Department of Neuroscience

The study also shows that tension headache and migraine are the most common illnesses in the world – only superseded by caries.

Not a rich-man's disease

The findings from the study build on the previous GBD which was carried out in 2000 under the auspices of the World Health Organization (WHO), but this time around most world regions have been included, and it confirms that migraine and headache is not only a Western complaint:

"The data set is much better – we have much more data from all over the world than before. Previously we had good data from perhaps Western-Europe, North-America and a few other regions. Now we have adequate data from more or less all regions. And they show that migraine is not a Western complaint among the rich. There is just as much migraine in many poor countries," explains Professor Lars Jacob Stovner at the Department of Neuroscience (INM) at NTNU, who has contributed to the research.

Headache is neglected

In light of the results from GBD 2010, Stovner thinks that the attention paid to migraine and other forms of headache is nowhere near what it should be, relative to the size of the problem.

"What we wish to highlight is that the resources allocated to migraine, both in terms of treatment and research, are much less than one would think considering their impact. This is a neglect of a big, worldwide health challenge."

Stovner wishes to put headache and migraine on the agenda of those who allocate resources to treatment and research:

"When it comes to priorities in the healthcare sector, these should perhaps to a larger degree be guided by objective measures such as this study and not just by traditions, powerful interest groups among patients and professionals, and by media agendas.

"The aim of the whole effort with Global Burden of Disease is that we should be able to prioritise resources correctly according to what actually affects people while they live, and what they die from," Stovner says.

An even more widespread problem

A weakness of the study is that it does not include the burden associated with the periods between headache attacks. It only measures disability in connection with actual attacks.

"Many of those suffering from these conditions feel rather restricted between headaches because they worry about the next attack – i.e. they feel anxiety and worry about attacks. Or they place restrictions on how they live their lives in order not to provoke attacks, and this has not been included," Stovner explains.

Publications and related links

• Migraine: The Seventh Disabler, Steiner TJ et.al.
• Global Burden of Disease
• GBD – Institute for Health Metrics and Evaluation

"The clinical relevance of the study is that MRI should be performed in the first weeks after a brain injury as important information could be lost if the MRI examination is performed too late," says medical doctor and PhD candidate Kent Gøran Moen at INM and the Department of Neurosurgery.

"CT is the most common imaging diagnostics tool for head injury, but the injury in the brain tissue is not shown very well by CT since only the ‘tip of the iceberg' is visible."

In a study based on 58 patients with moderate to severe head injuries admitted to St. Olavs Hospital over a three-year period, the researchers found that traumatic axonal injury gradually becomes less visible the longer one waits before MRI examination. The grade of the injury and localisation could have a great impact on a patient's prognosis and thereby on their continued treatment and rehabilitation.

Good diagnosis important for rehabilitation

The results found by Moen and his research team could be very useful in relation to rehabilitation of these patients, the largest part of whom were aged 20-40 with many years still to live:

"There have been cases where brain injury patients for example have started having problems at school or at work without us being able to identify why, as CT examinations have not shown any damage to the brain tissue. With early MRI we could perhaps have found lesions which could have predicted and explained these problems.

"A previous study from our research team has shown that patients with axonal injury in the brainstem have a poorer prognosis. To identify such lesions is therefore very important both in terms of predicting a prognosis, and to estimate the length of the rehabilitation period."

As early as possible

There are certain challenges to using MRI at an early stage after a head injury as the patients are often still in intensive care. MRI devices are not mobile and the patient has to be able to lie completely still for half an hour to achieve good quality MR images.

Nevertheless, based on the findings of the study, Moen recommends a routine for using MRI as early as reasonably possible, to obtain more information about the injuries to the brain tissue.

Visible and non-visible lesions

In the study, MRI was used on average a week after the initial injury, and then again after three and 12 months. The aim was to see how bleeding (so-called micro-haemorrhages) and non-bleeding traumatic axonal lesions develop over time.

"Previously it has been common to use MRI relatively late. But we have had a certain suspicion that we have missed parts of the injuries because they ‘disappear' from the MR images over time," Moen explains.

"In particular we saw that the non-bleeding lesions disappeared. Many of the lesions had disappeared at the three-month examination, whereas the bleeding lesions started to disappear at the 12-month examination.

Moen and his colleagues are now conducting a study involving 128 patients looking at the impact of visible traumatic axonal lesions on patient prognosis, and also plan studies in which non-visible lesions, which can be measured using the technique diffusion-MRI, are mapped. One of the goals is to investigate which lesions have the greatest impact on the outcome of head injuries.

Publication

• A longitudinal MRI study of traumatic axonal injury in patients with moderate and severe traumatic brain injury. Moen KG, et al.

Read more about INM's Center for Neural Computation (CNC) award at DMF.

"This is an important study in brain surgery because there has been a controversy over what is the best treatment for this type of tumours. Treatment practice has therefore varied greatly both nationally and internationally," says last author Ole Solheim.

The study, which involved 153 patients of an average age of around 40 with newly diagnosed diffuse LGG, was divided between two health regions in Norway. Patients at hospital A were followed-up with monitoring of the brain tumour, while patients in hospital B received early surgical treatment where possible.

The patients were followed over time, and the results show that after 5 years, 60% of the patients at hospital A were still alive, whereas 74% of patients at hospital B survived – this constitutes a difference of 14 percentage points. This remarkable difference has led to the acceptance of the study in the renowned Journal of the American Medical Association (JAMA).

International recognition

"This is the first comparative study of this patient group. Although it isn't a large study, the patients are young – and we're talking about a substantial gain in life years. This is probably the reason why it has been accepted in such a reputable journal as JAMA – the treatment effect is great," Solheim explains.

The study has already gained national and international recognition, and received great attention at the recent annual congress of the European Association of Neurological Societies (EANS).

Changed practice

The recommendation for early surgical treatment in patients with this type of brain tumours has already been acknowledged by hospital A in Norway, which has changed its practice.

What about quality of life?

"What we plan to do next is to look at morbidity and quality of life. We have looked at survival, and we now wish to look at how the survivors are doing," Solheim says.

The researchers have already begun interviewing surviving patients, both those being actively treated with surgery and those being monitored, on their quality of life.

Publication

• Comparison of a strategy favouring early surgical resection vs a strategy favouring watchful waiting in low-grade gliomas. Jakola et al.

The study was supported in part by the National Centre of Competence for Ultrasound and Image-Guided Therapy, which is a partnership between St. Olavs Hopsital, NTNU and Sintef.

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