Diffuse Axonal Injury Patients Research Articles

Diffusion Kurtosis Imaging and Radiomics in Diffuse Axonal Injury

This study aimed to assess the feasibility of radiomic features derived from diffusion kurtosis imaging (DK MRI) in identifying microstructural brain damage in diffuse axonal injury (DAI) and predicting its outcome. We hypothesized that radiomic features, computed from parametric DK MRI maps, may differ between healthy individuals and those with trauma, and may be related to DAI outcomes. The study included 31 DAI patients and 12 healthy volunteers. A total of 342,300 radiomic features were calculated (2282 features for each combination of 10 parametric DK maps with 15 regions of interest). Our findings suggest that the set of radiomic features effectively distinguishes between healthy and damaged brain tissues, and can predict DAI outcome. A broad spectrum of radiomic parameters based on DK MRI data showed high diagnostic and prognostic potential in DAI, presenting advantages beyond the traditionally used average values for the regions of interest on parametric DK MRI maps.

Clinical and Radiological Prognostication of Diffuse Axonal Injury

Introduction: We studied the efficacy of the admission neurological status (Glasgow Coma Score - GCS) and the radiological findings (Marshall, Rotterdam and MRI scoring systems) in prognostication of Diffuse Axonal Injury (DAI) using the Glasgow Outcome Score (GOS) to quantify the clinical outcome. Material and Methods: This is a prospective observational study of 158 consecutive Diffuse Axonal Injury (DAI) patients conducted at Madras Medical College. GCS at admission was taken as the clinical data. Marshall’s, Rotterdam and MRI scores were taken as radiological data. The patients’ GOS at 1 month was taken as clinical outcome. Statistical Analysis: Statistical analyses were then made to correlate the clinical and radiological data with the one-month outcome of the patients. Statistical analysis was done using the SPSS software – version 16 using statistical tests like Pearson’s coefficient and ANOVA. A p value of less than 0.05 was considered statistically significant. Results: The admission GCS and MRI grade of DAI showed a statistically significant correlation with the clinical outcome, but the Marshall and Rotterdam scores did not. Conclusion: Proper neurological evaluation of the patient with GCS score on admission and MRI brain when feasible, with both having a statistically significant correlation with clinical outcome, provide reliable prediction models for prognosticating outcome in DAI patients.

IDENTIFICATION OF NEW BIOMARKERS AND PROMISING NEURO IMAGING OF DIFFUSE AXONAL INJURY: AN OBSERVATIONAL STUDY

Objective: To determine the clinical patterns of the newly identified novel biomarkers of prognosis among adult patients with traumatic brain injury (TBI), diffuse axonal injury (DAI) and ophthalmic injury (OI) and micro bleeds in the Brain. Methods: According to the online search engine from the databases of PubMed, Embase, Ovid Science Direct, and the way of sciences of the original contribution articles which are providing with the essential information about outcome in patients with DAI in general, DAI vs. non-DAI, related to magnetic resonance imaging (MRI) classification , related to lesion and their specific , Specific location/load and their future outcomes. We have gone through the major references and checked their quality control (QC) assessments performed through International standard protocol/guidelines and our own experiences. Results: A total of 585 articles were included. TBI patients with DAI patients favorable outcomes are (75-90 %). The risk associated unfavorable outcome (RAUO) is in TBI with DAI was three to four times higher than in TBI without DAI in our Asian Indian patients.The Odds ratio (OR) for their unfavorable outcome was 2.7 as per increase of DAI grade on the MRI findings. Lesions are located in the area of the corpus callosum (CC) associated with an unfavorable outcomes reported frequently (85-95%). Conclusions: DAI patients management through MRI and patients with with TBI results unfavorable outcome are increasing in larger in numbers day by day in trauma care. MRI grading, locations, pattern of diffuse (POD) and axonal injury rates (AIR) are increasing in their three to four fold with every grade. Associated Lesions in the corpus callosum (CC) are associated with an unfavorable outcomes are those frequently associated with the DAI patients in TBI. Need appropriate diagnosis and management for DAI. Our newly developed biomarkers are quite useful for DAI patients associated within the TBI patients management and follow-up.

Diffuse Axonal Injury Pattern Predicts Timing of In-Hospital Neurologic Recovery: A Retrospective Case Series

Diffuse axonal injury (DAI) is a devastating traumatic neurological injury with variable prognosis. Although outcomes such as mortality have been described, the time course of neurological progression is poorly understood. We investigated the association between DAI neuroanatomical injury pattern and neurological recovery timing. A retrospective review of our institution's trauma registry identified patients diagnosed with DAI from 2017-2021. Neuroradiologist review of head CT was used to score DAI severity. In-hospital neurological exams were reviewed, and GCS was calculated for all patients throughout the hospital stay. Categorical variables were analyzed using Fisher's exact test and continuous variables were analyzed using Kruskal-Wallis test. Nineteen DAI patients (Grade 1=8; Grade 2=1; Grade 3=10) were included (mean age 31 years, 79% male). Mean Rotterdam CT score, Injury Severity Scale, and admission GCS were comparable across DAI grades. Mean time in days to follow commands was shorter for those with Grade 1 DAI (9.3) compared to Grade 2 (17 days) or Grade 3 (19 days) DAI (p=0.02). Throughout hospitalization, patients with Grade 1 DAI had higher motor (p=0.006), eye (p=0.001), and total GCS (p=0.011) score compared to those with Grade 2 or 3 DAI. At the time of discharge, total GCS and the frequency of command following was similar across DAI grades. Patients with Grade 1 DAI demonstrated the fastest short-term neurological recovery, although final discharge neurological examination was comparable across DAI grades. DAI classification can provide useful short-term prognostic information regarding in-hospital neurological improvement.

Cognitive impairment in diffuse axonal injury patients with favorable outcome.

Traumatic brain injury (TBI), especially the severe TBI are often followed by persistent cognitive sequalae, including decision-making difficulties, reduced neural processing speed and memory deficits. Diffuse axonal injury (DAI) is classified as one of the severe types of TBI. Part of DAI patients are marginalized from social life due to cognitive impairment, even if they are rated as favorable outcome. The purpose of this study was to elucidate the specific type and severity of cognitive impairment in DAI patients with favorable outcome. The neurocognition of 46 DAI patients with favorable outcome was evaluated by the Chinese version of the Montreal Cognitive Assessment Basic (MoCA-BC), and the differences in the domains of cognitive impairment caused by different grades of DAI were analyzed after data conversion of scores of nine cognitive domains of MoCA-BC by Pearson correlation analysis. Among the 46 DAI patients with favorable outcome, eight had normal cognitive function (MoCA-BC ≥ 26), and 38 had cognitive impairment (MoCA-BC < 26). The MoCA-BC scores were positively correlated with pupillary light reflex (r = 0.361, p = 0.014), admission Glasgow Coma Scale (GCS) (r = 0.402, p = 0.006), and years of education (r = 0.581, p < 0.001). Return of consciousness (r = -0.753, p < 0.001), Marshall CT (r = -0.328, p = 0.026), age (r = -0.654, p < 0.001), and DAI grade (r = -0.403, p = 0.006) were found to be negatively correlated with the MoCA-BC scores. In patients with DAI grade 1, the actually deducted scores (Ads) of memory (r = 0.838, p < 0.001), abstraction (r = 0.843, p < 0.001), and calculation (r = 0.782, p < 0.001) were most related to the Ads of MoCA-BC. The Ads of nine cognitive domains and MoCA-BC were all proved to be correlated, among patients with DAI grade 2. However, In the DAI grade 3 patients, the highest correlation with the Ads of MoCA-BC were the Ads of memory (r = 0.904, p < 0.001), calculation (r = 0.799, p = 0.006), orientation (r = 0.801, p = 0.005), and executive function (r = 0.869, p = 0.001). DAI patients with favorable outcome may still be plagued by cognitive impairment, and different grades of DAI cause different domains of cognitive impairment.

Effect of a Combinational therapy of Erythropoietin, Pentoxifylline, and Vitamin D on the Glasgow Outcome Scale in Patients with Traumatic Brain Injury

Background: Diffuse axonal injury (DAI) is the most prevalent nerve lesion in brain trauma. Given the known effects of erythropoietin and pentoxifylline on the reduction of cell death following hypoxia. Objectives: The current study assessed the possible effects of a combination of erythropoietin, pentoxifylline, and vitamin D on patients' consciousness level. Methods: The present research is a double-blind clinical trial with parallel groups addressing 64 DAI patients (average age: 26.5). The intervention group included 32 patients who, apart from the routine treatment, received a combination of erythropoietin, pentoxifylline, and vitamin D3. The control group also encompassed 32 patients who only received routine treatment. The effects of the interventions were assessed based on Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS) scores, and hospitalization duration. Results: The findings of the current research revealed that the GCS scores of the supplement (13.6±0.5) and control groups (12.4±1.6) were significantly different (P=0.043), being higher in the supplement group. The supplement group gained a higher GOS score compared to the controls (4.62±0.15 and 3.8±0.16, respectively, P=0.045). Moreover, a significant difference was observed in the hospitalization duration of the supplement (26.5±5.2) and control groups (21.4±3.2) (P=0.020). Nonetheless, the analysis of the extubation time and blood pressure of the two groups exhibited no substantial difference. Conclusion: In this study, GCS and GOS improved after supplementation. The patients in the supplement group displayed a significantly shorter hospitalization duration. No significant difference was, however, detected when the tube was removed.

A model for estimating the brainstem volume in normal healthy individuals and its application to diffuse axonal injury patients

Diffuse axonal injury (DAI) is a subtype of traumatic brain injury that causes acute-phase consciousness disorders and widespread chronic-phase brain atrophy. Considering the importance of brainstem damage in DAI, a valid method for evaluating brainstem volume is required. We obtained volume measurements from 182 healthy adults by analyzing T1-weighted magnetic resonance images, and created an age-/sex-/intracranial volume-based quantitative model to estimate the normal healthy volume of the brainstem and cerebrum. We then applied this model to the volume measurements of 22 DAI patients, most of whom were in the long-term chronic phase and had no gross focal injury, to estimate the percentage difference in volume from the expected normal healthy volume in different brain regions, and investigated its association with the duration of posttraumatic amnesia (which is an early marker of injury severity). The average loss of the whole brainstem was 13.9%. Moreover, the percentage loss of the whole brainstem, and particularly of the pons and midbrain, was significantly negatively correlated with the duration of posttraumatic amnesia. Our findings suggest that injury severity, as denoted by the duration of posttraumatic amnesia, is among the factors affecting the chronic-phase brainstem volume in patients with DAI.

1316: BLOOD PRESSURE VARIABILITY AND OUTCOME FOR PATIENTS WITH TRAUMATIC DIFFUSE AXONAL INJURY BY MRI

Introduction: Patients with high impact trauma can sustain Diffuse Axonal Injury (DAI) and may have poor prognosis. Blood pressure variability (BPV) has been shown to be associated with poor prognosis in TBI patients but it has not been studied among patients with DAI. Our study investigated whether 24-hour BPV after injury and other clinical factors would be associated with patients’ outcomes. Methods: This is a retrospective study involving all adult patients who presented to a Regional Quaternary Trauma Center between 01/01/2017-12/31/2021. Patients who were radiologically classified as having DAI and received MRI were eligible, as presence of DAI on Magnetic Resonance Imaging (MRI) is also associated with poor outcome. Outcomes were hospital dispositions (ranking from Being discharged home, Rehabilitation facility, Dead) and Glasgow Coma Scale on hospital day 5 (HD5GCS ranking from 3-8, 9-12, 13-14, 15), which also correlated with patients’ 90-day neurocognitive function. We performed ordinal logistic regression to measure association between clinical factors and outcome. Results: We identified and analyzed 154 patients. Mean age was 49 (± 20) years and 114 (74%) were male. Median [IQR] GCS at admission and 24-hour, hospital day 5 were 5 [3-11], 5 [7-10], 8 [6-11], respectively. Most common lesion location was Corpus (89/154, 58%), brain stem (68/154, 44%). Seventy-one (46%) patients had highest Adam score of 3. Ordinal regression showed that BPV components were not associated with DAI patients’ outcome. However, increased age (Coeff. -0.04, OR 0.95, 95%CI 0.92-0.99), Brainstem lesion (Coeff -3.1, OR 0.04, 95%CI 0.001-0.36), requiring anti-hypertensive infusion (Ceff -1.9, OR 0.15, 95%CI 0.03-0.891), blood transfusion (coeff -2.4, OR 0.08, 95%CI 0.01-0.51 were associated with higher mortality, while only high GCS at 24 hours was associated with high HD5GCS (Coeff -01.6, OR 0.85, 95%CI 0.74-0.99) Conclusions: Blood pressure variability was not associated with outcome among patients with DAI. However, increased age, having brainstem lesion, requiring anti-hypertensive infusion and blood products were associated with poor outcome, while high GCS on 24 hour after admission was associated with high GCS on hospital day 5.

UPLC/Q-TOF MS-Based Urine Metabonomics Study to Identify Diffuse Axonal Injury Biomarkers in Rat.

Diffuse axonal injury (DAI) represents a frequent traumatic brain injury (TBI) type, significantly contributing to the dismal neurological prognosis and high mortality in TBI patients. The increase in mortality can be associated with delayed and nonspecific initial symptoms in DAI patients. Additionally, the existing approaches for diagnosis and monitoring are either low sensitivity or high cost. Therefore, novel, reliable, and objective diagnostic markers should be developed to diagnose and monitor DAI prognosis. Urine is an optimal sample to detect biomarkers for DAI noninvasively. Therefore, the DAI rat model was established in this work. Meanwhile, the ultraperformance liquid chromatography quadrupole-time-of-flight hybrid mass spectrometry- (UPLC/Q-TOF MS-) untargeted metabolomics approach was utilized to identify the features of urine metabolomics to diagnose DAI. This work included 57 metabolites with significant alterations and 21 abnormal metabolic pathways from the injury groups. Three metabolites, viz., urea, butyric acid, and taurine, were identified as possible biomarkers to diagnose DAI based on the great fold changes (FCs) and biological functions during DAI. The present study detected several novel biomarkers for noninvasively diagnosing and monitoring DAI and helped understand the DAI-associated metabolic events.

The Effects of Ultra-early Hyperbaric Oxygen Intervention in the Treatment of Diffuse Axonal Injury

Objective: To investigate the efficacy and mechanism of ultra-early hyperbaric oxygen intervention in the treatment of diffuse axonal injury (DAI). Methods: Eighty-six patients with diffuse axonal injury were selected and then divided into an ultra-early hyperbaric oxygen treatment group and a conventional treatment group with 43 patients in each group. The Glasgow Coma Scale (GCS) on the 10th day (10d), 20th day (20d), and 30th day (30d) after treatment and the Glasgow Outcome Score (GOS) 6 months later were observed and compared between both the groups. Results: The average score of the GCS at 10d, 20d, and 30d as well as the GOS 6 months later in the ultra-early hyperbaric oxygen treatment group were higher than those in the conventional treatment group (P &lt; 0.05). Conclusion: Hyperbaric oxygen therapy is one of the unique and effective methods in clinical treatment especially for the treatment of DAI patients and it is worthy of promotion.

White matter degeneration in diffuse axonal injury and mild traumatic brain injury observed with automatic tractography.

A better understanding of white matter tract damage in patients with diffuse axonal injury (DAI) and mild traumatic brain injury (MTBI) is important to obtain an objective basis for sequelae. The purpose of this study was to clarify the characteristics of white matter tract degeneration in DAI and MTBI using automated tractography. T1-weighted and diffusion tensor imaging (DTI) was performed on seven DAI and seven MTBI patients as well as on nine healthy subjects. Automated probabilistic tractography analysis was performed using FreeSurfer and TRACULA (tracts constrained by underlying anatomy) for the reconstruction of major nerve fibers. We investigated the difference between DTI quantitative values in each white matter nerve fiber between groups and attempted to evaluate the classification accuracy of DAI and MTBI using receiver operator curve analysis. Both DAI and MTBI appeared to exhibit axonal degeneration along the nerve fiber tract in a scattered manner. The mean diffusivity of the ampulla of the corpus callosum was significantly higher in DAI than that in MTBI patients, suggesting axonal degeneration of the corpus callosum in DAI patients. Using mean diffusivity of the right cingulum-angular bundle, DAI and MTBI could be discriminated with an area under the curve of 94%. Both DAI and MTBI exhibited scattered axonal degeneration; however, DAI appeared to exhibit more pronounced axonal degeneration in the ampulla of the corpus callosum than MTBI. Our results suggest that DAI and MTBI can be accurately distinguished using DTI.

Combination of Neutrophil-to-Lymphocyte Ratio and Admission Glasgow Coma Scale Score Is Independent Predictor of Clinical Outcome in Diffuse Axonal Injury

The neutrophil-to-lymphocyte ratio (NLR) is an independent predictor of clinical outcome of different diseases, such as acute ischemic stroke, intracerebral hemorrhage, malignant tumor, and traumatic brain injury. However, the prognostic value of NLR plus admission Glasgow Coma Scale score (NLR-GCS) is still unclear in patients with diffuse axonal injury (DAI). Therefore this study assessed the relationship between the NLR-GCS and 6-month outcome of DAI patients. The clinical characteristics of DAI patients admitted to our department between January 2014 and January 2020 were retrospectively analyzed. The candidate risk factors were screened by using univariate analysis, and the independence of resultant risk factors was evaluated by the binary logistic regression analysis and least absolute shrinkage and selection operator regression analysis. The predictive value of NLR-GCS in an unfavorable outcome was assessed by the receiver operating characteristics curve analysis. A total of 93 DAI patients were included. Binary logistic regression analysis and least absolute shrinkage and selection operator regression analysis showed the level of NLR on admission was an independent risk factor of unfavorable outcomes in DAI patients. The ROC curve analysis showed that the predictive capacity of the combination of NLR and admission GCS score and combination of NLR and coma duration outperformed NLR, admission GCS score, and coma duration alone. The higher NLR level on admission is independently associated with unfavorable outcomes of DAI patients at 6 months. Furthermore, the combination of NLR and admission GCS score provides the superior predictive capacity to either NLR or GCS alone.

Functional Connectivity Density with Frequency-Dependent Changes in Patients with Diffuse Axonal Injury: A Resting-State Functional Magnetic Resonance Imaging Study.

PurposeWe explored changes in spontaneous brain connectivity in patients with diffuse axonal injury (DAI), assessed via functional connectivity density (FCD) tests using different frequency bands.Patients and MethodsIn all, 23 patients with DAI (17 males and 6 females) and 23 healthy controls (HCs; 17 males and 6 females) were included. Functional magnetic resonance imaging scans were performed when the participants were in a resting state and the FCD levels in three frequency bands (slow-4: 0.027–0.073 Hz, slow-5: 0.01–0.027 Hz, and typical: 0.01–0.08 Hz) were measured. In addition, Pearson’s correlation coefficient was used to explore the relationship between clinical indices and brain regions with abnormal FCD values.ResultsCompared to HCs, DAI patients had significantly greater FCD values in the right extranuclear/limbic lobe/cingulate gyrus and left limbic lobe/hippocampus/parahippocampal gyrus, and significantly lower FCD values in the left precuneus/posterior cingulate gyrus, in the slow-4 band. In the slow-5 band, the DAI patients had higher FCD values in the left inferior temporal gyrus/superior temporal gyrus, left parahippocampal gyrus/limbic lobe, left extranuclear/cingulate gyrus, and right medial frontal gyrus, and lower values in the right inferior frontal gyrus, right inferior parietal lobule, and left cingulate gyrus/limbic lobe. Moreover, compared to HCs, the values in the typical band were higher in the right extranuclear/limbic lobe/hippocampus/parahippocampal gyrus, but were significantly lower in the right precuneus/posterior cingulate gyrus and right inferior parietal lobule/supramarginal gyrus. The abnormal FCD values of these brain regions were linearly correlated with different clinical scale scores.ConclusionDAI patients had abnormal FCD values in various brain regions, indicating disruption to the brain functional network. Moreover, the values were frequency dependent. Our results provide new evidence for the pathogenesis of functional impairment and may explain the neuropathological or compensatory mechanism of the disease.

Disentangling local functional connectivity and its variability as a biomarker for predicting dysfunction in patients with diffuse axonal injury

To investigates and better understand local functional connectivity and its variability, and explore their predictive values of patients with diffuse axonal injury (DAI). We prospectively enrolled 24 DAI patients and well-matched healthy controls (n = 26) receiving resting-state functional magnetic resonance imaging. We first assessed static and dynamic regional homogeneity (ReHo); then, a k-means clustering algorithm were performed to cluster ReHo states; finally, the prediction of clinical scores of the altered static and dynamic ReHo values was conducted using a general linear model. Compared with healthy subjects, the DAI patients showed distributed alteration in static and dynamic ReHo in several regions, and their alteration commonly located in the left cerebellum posterior lobe (P < 0.01 and Gaussian random field correction at P < 0.05). Importantly, a relationship was observed in disease-specific differences in static or dynamic ReHo and the clinical assessment: the static ReHo values of the left inferior parietal lobule predicted Glasgow Coma Scale scores (ρ = 0.462, P = 0.010). Notably, the results suggested that DAI patients make different transitions to some states (states 1 and 2) compared to healthy controls, but these dynamic transitions were not predictive of clinical associations with ReHo variability. Our findings suggested alterations in both static and dynamic ReHo (less temporal variability) in several regions in the DAI patients. The static ReHo values of the left inferior parietal lobule could be useful as a novel predictive indicator to develop objective neuromarker for future artificial intelligence analyses.

Characterizing Static and Dynamic Fractional Amplitude of Low-Frequency Fluctuation and its Prediction of Clinical Dysfunction in Patients with Diffuse Axonal Injury

Recently, advanced magnetic resonance imaging has been widely adopted to investigate altered structure and functional activities in patients with diffuse axonal injury (DAI), this patient presumed to be caused by shearing forces and results in significant neurological effects. However, little is known regarding cerebral temporal dynamics and its predictive ability in the clinical dysfunction of DAI. In this study, static and dynamic fractional amplitude of low-frequency fluctuation (fALFF), an improved approach to detect the intensity of intrinsic neural activities, and their temporal variability were applied to examine the alteration between DAI patients (n = 24) and healthy controls (n = 26) at the voxel level. Then, the altered functional index was used to explore the clinical relationship and predict dysfunction in DAI patients. We discovered that, compared to healthy controls, DAI patients showed commonly altered regions of static fALFF, and its variability was mainly located in the left cerebellum posterior lobe. Furthermore, decreased static fALFF values over the left cerebellum posterior lobe and bilateral medial frontal gyrus showed significant correlations with disease duration and Mini-Mental State Examination scores. More important, the increased temporal variability of dynamic fALFF in the left caudate could predict the severity of the Glasgow Coma Scale score in DAI patients. Overall, these results suggested selective abnormalities in intrinsic neural activities with reduced intensity and increased variability, and this novel predictive marker may be developed as a useful indicator for future connectomics or artificial intelligence analyses.

Thalamic atrophy and dysfunction in patients with mild-to-moderate traumatic diffuse axonal injury

Disrupted white matter structure has been established in patients with diffuse axonal injury (DAI), but morphological changes in gray matter and local intrinsic activity in the short and midterm (before 6 months) have not been documented in DAI patients. We hypothesized that regionally selective atrophy observed in deep gray matter in the short-term and mid-term periods in patients with mild-to-moderate DAI, local atrophy, and/or dysfunction would be related to clinical characteristics. We evaluated the changes in regional density and synchronization in 18 DAI patients separately using Diffeomorphic Anatomical Registration through Exponentiated Lie algebra-enhanced voxel-based morphometry and regional homogeneity (ReHo). Compared with the controls, DAI patients showed a decreased density in the bilateral thalami and decreased ReHo values in the ventral anterior and ventral lateral nuclei of the bilateral thalami. Pearson’s correlation analysis showed that decreased density in the bilateral thalami was correlated negatively with time since injury and decreased ReHo values in the ventral anterior and ventral lateral nuclei of the bilateral thalami were associated with a worsened motor assessment scale. These findings suggest that mild-to-moderate traumatic DAI within the short and midterm could lead to thalamic atrophy and that dysfunction in the bilateral thalami is associated with declining motor function. This study could potentially provide complementary evidence as an important element in longitudinal studies.

Role of susceptibility-weighted imaging and diffusion tensor imaging sequence of MRI in diagnosis and prognosis evaluation of diffuse axonal injury

Objective To evaluate the clinical application of SWI and DTI of MRI in the diagnosis and prognosis of diffuse axonal injury (DAI). Methods A retrospective case series study was conducted on the clinical data of 16 patients with DAI admitted from January 2015 to December 2017. There were nine males and seven females, aged (56.3±4.1)years. According to Glasgow Coma Scale (GCS), there were seven patients with 3-8 points, eight with 9-12 points, and one with 13 points. All patients received head CT examination on admission and then received head MRI examination within one week to record the number of lesions on T1WI, T2WI, DWI, and SWI in CT and MRI examination. On the DTI sequence, five regions including the subcortical white matter, the corpus callosum, the thalamus, the cerebellum, and the brain stem were selected for measurement of the apparent diffusion coefficient (ADC) and partial fraction of anisotropy (FA) values. The Glasgow outcome scale (GOS) was evaluated 6 months after injury. The linear correlation between ADC, FA values, GCS, and GOS on admission and after 6 months were analyzed. Results The statistical analysis of CT, T1WI, T2WI, DWI and SWI in 16 patients showed that the detection rates of DAI lesions were 25.6% (43/168), 30.4% (51/168), 44.0% (74/168), 51.8% (87/168), and 100%, respectively (P 0.05). The correlation strength of ADC values in each region with the GCS score in descending order was the thalamus, the corpus callosum, and the brain stem (P<0.05 or 0.01); for ADC with the GOS score, it was the corpus callosum, the thalamus and the brain stem (P<0.05 or 0.01); for FA with GCS and GOS scores, it was thalamus, corpus callosum, and brainstem (P<0.05 or 0.01). Conclusion The SWI has better sensitivity to detect DAI lesions than CT and conventional MRI sequences. DTI can accurately, objectively and visually detect the integrity of cerebral white matter fibers. Both SWI and DTI can help make early diagnosis and evaluate the prognosis of DAI patients accurately. Key words: Diffuse axonal injury; Magnetic resonance imaging; Susceptibility-weighted imaging

Diffuse axonal injury (DAI) in moderate to severe head injured patients: Pure DAI vs. non-pure DAI

ObjectiveDiffuse axonal injury (DAI) is known to be associated with poor outcome. DAI often associates with other intracranial injuries but their distinct features have not been established. In this retrospective cohort study, we compared clinical outcomes between pure and non-pure DAI patients. Patients and MethodsTotal of 1047 traumatic brain injury (TBI) patients visited our institute between 2011 and 2017. Age ranged between 15–85 years old and Glasgow coma scale (GCS) score less than 13 were included. DAI was diagnosed in 45 patients using CT and MRI and their clinical features and outcomes were compared depending on their associated cranial injury; 20 patients without evidence of associated injury (Pure DAI group) and other 25 patients with associated injury (Non-pure DAI group). DAI stage was adopted using Gentry, L.R. classification. Glasgow outcome scale (GOS) was measured at least 6 months after trauma to evaluate their functional outcome. ResultsThe mean age and follow-up period were 45.36 years and 15.09 months, respectively. There were no significant differences between pure and non-pure DAI groups regarding demographic data and clinical findings on their admission. Logistic regression model was used to examine the association between GOS and clinical factors. In this analysis, pure DAI was no significantly different to non-pure DAI (p = 0.607). However, DAI Stage, transfusion, and hypotension on admission were strongly related to poor outcome. Stage III showed sevenfold higher risk when compared to Stage I (p = 0.010). The risk was also high when Stage III was compare to Stage I and II (p = 0.002). Interestingly, no significant difference was observed between Stage I and II (p = 0.847). ConclusionsUnfavorable outcome was observed in 14 patients (31.11%) which was lower than we expected. Interestingly, non-pure DAI was no worse than pure DAI on their functional outcome. However, DAI Stage III was independently associated with poor outcome when compared to Stage I or I and II. Finally, we concluded that Stage II is clinically more related to Stage I, rather than Stage III.

Effects of transcranial LED therapy on the cognitive rehabilitation for diffuse axonal injury due to severe acute traumatic brain injury: study protocol for a randomized controlled trial

BackgroundPhotobiomodulation describes the use of red or near-infrared light to stimulate or regenerate tissue. It was discovered that near-infrared wavelengths (800–900 nm) and red (600 nm) light-emitting diodes (LED) are able to penetrate through the scalp and skull and have the potential to improve the subnormal cellular activity of compromised brain tissue. Different experimental and clinical studies were performed to test LED therapy for traumatic brain injury (TBI) with promising results. One of the proposals of this present study is to develop different approaches to maximize the positive effects of this therapy and improve the quality of life of TBI patients.Methods/designThis is a double-blinded, randomized, controlled trial of patients with diffuse axonal injury (DAI) due to a severe TBI in an acute stage (less than 8 h). Thirty two patients will be randomized to active coil helmet and inactive coil (sham) groups in a 1:1 ratio. The protocol includes 18 sessions of transcranial LED stimulation (627 nm, 70 mW/cm2, 10 J/cm2) at four points of the frontal and parietal regions for 30 s each, totaling 120 s, three times per week for 6 weeks, lasting 30 min. Patients will be evaluated with the Glasgow Outcome Scale Extended (GOSE) before stimulation and 1, 3, and 6 months after the first stimulation. The study hypotheses are as follows: (1) transcranial LED therapy (TCLT) will improve the cognitive function of DAI patients and (2) TCLT will promote beneficial hemodynamic changes in cerebral circulation.DiscussionThis study evaluates early and delayed effects of TCLT on the cognitive rehabilitation for DAI following severe acute TBI. There is a paucity of studies regarding the use of this therapy for cognitive improvement in TBI. There are some experimental studies and case series presenting interesting results for TBI cognitive improvement but no clinical trials.Trial registrationClinicalTrials.gov, NCT03281759. Registered on 13 September 2017.

Altered Intracortical Inhibition in Chronic Traumatic Diffuse Axonal Injury.

Overactivation of NMDA-mediated excitatory processes and excess of GABA-mediated inhibition are attributed to the acute and subacute phases, respectively, after a traumatic brain injury (TBI). However, there are few studies regarding the circuitry during the chronic phase of brain injury. To evaluate the cortical excitability (CE) during the chronic phase of TBI in victims diagnosed with diffuse axonal injury (DAI). The 22 adult subjects were evaluated after a minimum of 1 year from the onset of moderate or severe TBI. Each of the subjects first had a comprehensive neuropsychological assessment to evaluate executive functions-attention, memory, verbal fluency, and information processing speed. Then, CE assessment was performed with a circular coil applying single-pulse and paired-pulse transcranial magnetic stimulation over the cortical representation of the abductor pollicis brevis muscle on M1 of both hemispheres. The CE parameters measured were resting motor threshold (RMT), motor-evoked potentials (MEPs), short-interval intracortical inhibition (SIICI), and intracortical facilitation (ICF). All data were compared with that of a control group that consisted of the healthy age-matched individuals. No significant differences between the left and right hemispheres were detected in the DAI subjects. Therefore, parameters were analyzed as pooled data. Values of RMT, MEPs, and ICF from DAI patients were within normal limits. However, SIICI values were higher in the DAI group-DAI SIICI = 1.28 (1.01; 1.87) versus the control value = 0.56 (0.33; 0.69)-suggesting that they had a disarranged inhibitory system (p < 0.001). By contrast, the neuropsychological findings had weak correlation with the CE data. As inhibition processes involve GABA-mediated circuitry, it is likely that the DAI pathophysiology itself (disruption of axons) may deplete GABA and contribute to ongoing disinhibition of these neural circuits of the cerebrum during the chronic phase of DAI.