with that?

[Gregory Hawryluk, MD, PhD] (10:40 - 11:21)

Yeah. So what I would say is that I think it's fairly well accepted right now that to be diagnosed as a concussion, both a CT and an MRI should be normal. There may be metabolic imaging, things like that, that could be abnormal in a concussion.

But I think that's fairly widely agreed upon right now. But in terms of the distinction between a mild TBI versus a concussion, that continues to be a point of some controversy. There's real movement to try and unify those.

But I think the pretty firm view is that although a mild TBI may have some imaging anomalies, a concussion, at least on CT and MR, should not.

[Andrew Wilner, MD] (11:23 - 11:46)

We've recently recognized that a lot of head injuries where the scanning was normal, if you look at the scanning with fancy sequences like SWI, you see diffuse axonal injury. So is that compatible with the term concussion or does that mean you've got a mild brain injury outside of the bounds of concussion?

[Gregory Hawryluk, MD, PhD] (11:47 - 13:05)

Yeah. And again, I think that would be, you probably could get 10 experts in a room and get 12 opinions on it. So my take on that is that probably the MR lesions would put you out of the realm of concussion and more into a mild TBI.

And certainly, I think it's been pretty well described now that people that have normal CTs very often have abnormal MRIs. And in fact, we're finding it very hard to find controls for concussion patients. There was a view that perhaps we could take orthopedic patients that had a limb fracture.

But it turns out that they have a very high prevalence of brain lesions on MR and positive biomarkers that we're now starting to look at. So I think one of the things we're finding is that concussion or mild TBI, they're both far more prevalent than we thought they were. And another big thing that one of my mentors, Jeff Manley, has discovered is that these are really being under triage.

So a lot of these people actually have a lot of deficits, but too often they're sort of left to leave the emergency department. They look pretty normal, and yet they suffer job losses, various cognitive and functional deficits. They don't get enough medical attention.

So I think there's been a real push in recent years to try and improve the care that these patients are getting.

[Andrew Wilner, MD] (13:07 - 13:36)

One observation I think you can help me with, I remember when I was a resident, I had the opportunity to scrub in on a few neurosurgery cases. And of course, you do that on a pretty regular basis. I think most people don't realize, perhaps because the brain is nicely nestled into what is quite often a hard head, that the brain is a very soft, vulnerable structure.

Tell me what you see when you're operating on the brain.

[Gregory Hawryluk, MD, PhD] (13:37 - 14:05)

Yeah, I don't know if it would be better to compare it to Jell-O or pudding, but it absolutely is pretty soft, especially once you get through the pia. The pia has a little bit of a turdier to it, but everything below that is a lot more like pudding. So it's absolutely a very delicate organ, and smashing something that's like pudding up against the bony skull base tends to lead to injury.

[Andrew Wilner, MD] (14:05 - 14:20)

Right, so I'm going to use that to segue. What do you think, as an expert in concussion and mild traumatic brain injury, about contact sports?

[Gregory Hawryluk, MD, PhD] (14:22 - 17:18)

So, jeez, everything we're talking about this morning is controversial. So my view is that I still play contact sports, and I encourage my kids to, and frankly even collision sports. So I probably wouldn't box, I know physicians that do.

But I think the benefits of physical activity really outweigh some of the risks of the sports that are a concern these days. I think that it's a complex discussion. I think whenever you're engaging in a sport like football, or frankly even soccer, is another one that's correlated with a lot of concussions.

It really comes down to having respect for your own body, having respect for your competitors, not going out trying to hurt them. I think that there's been a lot of work with rules. So for instance, things like mouth guards have been shown to reduce concussion by 30%.

There's been work in hockey. So they brought in things like stop signs in the back of people's uniforms to discourage checking from behind. So a lot of the measures in hockey have reduced concussions by 50%.

So I continue to feel that the benefits of these sports really outweighs the potential risks. They've looked at all sorts of different things. They've looked at NFL players, and they found that their overall health is not worse than the average population from a cognitive and brain standpoint.

In fact, one of my colleagues, Sparkel Uzma Samadani, published a paper looking at neurosurgery and orthopedic chairmen. And what she found is that they played far more contact and collision sports than their college classmates. A lot of them reported concussions.

And yet have gone on to do well in their careers. So I think that the jury is still out. I think that CTE remains a controversial diagnosis.

I'm very interested in a lot of the work that Dan Pearl does. He's a very prominent pathologist. And I think every time we think we're making progress in understanding CTE, there's sort of a new range that comes up.

So for instance, in the military, we're finding that people in the military aren't getting CTE. CTE really seems specific to contact sports. In the military, they're getting these boundary scarring lesions.

And really a low rate of CTE, only about 4%. The people in the military that are getting it had a history of contact sports. So I think that the jury is still really out on potential harms.

And I think there's unquestionable benefits. So I continue to feel that with appropriate safeguards, things like football, hockey, soccer, people should be out doing that stuff if they enjoy it.

[Andrew Wilner, MD] (17:19 - 18:09)

Well, okay, that's reassuring. Now let's get to, first of all, concussions are, as you mentioned, incredibly common. And I remember when the treatment for concussion was strict bed rest.

You lie there, no video games, don't do anything difficult. Just relax, let the brain heal. And then there was a flip.

It's like, nope, out of bed as soon as you can. Do as much as you can, but not too much. And get back with the program.

Plus, there's a lot of, I don't know, we call nonspecific symptoms, right? Fatigue, headache, I just don't feel well, lack of energy, dizzy. You know, things that are hard for anyone else to quantify.

So where are we now with the treatment of concussion?

[Gregory Hawryluk, MD, PhD] (18:10 - 20:09)

Yeah, you're absolutely right. And concussion has really been a hard thing to study, which is why I think that there's been a lot of back and forth and flip-flopping. At the end of the day, if you can't define it, sort of alluding to things we talked about earlier, then it's going to be hard to study something that you can't define as a baseline.

So you're absolutely right that, you know, even five years ago, there were a lot of doctors that were recommending strict rest. I think the idea there is that you've got some strained neurons. And if we can keep those neurons from firing, we hopefully might be able to preserve them a little bit better.

The studies that have been done over the last five years, though, really haven't shown a benefit to that approach. And now the thinking has flipped a little bit, where we know that a key trigger for neurons to grow and to heal is activation, actually. So it's one of the benefits to physical therapy.

It's not just you're building up a muscle. You're sending a signal from the muscle to the nerve saying, come innervate me. So I think that this is the reason that underlies the switch.

I think there's a happy medium, though. So I think that, you know, a lot of patients are going to report some fatigue or a sense of feeling unwell when they overdo it. For a lot of my patients, the thing that really does them in is a trip to a big department store, a place that's really busy.

The brain, I think, struggles after a concussion for a lot of people to integrate, you know, a lot of the complex sensory stimuli. So the advice that certainly I'm giving to patients, and I think a lot are, is, you know, to expose yourself to that stimulation, ease in. When you're feeling tired or overwhelmed, rest.

You don't necessarily have to sleep, but just put your head down, close your eyes for an hour, and sort of expose yourself, you know, in a graded fashion and take rest as often as you need to.

[Andrew Wilner, MD] (20:09 - 20:21)

Thanks for that. Maybe we can squeeze in a little public service announcement about seatbelts and helmets. You want to say something about those?

Motorcycles. What do you think?

[Gregory Hawryluk, MD, PhD] (20:21 - 21:27)

Yeah, the bottom line is that those things work. So early in my career, I went to train with a luminary in the field, Ross Bullock, down in Richmond, Virginia. And there had been a big push in terms of, you know, safety measures in automobiles and a public campaign.

And I didn't see as many head injuries as I hate to wish them on anyone, but when you're a doctor, you want to go train and learn. So we didn't see a lot of head injuries over that three-month period. So it's very clear that these things work.

I think another key message is that, you know, doctors a lot of times think that their role is really in the hospital. But I think, you know, there's a lot of doctors that have great talents with engineering. I think doctors have learned that we can be very influential with public policy.

So I think that preventing head injury is not only effective, but it's a domain where doctors can really have an impact. So I think all of us that work in this field need to do the things we're able to to try and reduce the incidence of head injury and concussion. Because at the end of the day, no treatment will ever be as good as prevention.

[Andrew Wilner, MD] (21:29 - 22:47)

Yes, no treatment will ever be as good as prevention. Be kind to your brain. All right.

One last topic I'd like you to address are alternative therapies for traumatic brain injury. You know, we don't have a lot of treatments other than make sure it doesn't get infected and fix up the wound and physical therapy. And there are a lot of people, not necessarily doctors, offering alternative therapies that are not FDA approved, but where they claim great success.

I'll mention one, hyperbaric medicine, that I'm familiar with, which does have definite FDA approved indications, but is also being used for post-traumatic injuries. I wondered if, and of course, these are expensive. And, you know, the problem with these therapies is that it kind of saps energy and dollars out of the patient's account that could maybe be better spent.

So, but I don't want to put words in your mouth. So tell me what's your take? Are there any alternative therapies that are worth it?

Or which ones should, are there any that you see that are commonly used that ought to be avoided?

[Gregory Hawryluk, MD, PhD] (22:47 - 24:33)

Yeah, no, that's a really great question. And the one I often see as well is stem cells. And fortunately, that was what I did my PhD in.

So I really have to sit down with patients that are considering that. And as you allude to, it's often the patients who have some financial means that are particularly vulnerable because people pay a lot of money for hope in something that might help them. You know, for a lot of these treatments, if I don't think it's something that's going to be harmful and not necessarily something that I think there's strong evidence for, you know, I certainly tell people I don't have a problem if you want to pursue it.

But I think for the more invasive or expensive things, I do tend to offer some words of caution. And I think we have to be a bit careful. You know, I have a very memorable patient that swore by the hyperbaric oxygen treatment that she got.

You know, pretty hard to tell how much that could be a placebo effect or, you know, she had just achieved the normal recovery that she would have had anyways. You know, it's hard to know. And there is some evidence.

It's not very strong evidence. So, you know, what I what I would really like to see is that a lot of these treatments are done under the auspices of trials and studies that generate really good evidence. So it's a tricky point right now.

So, you know, the other thing is that, you know, in head injury, we're often dealing with people that are a bit vulnerable, that don't have their full cognitive capacity. And I think that we really have to, you know, make sure that they aren't getting themselves into things that have a lot of financial commitments without proven benefits.

[Andrew Wilner, MD] (24:34 - 25:06)

Later today, I'm going to be interviewing Matt Hongoltz-Hetling, who just wrote a book about sort of alternative therapies, not necessarily for head injury, but for just about everything, and that it's a big business exploiting people. So I think, you know, pretty soon what I'd like to see is these alternative therapies included in your guidelines when there's some evidence behind them one way or the other, so that people really know what to do.

[Gregory Hawryluk, MD, PhD] (25:07 - 26:16)

You know, it's interesting. So there's so little evidence for a lot of the mainstream stuff in head injury. And the bar with guidelines has gone up over the years.

So what used to be enough evidence isn't anymore. And so what's really interesting is that we've had to change our approach. So for the Brain Trial Foundation to produce usable guidelines, we've actually had to incorporate expert opinion.

And we've tried to do it in a rigorous formal way. So we use a Delphi consensus process that's blinded. And that way you don't have the expert in the room sort of potentially bullying other people to, you know, to all sort of, you know, come over the viewpoint of that high expert.

So we've had to incorporate that. So that's going to be the real challenge, I think, with some of these alternative things is I think we may end up being left wholly with expert opinion. But I think this is a challenge to all of us to go out and do those studies.

I think everything in head injuries is fair game. I think we don't have good enough evidence for anything that we do. In all of our guidelines, there is only one level one evidence recommendation, and that is not to give steroids.

Everything else is up for revision and further study.

[Andrew Wilner, MD] (26:17 - 26:21)

Greg, this has been a great conversation. Is there anything you'd like to add?

[Gregory Hawryluk, MD, PhD] (26:22 - 27:20)

No, I really enjoyed speaking with you today. So, you know, I think head injury really continues to be a big problem. It's an especially big problem in the military.

I would say that we're very proud we've now partnered with the military. They've had a big push to do some things that are going to bring some quick benefits to soldiers. I think instead of some of the preclinical trials that can take five or ten years, they've made a big investment in the Brain Trial Foundation, our guidelines to try and identify best evidence and bring some new things to soldiers pretty quickly.

So we're looking at right now penetrating head injury. We're looking at head injury care in combat and austere environments. We're going to be doing some new concussion stuff as well in the next few years.

So a lot of stuff on the docket for us and really appreciate your interest and everyone out there, you know, trying to provide best care to their patients.

[Andrew Wilner, MD] (27:22 - 29:36)

Thanks for that. Dr. Gregory Harlick, thanks for joining me on the Art of Medicine. And now a final thanks to our sponsor, locamstory.com.

Locamstory.com is a free, unbiased educational resource about locam tenens. It's not an agency. Locamstory exists to answer your questions about the how-tos of locams on their website, podcast, webinars, and videos.

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Thanks again to locamstory.com for sponsoring this episode of the Art of Medicine. I'm Dr. Andrew Willner. See you next time.

This program is hosted, edited, and produced by Andrew Willner, MD, FACP, FAAN. Guests receive no financial compensation for their appearance on the Art of Medicine. Andrew Willner, MD, is Associate Professor of Neurology at the University of Tennessee Health Science Center, Memphis, Tennessee.

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