OPTIMA-TBI Pilot Study

Primary brain injury, the initial physical injury to brain tissue post-trauma, responds only
to measures that prevent TBI from occurring in the first place. However, secondary brain
injury, a complex cascade of events causing additional brain injury following primary brain
injury, is more amenable to pharmacologic treatment. Neuroinflammation is one of the
recognized mechanisms of secondary brain injury. In response to primary brain injury,
activated microglia and injured neurons both release signaling proteins including cytokines
and chemokines. Ω-3 and ω-6 fatty acids are major components of immune cells and neuronal
cell membranes. They are also precursors to neuromodulatory lipids such as eicodanoids,
endovanilloids and endocannabinoids that have antinociceptive and anxiolytic properties.
Docosahexaenoic acid (DHA) is one of the most abundant fatty acid components of brain cell
membrane phospholipids. In rodent model studies, dietary supplementation with omega-3 fatty
acids (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) decreased secondary axonal
injury, attenuated endoplasmic reticulum stress response, decreased neuroinflammation
post-TBI, and improved short and long-term neurologic outcomes. Additionally, DHA
supplementation post-TBI enhances neurogenesis by counteracting reductions in neuroplasticity
biomarkers such as brain-derived neurotrophic factor. Furthermore, DHA deficient rodents are
more likely to have a greater amount of axonal injury and slower recovery neurologic recovery
post-TBI. To our knowledge there are no human studies examining the effect of omega-3 fatty
acid supplementation post-TBI on functional, symptomatic and neurologic outcomes. However, a
study of collegiate football players who were randomized to 2, 4 or 6g/day of DHA or placebo
for a total of 189 days (including 80 pre-season days). Irrespective of the dose of DHA
supplementation, those receiving DHA had lower values of serum neurofilament light chain, a
biomarker of axonal injury, than those receiving placebo.

Inclusion Criteria:

- Individuals presenting to the emergency department (ED) within 24 hours of injury, who
meet the American Congress of Rehabilitation Medicine (ACRM)'s definition of having
mild traumatic brain injury (mTBI) will be eligible

- The ACRM defines mTBI as a traumatically-induced physiological disruption of brain
function as a consequence of the head being struck, striking an object, or undergoing
an acceleration/deceleration movement without direct external head trauma and
resulting in at least one of the following:

- any period of loss of consciousness (LOC)

- any loss of memory for events immediately before or after the injury

- any alteration in mental state at the time of the injury (eg, feeling dazed,
disoriented, or confused)

- focal neurological deficit(s) that may or may not be transient

Exclusion Criteria:

- GCS<13 at any time during ED stay.

- Significant polytrauma including: bony fracture or solid organ injury

- Study medication cannot be administered within 24 hours of injury

- Patient cannot be relied on to complete follow-up (i.e. no reliable telephone number,
substance dependence, homeless)

- Cannot communicate in English

- Take an anticoagulant (coumadin or a novel oral anticoagulant) daily

- Age less than 18 years or greater than 65 years

- Patients already taking fish oil supplements daily

- History of cognitive impairment

- Allergic to fish/fish oil

- Pregnant women (self-reported)