Assessment of brain and eye blood flow after traumatic brain injury

ISRCTN ISRCTN33668699
DOI https://doi.org/10.1186/ISRCTN33668699
IRAS number 339540
Secondary identifying numbers RG_24-008, CPMS 63262
Submission date
03/06/2025
Registration date
26/08/2025
Last edited
01/09/2025
Recruitment status
Recruiting
Overall study status
Ongoing
Condition category
Injury, Occupational Diseases, Poisoning
Prospectively registered
Protocol
Statistical analysis plan
Results
Individual participant data
Record updated in last year

Plain English summary of protocol

Background and study aims
Traumatic brain injury (TBI) is a leading global cause of disability and death among military personnel. In the military, severe head impacts, explosions, and wounds to the head cause TBI. Brain injury occurs in two stages. The initial injury is called the primary injury, and secondary injury, which occurs in response to injury, leads to delayed brain damage. In secondary injury, brain damage may be worsened by reduced blood flow, low oxygen levels, increased pressure in the brain, and brain swelling. To prevent secondary injury occurring, early and accurate assessment of the brain's blood supply is crucial. However, current techniques to monitor brain blood supply are invasive, limited in effectiveness, or slow, especially in emergencies. A non-invasive and quicker intervention may allow early treatment and therefore improve patient recovery and survival.
This study explores whether eye imaging techniques can reflect brain damage and brain health after TBI. The eye and the brain share blood vessels. In healthy individuals, blood flow in the back of the eye, known as the retina, and the brain vary together. Optical coherence tomography angiography (OCTA) is an imaging technique widely used in eye clinics and images blood vessels in the retina. We, therefore, aim to determine if blood flow in the retina, measured by OCTA, can be used as a proxy measure for brain blood flow after TBI.
Retinal venous pulsations (RVPs) are blood flow movements in retinal veins. RVPs are affected by brain pressure. TBI commonly increases brain pressure, causing RVPs to be altered or absent. Assessing RVPs will allow us to determine whether we can use it to assess brain pressure.
A protein called aquaporin-4 (AQP4) controls water movement in the brain and eye. Increased AQP4 levels have been linked to brain swelling after TBI and may be connected to retinal swelling. We will assess the relationship between brain swelling and retinal swelling after TBI by comparing brain imaging and AQP4 levels with retinal thickness measurements.

Who can participate?
The study will include a control group of healthy individuals and an acute TBI group. Control participants must have no previous history of TBI, degenerative disease affecting the brain or eye, be willing and able to follow the protocol, have capacity to consent and have two eyes. Individuals in the TBI group will be admitted to the Queen Elizabeth Hospital, Birmingham, UK with moderate to severe TBI, with preplaced or planned placement of invasive neuromonitors. Participants of both groups must be over 18 years of age with at least one eye available for retinal imaging. Individuals under 18 years of age and pregnant females are excluded from the study.

What does the study involve?
For the acute TBI group, eye and brain imaging, invasive brain monitoring, and the collection of blood and fluid from the brain and spine will occur at enrolment, 24, 48, 72 hours and 28 days later, or until the invasive monitors are removed. A disability rating measurement will occur at 28 days. For the control group, an initial assessment involving eye and brain imaging, blood collection, and a disability rating measurement will occur.

What are the possible benefits and risks of participating?
There is no increased risk in participating in this study as the techniques are non-invasive or occurring as part of routine care.

Where is the study run from?
Queen Elizabeth Hospital, Birmingham, UK

When is the study starting and how long is it expected to run for?
January 2024 to August 2029

Who is funding the study?
United States Department of Defence

Who is the main contact?
1. Lt Col. Prof. Richard Blanch, r.j.blanch@bham.ac.uk
2. Prof. Antonio Belli, a.belli@bham.ac.uk

Contact information

Prof Richard Blanch
Public, Scientific, Principal Investigator

Department of Ophthalmology
Queen Elizabeth Hospital
Edgbaston
Birmingham
B15 2TH
United Kingdom

ORCiD logoORCID ID 0000-0002-6142-3280
Phone +44 (0)121 3712000
Email r.j.blanch@bham.ac.uk

Study information

Study designSingle-centre observational study
Primary study designObservational
Secondary study designCohort study
Study setting(s)Hospital
Study typeDiagnostic, Prevention
Participant information sheet Not available in web format, please use contact details to request a participant information sheet.
Scientific titleReal-time assessment of retinal perfusion and blood flow as a surrogate measure for cerebral perfusion in severe traumatic brain injury
Study acronymRETINA-TBI
Study objectives1. Retinal perfusion, measured by optical coherence tomography angiography (OCTA), mirrors cerebral blood flow after traumatic brain injury (TBI).
1.1. Higher injury severity, assessed by extended IMPACT score, is associated with lower retinal perfusion.
1.2. Lower retinal perfusion acutely after injury and greater retinal neurodegeneration at follow up associates with worse early functional outcomes after TBI.
2. The magnitude of retinal venous pulsation is associated with intracranial pressure (ICP) after TBI.
3. Retinal oedema is associated with cerebral cellular oedema, mediated by aquaporin 4 upregulation.
Ethics approval(s)

Submitted 28/05/2024, Wales Research Ethics Committee 2 Cardiff (Health and Care Research Wales, Cardiff, CF11 9AB, United Kingdom; +44 (0)2922941119; +44 (0)2922 940959; Wales.REC2@wales.nhs.uk), ref: 24/WA/0196

Health condition(s) or problem(s) studiedAcute severe traumatic brain injury
InterventionPatients will have cerebral and retinal perfusion assessed after TBI. Invasive neuromonitoring will assess cerebral oxygenation and intracranial pressure and collect cerebral microdialysis. Ocular imaging techniques, optical coherence tomography and optical coherence tomography angiography, will assess retinal oedema and retinal perfusion, respectively. Non-invasive measures of cerebral perfusion will include transcranial Doppler ultrasound and Near Infra-red Spectroscopy. Biofluids such as blood, CSF, and microdialysate will be collected to assess AQP4 expression. The disability rating scale will assess early functional outcomes.
Intervention typeDevice
Pharmaceutical study type(s)Not Applicable
PhaseNot Applicable
Drug / device / biological / vaccine name(s)N/A
Primary outcome measureThe primary outcome is the correlation between retinal perfusion and invasive neuromonitoring data:
1. Retinal perfusion will be assessed by OCTA at the time invasive neuromonitors are inserted, 24, 48, 72 hours (if neuromonitoring remains in situ), and 28 days later.
2. Cerebral perfusion pressure will be calculated as the difference between mean arterial pressure and intracranial pressure at the time invasive neuromonitors are inserted, 24, 48, and 72 hours later, or until invasive monitors are removed.
3. Cerebral oxygenation will be measured by brain tissue oxygen tension at the time invasive neuromonitors are inserted, 24, 48, 72 hours later or until the monitors are removed.
4. Cerebral microdialysis lactate to pyruvate ratio will be measured at the time invasive neuromonitors are inserted, 24, 48, 72 hours later or until invasive neuromonitors are removed.
Secondary outcome measures1. Middle cerebral artery Doppler will measure mean velocity, peak velocity, end diastolic velocity, and pulsatility index at the time of neuromonitors insertion, 24, 48, 72 hours, and 28 days later
2. Near infrared spectroscopy will assess cerebral cortical perfusion (total haemoglobin, oxyhaemoglobin, and deoxyhaemoglobin) at the time invasive neuromonitors are inserted, 24, 48, 72 hours, and 28 days later
3. 28-day mortality
4. 28-day neurological outcome assessed by the disability rating scale
5. The amplitude of retinal venous pulsation will be measured on video fundoscopy at the time invasive neuromonitors are inserted, 24, 48, 72 hours, and 28 days later
6. Microdialysate, CSF, and blood AQP4 expression will be assessed at the time invasive neuromonitors are inserted, 24, 48, 72 hours, or until the removal of invasive neuromonitors; primarily by ELISA
7. Total retinal, ganglion cell layer, and retinal nerve fibre layer thickness in the macula and peripapillary retina will be assessed with OCT at the time of neuromonitor insertion, 24, 48, 72 hours, and 28 days later
8. Intracranial pressure will be assessed by an invasive ICP monitor at the time of neuromonitor insertion, 24, 48, 72 hours later or until invasive neuromonitoring removal
Overall study start date01/01/2024
Completion date08/08/2029

Eligibility

Participant type(s)Healthy volunteer, Patient
Age groupAdult
Lower age limit18 Years
SexBoth
Target number of participants80 (40 TBI, 40 healthy control)
Key inclusion criteriaPatients with acute TBI:
1. Moderate to severe TBI
2. Over 18 years of age
3. Planned invasive neuromonitoring or insertion of invasive neuromonitoring consistent with the study protocol within the prior 24 hours
4. At least one eye with optically clear media to allow retinal imaging

Healthy control participants:
1. Over 18 years of age
2. Two eyes
3. Capacity to consent
4. Willing and able to follow the protocol
5. No prior history of moderate to severe TBI
6. No prior history of retinal or optic nerve degenerative disease
7. At least one eye with optically clear media to allow retinal imaging
Key exclusion criteria1. Under 18 years of age
2. Pregnancy
Date of first enrolment01/06/2025
Date of final enrolment08/07/2029

Locations

Countries of recruitment

  • England
  • United Kingdom

Study participating centre

University Hospitals Birmingham NHS Foundation Trust
Queen Elizabeth Hospital
Mindelsohn Way
Edgbaston
Birmingham
B15 2GW
United Kingdom

Sponsor information

Funders

Funder type

Government

U.S. Department of Defense
Government organisation / National government
Alternative name(s)
United States Department of Defense, Department of Defense, U.S. Dept of Defense, US Department of Defense, DOD, USDOD
Location
United States of America

Results and Publications

Intention to publish date01/08/2030
Individual participant data (IPD) Intention to shareYes
IPD sharing plan summaryAvailable on request
Publication and dissemination planPlanned publication in open access, peer reviewed journals and dissemination at national and international conferences.
IPD sharing planThe final deidentified dataset will be made available on reasonable request subject to data transfer agreement. Please contact Lt Col Prof Richard Blanch (r.j.blanch@bham.ac.uk).

Editorial Notes

01/09/2025: Internal review.
03/06/2025: Study's existence confirmed by the HRA.