Starting with the End in Mind: Recommendations to Optimize Implementation of a Novel TBI Classification from the 2024 NINDS TBI Classification and Nomenclature Workshop’s Knowledge to Practice Working Group

以终为始：2024 年NINDS创伤性脑损伤分类及命名研讨会 “知识到实践” 工作组关于优化新型创伤性脑损伤分类系统实施的建议

The Knowledge to Practice Working Group (K2P WG) was one of six expert groups convened in early 2023 to plan the 2024 National Institute of Neurological Disorders and Stroke Traumatic brain injury (TBI) Classification and Nomenclature Workshop. Recognizing that implementation of revised classification systems is essential to achieve intended impact, the K2P WG's key aims were to foster shared understanding of knowledge translation (KT), build capacity for implementation of a revised TBI classification system, identify and prioritize KT actions, implementation steps and audiences; and make recommendations to advance implementation. The cornerstone of this work was a focused survey to identify "who needs to do what differently," while prioritizing potential implementation actions. Survey findings, dialogue with other working groups, stakeholder discussions, and public feedback were also utilized to support implementation of the revised Clinical, Biomarker, Imaging-Modifiers and retrospective TBI classification system. Forty researchers across five working groups responded to the survey (Response Rate = 59.7%). Fifty-two unique implementation actions were identified. The top 15 priorities across the five working groups comprised six pertaining to clinical practice (e.g., change Glasgow Coma Scale [GCS] assessment); seven focusing on research (e.g., develop tools for measuring psychological and environmental factors); and one each on lived experience (simplified language for patients and families) and other settings (insurance company support for biomarker testing). Twenty-seven stakeholder groups and 18 target settings were identified as being most impacted by the revised classification system. Key recommendations included: develop guidelines based on systematic reviews, clearly explain the rationale for the change, develop implementation toolkits with input from all stakeholders, and embed the new classification in a learning health system database to facilitate implementation strategies based on audits, feedback, and cost-effectiveness analyses.

“知识到实践” 工作组（K2P WG）是 2023 年初为筹备 2024 年美国国家神经疾病与卒中研究所创伤性脑损伤（TBI）分类及命名研讨会而召集的六个专家小组之一。该工作组认识到，修订后的分类系统的实施是实现预期影响的关键，其核心目标包括：促进对知识转化（KT）的共识理解、提升修订后的 TBI 分类系统的实施能力、确定知识转化行动、实施步骤及目标受众并划分优先级，以及为推进实施工作提出建议。 此项工作的核心是开展一项针对性调查，以明确 “哪些人需要做出哪些改变”，同时对潜在的实施行动进行优先级排序。调查结果、与其他工作组的对话、利益相关者的讨论以及公众反馈也被用于支持修订后的临床、生物标志物、影像 - 修正因素及回顾性 TBI 分类系统的实施。 来自五个工作组的 40 名研究人员参与了此次调查（应答率为 59.7%）。调查共识别出 52 项独特的实施行动。五个工作组共同认定的前 15 项优先行动中，有 6 项与临床实践相关（例如，改进格拉斯哥昏迷量表 [GCS] 评估）；7 项聚焦于研究领域（例如，开发用于测量心理和环境因素的工具）；1 项涉及亲身经历者（为患者及家属提供简化表述）；1 项与其他场景相关（保险公司对生物标志物检测的支持）。 经确认，有 27 个利益相关者群体和 18 个目标场景将受到修订后分类系统的最大影响。主要建议包括：基于系统综述制定指南、清晰阐释变革的理由、在所有利益相关者的参与下开发实施工具包，以及将新分类系统纳入学习型卫生系统数据库，以便基于审计、反馈和成本效益分析制定实施策略。

REF: Bragge P, McNett M, Bayley M, et al. Starting with the End in Mind: Recommendations to Optimize Implementation of a Novel TBI Classification from the 2024 NINDS TBI Classification and Nomenclature Workshop's Knowledge to Practice Working Group. J Neurotrauma. 2025;42(13-14):1096-1108. doi:10.1089/neu.2024.0576 PMID: 40331687

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Retrospective Identification and Characterization of Traumatic Brain Injury—Recommendations from the 2024 National Institute of Neurological Disorders and Stroke Traumatic Brain Injury Classification and Nomenclature Initiative Retrospective Classification Working Group

创伤性脑损伤的回顾性识别与特征描述：2024 年NINDS创伤性脑损伤分类及命名倡议——回顾性分类工作组的建议

The National Institute of Neurological Disorders and Stroke (NINDS) convened experts in traumatic brain injury (TBI) research, policy, clinical practice and people with lived experience to propose a system of injury classification less susceptible to misinterpretation and misrepresentation inherent in the current use of "mild", "moderate" and "severe". One of six working groups addressed Retrospective Classification of TBI. The Working Group consisted of 14 experts in brain injury research representing a breadth of professional disciplines. Initial conclusions based on expert opinion were vetted and revised based on public input at the January 2024 NINDS TBI Classification and Nomenclature Workshop. The Working Group examined five types of methodologies for identifying past TBIs (self/proxy-report, medical record extraction, imaging, fluid-based biomarkers, and performance-based tests). They concluded that self/proxy-report is essential for clinical, research and surveillance applications and that clinicians and researchers should employ elicitation protocols that have been studied and found valid. Medical record extraction was also identified as an invaluable tool for identification of past history of medically attended TBIs; however, there is a need to standardize the case definition employed and procedures used. The use of imaging methods, fluid-based biomarkers, and performance-based assessments in isolation lacked sufficient evidence of both sensitivity and specificity in detecting past histories of TBI to be recommended for this use at this time. The Working Group also evaluated identification of repetitive head impacts (RHI), finding no evidence of a common definition of RHI, a requisite initial step for the development and validation of standardized instruments.

美国国家神经疾病与卒中研究所（NINDS）召集了创伤性脑损伤（TBI）研究、政策、临床实践领域的专家以及有亲身经历者，旨在提出一套损伤分类系统，以减少当前使用 “轻度”“中度”“重度” 分类时固有的误解与误传问题。六个工作组中，有一个专门负责创伤性脑损伤的回顾性分类研究。该工作组由 14 位脑损伤研究领域的专家组成，涵盖多个专业学科。基于专家意见形成的初步结论，在 2024 年 1 月举行的 NINDS 创伤性脑损伤分类与命名研讨会上，经公众意见审核后进行了修订。 工作组考察了五种用于识别既往创伤性脑损伤的方法（自我 / 代理人报告、医疗记录提取、影像学检查、基于体液的生物标志物检测和基于表现的测试）。他们得出结论：自我 / 代理人报告对于临床、研究和监测应用而言至关重要，临床医生和研究人员应采用经过研究验证有效的询问流程。医疗记录提取也被认定为识别既往有医疗记录的创伤性脑损伤病史的宝贵工具；但目前仍需对所采用的病例定义和流程进行标准化。就目前而言，单独使用影像学方法、基于体液的生物标志物检测以及基于表现的评估，在检测既往创伤性脑损伤病史方面，其敏感性和特异性均缺乏充分证据支持，因此暂不推荐用于该用途。 工作组还对重复性头部撞击（RHI）的识别进行了评估，发现目前尚无公认的重复性头部撞击定义，而这是开发和验证标准化工具的必要前提。

REF: Corrigan JD, Alosco ML, van der Naalt J, et al. Retrospective Identification and Characterization of Traumatic Brain Injury-Recommendations from the 2024 National Institute of Neurological Disorders and Stroke Traumatic Brain Injury Classification and Nomenclature Initiative Retrospective Classification Working Group. J Neurotrauma. 2025;42(13-14):1086-1095. doi:10.1089/neu.2024.0590 PMID: 40393476

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Blood-Based Biomarkers for Improved Characterization of Traumatic Brain Injury: Recommendations from the 2024 National Institute for Neurological Disorders and Stroke Traumatic Brain Injury Classification and Nomenclature Initiative Blood-Based Biomarkers Working Group

基于血液的生物标志物助力创伤性脑损伤的精准特征描述：2024 年NINDS创伤性脑损伤分类及命名倡议——血液生物标志物工作组的建议

This report presents the findings and recommendations from the blood-based biomarker (BBM) working group, including feedback from the workshop and subsequent public review. The application of BBMs in a TBI classification system has potential to allow for a more adaptable and nuanced approach to triage, diagnosis, prognosis, and treatment. Current evidence supports the use of glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase L1, and S100B calcium-binding protein (S100B) to assist in reclassification of TBI at acute time points (0-24 h) primarily in emergency department settings, while neurofilament light chain (NfL), GFAP, and S100B have utility at subacute time points (1-30 days) in-hospital and intensive care unit settings. Blood levels of these biomarkers reflect the extent of structural brain injury in TBI and may be useful for describing the extent of structural brain injury in a classification system. While there is insufficient evidence to support a role for BBMs at chronic time points (>30 days), emerging evidence suggests that NfL and phosphorylated tau may have a potential future role in this regard. For inclusion in a revised TBI classification system, BBM assays must have appropriate age- and sex-specific reference ranges, be harmonized across platforms, and achieve high analytical precision, including accuracy, linearity, detection limits, selectivity, recovery, reproducibility, and stability. Improving transparency in BBM assay development can be achieved through large-scale data sharing of methods and results. Future research should focus on methods for promoting clinical adoption of BBM results, correlating BBMs with advanced neuroimaging, and on discovering new biomarkers for improved diagnosis and prognosis.

本报告呈现了血液生物标志物（BBM）工作组的研究结果和建议，包括来自研讨会的反馈及后续的公众评审意见。在创伤性脑损伤分类系统中应用血液生物标志物，有望为分诊、诊断、预后评估和治疗提供更具适应性和精细化的方法。现有证据支持在急性期（0-24 小时），主要在急诊科场景下，使用胶质纤维酸性蛋白（GFAP）、泛素 C 末端水解酶 L1 和 S100 钙结合蛋白 B（S100B）辅助创伤性脑损伤的重新分类；而在亚急性期（1-30 天），在住院及重症监护场景中，神经丝轻链（NfL）、GFAP 和 S100B 具有应用价值。这些生物标志物的血液水平可反映创伤性脑损伤中脑结构损伤的程度，或许能在分类系统中用于描述脑结构损伤的范围。 尽管目前尚无足够证据支持血液生物标志物在慢性期（>30 天）的作用，但新兴证据表明，神经丝轻链和磷酸化 tau 蛋白未来可能在该时期发挥作用。若要纳入修订后的创伤性脑损伤分类系统，血液生物标志物检测方法必须具备适当的年龄和性别特异性参考范围，在不同检测平台间保持一致性，并达到较高的分析精密度，包括准确性、线性、检测限、选择性、回收率、重现性和稳定性。通过大规模共享检测方法和结果数据，可提高血液生物标志物检测方法研发的透明度。 未来的研究应聚焦于推动血液生物标志物检测结果临床应用的方法、将血液生物标志物与先进神经影像学检查相关联，以及发现有助于改善诊断和预后评估的新生物标志物。

REF: Bazarian JJ, Zetterberg H, Buki A, et al. Blood-Based Biomarkers for Improved Characterization of Traumatic Brain Injury: Recommendations from the 2024 National Institute for Neurological Disorders and Stroke Traumatic Brain Injury Classification and Nomenclature Initiative Blood-Based Biomarkers Working Group. J Neurotrauma. 2025;42(13-14):1065-1085. doi:10.1089/neu.2024.0581 PMID: 40393505

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Neuroimaging Characterization of Acute Traumatic Brain Injury with Focus on Frontline Clinicians: Recommendations from the 2024 National Institute of Neurological Disorders and Stroke Traumatic Brain Injury Classification and Nomenclature Initiative Imaging Working Group

急性创伤性脑损伤的神经影像特征描述（聚焦一线临床医生）：2024 年NINDS创伤性脑损伤分类及命名倡议——影像工作组的建议

Motivated by prior efforts to standardize the nomenclature for pathoanatomic imaging findings of TBI for research and clinical trials, along with more recent studies supporting the refinement of the originally proposed definitions, the Imaging Working Group sought to update and expand this application specifically for consideration of use in clinical practice. Here we report the recommendations of this working group to enable the translation of structured imaging common data elements to the standard of care. These leverage recent advances in imaging technology, electronic medical record (EMR) systems, and artificial intelligence (AI), along with input from key stakeholders, including patients with lived experience, caretakers, providers across medical disciplines, radiology industry partners, and policymakers. It was recommended that (1) there would be updates to the definitions of key imaging features used for this system of classification and that these should be further refined as new evidence of the underlying pathology driving the signal change is identified; (2) there would be an efficient, integrated tool embedded in the EMR imaging reporting system developed in collaboration with industry partners; (3) this would include AI-generated evidence-based feature clusters with diagnostic, prognostic, and therapeutic implications; and (4) a "patient translator" would be developed in parallel to assist patients and families in understanding these imaging features. In addition, important disclaimers would be provided regarding known limitations of current technology until such time as they are overcome, such as resolution and sequence parameter considerations. The end goal is a multifaceted TBI characterization model incorporating clinical, imaging, blood biomarker, and psychosocial and environmental modifiers to better serve patients not only acutely but also through the postinjury continuum in the days, months, and years that follow TBI.

此前已有为 TBI 病理解剖影像学发现制定标准化命名（用于研究和临床试验）的相关努力，同时近期有更多研究支持对最初提出的定义进行完善。受此启发，影像工作组致力于更新和扩展这一应用，专门考虑将其用于临床实践。本文将报告该工作组的建议，以推动结构化影像通用数据元素向临床标准护理的转化。这些建议充分利用了影像技术、电子病历（EMR）系统和人工智能（AI）的最新进展，并纳入了关键相关者的意见，包括有 TBI 亲身经历的患者、护理人员、各医学学科的医护人员、放射科行业合作伙伴及政策制定者。 建议内容如下：（1）更新该分类系统所使用的关键影像特征定义，并随着能解释信号变化的潜在病理新证据的发现，进一步完善这些定义；（2）与行业合作伙伴协作，开发一个高效的集成工具，嵌入电子病历的影像报告系统中；（3）该工具应包含由人工智能生成的、具有诊断、预后和治疗意义的循证特征集群；（4）同步开发“患者解读工具”，帮助患者及其家属理解这些影像特征。此外，对于当前技术的已知局限性（如分辨率和序列参数方面的问题），在这些问题得到解决之前，应提供重要的免责说明。 最终目标是建立一个多维度的 TBI 特征描述模型，整合临床、影像、血液生物标志物以及社会心理和环境修正因素，不仅在急性期为患者提供更好的服务，还能在 TBI 发生后的数天、数月乃至数年内，为患者在损伤后的整个恢复过程中提供支持。

REF: Mac Donald CL, Yuh EL, Vande Vyvere T, et al. Neuroimaging Characterization of Acute Traumatic Brain Injury with Focus on Frontline Clinicians: Recommendations from the 2024 National Institute of Neurological Disorders and Stroke Traumatic Brain Injury Classification and Nomenclature Initiative Imaging Working Group. J Neurotrauma. 2025;42(13-14):1056-1064. doi:10.1089/neu.2025.0079 PMID: 40393517

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Clinical Assessment on Days 1–14 for the Characterization of Traumatic Brain Injury: Recommendations from the 2024 NINDS Traumatic Brain Injury Classification and Nomenclature Initiative Clinical/Symptoms Working Group

创伤性脑损伤特征描述的 1-14 天临床评估：2024 年NINDS创伤性脑损伤分类及命名倡议——临床 / 症状工作组的建议

The CSWG primarily focused on acute clinical assessment of TBI in hospital settings, with discussion and recommendations based on pragmatic expert reviews of literature. Key areas reviewed included: assessment of neurological status; performance-based assessment tools; age and frailty, pre-existing comorbidities, and prior medication; extracranial injuries; neuroworsening; early physiological insults; and physiological monitoring in critical care. This article reports their discussions and recommendations. The CSWG concluded that the GCS remains central to TBI characterization but must include detailed scoring of eye, verbal, and motor components, with identification of confounding factors and clear documentation of non-assessable components. Pupillary reactivity should be documented in all patients, but recorded separately from the GCS, rather than as an integrated GCS-Pupils score. At ceiling scores on the GCS (14/15), history of loss of consciousness (LoC) and the presence and duration of post-traumatic amnesia should be recorded using validated tools, and acute symptoms documented in patients with a GCS verbal score of 4/5 using standardized rating scales. Additional variables to consider for a more complete characterization of TBI include injury mechanism, acute physiological insults and seizures; and biopsychosocial-environmental factors (comorbidities, age, frailty, socioeconomic status, education, and employment). The CSWG recommended that, for a complete characterization of TBI, disease progression/resolution should be monitored over 14 days. While there was a good basis for the recommendations listed above, evidence for the use of other variables is still emerging. These include: detailed documentation of neurological deficits, vestibulo-oculomotor dysfunction, cognition, mental health symptoms, and (for hospitalized patients) data-driven integrated measures of physiological status and therapy intensity. These recommendations are based on expert consensus due to limited high-quality evidence. Further research is needed to validate and refine these guidelines, ensuring they can be effectively integrated into the CBI-M framework and clinical practice.

临床 / 症状工作组（CSWG）主要聚焦于医院环境下创伤性脑损伤的急性临床评估，基于务实的专家文献综述展开讨论并提出建议。所审查的关键领域包括：神经功能状态评估、基于表现的评估工具、年龄与衰弱状态、既往合并症及用药史、颅外损伤、神经功能恶化、早期生理损伤以及重症监护中的生理监测。本文将介绍该工作组的讨论内容及建议。 临床 / 症状工作组认为，格拉斯哥昏迷量表（GCS）仍是创伤性脑损伤（TBI）特征描述的核心，但必须包含对睁眼、言语和运动成分的详细评分，同时明确混杂因素，并清晰记录无法评估的成分。所有患者均应记录瞳孔反应性，但需与 GCS 评分分开记录，而非整合为 GCS - 瞳孔评分。当 GCS 达到最高分（14/15 分）时，应使用经过验证的工具记录意识丧失史（LoC）以及创伤后遗忘的存在与否及持续时间；对于 GCS 言语评分为 4/5 分的患者，应使用标准化评定量表记录急性症状。 为更全面地描述创伤性脑损伤（TBI），还需考虑其他变量，包括损伤机制、急性生理损伤与癫痫发作，以及生物 - 心理 - 社会 - 环境因素（合并症、年龄、衰弱状态、社会经济地位、教育程度和就业状况）。临床 / 症状工作组建议，为全面描述创伤性脑损伤，应在 14 天内监测疾病的进展 / 好转情况。 尽管上述建议有充分的依据，但关于其他变量应用的证据仍在不断涌现，这些变量包括：神经功能缺损、前庭眼动功能障碍、认知功能、心理健康症状的详细记录，以及（针对住院患者）基于数据的生理状态和治疗强度综合评估。由于高质量证据有限，这些建议基于专家共识形成。未来还需开展进一步研究，以验证和完善这些指南，确保其能有效整合到 CBI-M 框架及临床实践中。

REF: Menon DK, Silverberg ND, Ferguson AR, et al. Clinical Assessment on Days 1-14 for the Characterization of Traumatic Brain Injury: Recommendations from the 2024 NINDS Traumatic Brain Injury Classification and Nomenclature Initiative Clinical/Symptoms Working Group. J Neurotrauma. 2025;42(13-14):1038-1055. doi:10.1089/neu.2024.0577 PMID: 40393504

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Toward More Holistic Early Traumatic Brain Injury Evaluation and Care: Recommendations from the 2024 National Institute of Neurological Disorders and Stroke Traumatic Brain Injury Classification and Nomenclature Initiative Psychosocial and Environmental Modifiers Working Group

迈向更全面的创伤性脑损伤早期评估与医疗：2024 年NINDS创伤性脑损伤分类及命名倡议——社会心理与环境修正因素工作组的建议

We summarize the membership, methods, and outcomes of the PEM Working Group activities. Modifiers were considered with the NINDS Social Determinants of Health Framework in mind and fall under three broad headings: individual-level variables (e.g., demographics, preinjury health, culture), injury-related variables (e.g., cause and context of injury, second insults), and community-/societal-level factors (e.g., family/community support, socioeconomic position, structural racism). Recommendations include steps to increase awareness of Modifiers in health care encounters, identify Modifier-related disparities in TBI-related care and outcomes, better understand the mechanisms by which Modifiers influence TBI-related clinical presentation and outcomes, and intervene to improve the health and well-being of persons exposed to TBI. These recommendations are intended to be a starting point that will evolve as knowledge grows and additional input is incorporated.

本文总结了社会心理与环境修正因素（PEM）工作组的成员构成、工作方法及成果。这些修正因素的考量借鉴了 NINDS 健康社会决定因素框架，主要分为三大类：个体层面变量（如人口统计学特征、受伤前健康状况、文化背景）、损伤相关变量（如损伤原因及背景、二次损伤）以及社区 / 社会层面因素（如家庭 / 社区支持、社会经济地位、结构性种族主义）。 建议内容包括：在医疗服务中提高对这些修正因素的关注度；识别创伤性脑损伤相关护理及预后中与修正因素相关的差异；深入理解修正因素影响创伤性脑损伤临床表现及预后的机制；采取干预措施以改善创伤性脑损伤患者的健康状况和生活质量。这些建议旨在作为一个起点，随着知识的积累和更多意见的纳入而不断完善。

REF: Nelson LD, Wilson L, Albrecht JS, et al. Toward More Holistic Early Traumatic Brain Injury Evaluation and Care: Recommendations from the 2024 National Institute of Neurological Disorders and Stroke Traumatic Brain Injury Classification and Nomenclature Initiative Psychosocial and Environmental Modifiers Working Group. J Neurotrauma. 2025;42(13-14):1023-1037. doi:10.1089/neu.2024.0569 PMID: 40464097 PMCID: PMC12270537

由人工翻译修正