Diffuse Axonal Injury Patients Research Articles

Corpus callosum injury in patients with diffuse axonal injury: A diffusion tensor imaging study

Little is known about diffusion tensor image (DTI) findings of corpus callosum (CC) injury in patients with diffuse axonal injury (DAI). In the present study, we investigated the presence and extent of CC injury in patients with DAI. Twenty patients with DAI and 20 age-and sex-matched normal healthy controls subjects were recruited. Patients were divided into two groups according to the presence of a CC lesion on conventional brain MRI, namely, the CC (+) group (8 patients) and the CC (-) group (12 patients). DTIs were acquired using a sensitivity-encoding head coil at 1.5 T. The CC was divided into six mid-sagittal segments: the genu, rostral midbody, anterior midbody, posterior midbody, isthmus, and splenium. Fractional anisotropies (FA) and apparent diffusion coefficients (ADCs) were measured. FA values of all CC segments in DAI patients were significantly lower than those of controls (p < 0.001); whereas ADC values were either similar or marginally higher. FA values of the six sagittal segments in the CC (-) and (+) groups were significantly lower than those of controls, and ADC values were slightly higher, or showed no change. CC lesions may be present in DAI patients, irrespective of detection on conventional brain MRI. The authors suggest the probability that in cases of corpus callosum injury, DTI can offer a powerful means of detecting DAI.

Clinical Utility of Diffusion Tensor Imaging for Evaluating Patients with Diffuse Axonal Injury and Cognitive Disorders in the Chronic Stage

Although diffuse axonal injury (DAI) usually ellicits cognitive disorders, abnormal brain findings are generally undetected by conventional imaging techniques. The aim of this study was to evaluate the feasibility of using diffusion tensor imaging (DTI) to detect lesions in DAI patients and to investigate the correlation between DAI lesions and cognitive disorders. We examined 16 healthy controls and 11 patients with DAI. Using voxel-based analysis, we found that there were significantly more brain regions with decreased fractional anisotropy (FA) in the brain but DAI patients compared to healthy controls (p < 0.001), whereas few lesions were detected via conventional magnetic resonance imaging. There was a significant relationship between the results of the Wechsler Adult Intelligence Scale-Revised, Trail Making Test, and some indices of the Wechsler Memory Scale-Revised and the decreased FA observed in various areas of the brain (p < 0.001). The total cognitive scores on the functional independence and functional assessment measures, which represent behavioral problems, were correlated with the cluster (number of DAI lesions, p = 0.007) and voxel numbers (total size of all DAI lesions, p = 0.001). In the fiber tractography-based analysis, DAI patients with memory disorders showed an interruption of fibers within the fornix compared to healthy controls. These results indicate that DTI is a useful technique not only for detecting DAI lesions but also for examining cognitive disorders in DAI patients.

Cerebral Vasospasm: New Strategies in Research and Treatment

Cerebral Vasospasm: New Strategies in Research and Treatment

Brain activations in errorless and errorful learning in patients with diffuse axonal injury: A functional MRI study

Primary objective: Errorless learning has been reported to be effective in the rehabilitation of patients with impaired cognitive functions following brain injury. This study compared brain activations in errorless learning (EL) and errorful learning (EF) in patients with diffuse axonal injury (DAI) using a functional magnetic resonance imaging (fMRI).Methods and procedures: The participants were 13 patients with DAI. Thirteen healthy individuals were evaluated as a control group. The participants learned words under the EL and EF conditions in advance and performed the recognition task during fMRI scanning.Main outcomes and results: EL in the control group was significantly faster than EF (p = 0.005), but not in the DAI group. EL in the DAI group scored significantly higher than EF (p = 0.026). An fMRI showed significant activations in the posterior cingulate gyrus (BA 31) and precuneus (BA 7) in the control group when EF > EL, but in the precuneus (BA 7, 31) and bilateral inferior parietal lobules (BA 39, 40) in the DAI group.Conclusions: These results indicate the disadvantage of EF and advantage of EL to DAI patients. The findings also reflect brain plasticity in patients with DAI in the chronic phase.

Combined Behavioral and EEG Power Analysis in DAI Improve Accuracy in the Assessment of Sustained Attention Deficit

In clinical routine, the evaluation of sustained attention is often performed by analyzing the behavioral data collected during specific tests. Such analyses are rarely accompanied by a detailed examination of the subject's simultaneous electroencephalographic (EEG) activity, and particularly its frequency content. In this study, a group of healthy volunteers and a group of patients affected by diffuse axonal injury (DAI) were tested while performing a modified version of the Conners' continuous performance test. A comparative study was carried out between the behavioral and neuropsychological data obtained during the task, to investigate neural activation. Spectral power was calculated for each of the recorded EEG signals, taking account of the frequency bands traditionally considered in literature. Then a compressed spectral array sequence of spectra was plotted to put into evidence the temporal modifications in the signal power spectral density, and, finally, the analysis of the rhythm variability was carried out. Evaluation of the results thus obtained shows that the two groups registered very different cerebral activation dynamics during the ongoing attentional task. Moreover, DAI patients showed mild cortical activation in the prefrontal region, spread equally throughout both brain hemispheres, while controls showed strong predominant activation of the right prefrontal area. Our findings encourage further investigations of the combined employment of tests and EEG recordings during the clinical assessment of sustained attention performance.

Cerebral blood flow in patients with diffuse axonal injury – examination of the easy Z‐score imaging system utility

To evaluate the utility of easy Z-score imaging system (eZIS) in 27 diffuse axonal injury (DAI) cases. Twenty-seven DAI patients were examined with an magnetic resonance imaging (MRI) T2* sequence and with eZIS (seven women, 20 men; age range, 19-35 years; median age: 26.6 years). In this investigation, we excluded patients who exhibited complications such as acute subdural hematoma, acute epidural hematoma, intracerebral hematoma, or brain contusion. We examined the neuropsychological tests and correlated with findings from MRI/eZIS. Furthermore, we evaluated the degree of ventricular enlargement in the bifrontal cerebroventricular index (CVI). Patients were divided into two groups: the enlargement group (bifrontal CVI > 35%, 12 patients) and the non-enlargement group (bifrontal CVI < 35%, 15 patients). All of the patients showed cognitive deficits as observed from the neuropsychological test results. Fifteen out of 27 patients by MRI T1/T2 weighted images and fluid attenuated inversion recovery (FLAIR), 22 out of 27 patients by MRI T2* weighted images and 24 out of 27 patients by eZIS showed abnormal findings. In MRI T2* weighted imaging, the white matter from the frontal lobe, corpus callosum, and brainstem showed abnormal findings. With eZIS, 22 patients (81.5%) showed blood flow degradation in the frontal lobe, and 12 patients (44.4%) in cingulate gyrus. In the enlargement group, Functional Independence Measure, Mini-Mental State Examination, Verbal IQ (VIQ)/Full Scale IQ (FIQ), Trail Making Test-B (TMT-B), and Non-paired of Miyake Paired Test were significantly lower. Amongst 12 patients without ventricular enlargement who had no abnormal findings in MRI T1/T2 weighted images and FLAIR, abnormal findings were detectable in seven patients with MRI T2* weighted imaging and to 10 patients with eZIS. Results of the MRI examination alone cannot fully explain DAI frontal lobe dysfunction. However, addition of the eZIS-assisted analysis derived from the single photon emission computed tomography (SPECT) data enabled us to understand regions where blood flow was decreased, i.e., where neuronal functions conceivably might be reduced.

Diffusion tensor imaging fiber tractography for evaluating diffuse axonal injury

Patients with Diffuse axonal injury (DAI) frequently exhibit cognitive disorders chronically. Radiologic recognition of DAI can help understand the clinical syndrome and to make treatment decisions. However, CT and conventional MRI are often normal or demonstrate lesions that are poorly related to the cognitive disorders. Recently, diffusion tensor imaging (DTI) fiber tractography has been shown to be useful in detecting various types of white matter damage. The aim of this study was to evaluate the feasibility of using DTI fiber tractography to detect lesions in DAI patients, and to correlate the DAI lesions with the cognitive disorders. We investigated two patients with chronic DAI. Both had impaired intelligence, as well as attention and memory disorders that restricted their activities of daily living. In both patients, DTI fiber tractography revealed interruption of the white matter fibers in the corpus collosum and the fornix, while no lesions were found on conventional MRI. The interruption of the fornix which involves the circuit of Papez potentially correlates with the memory disorder. Therefore, DTI fiber tractography may be a useful technique for the evaluation of DAI patients with cognitive disorders.

Role of diffusion-weighted magnetic resonance imaging in diffuse axonal injury

To determine whether the signal changes on magnetic resonance imaging (MRI), including fluid attenuated inversion recovery (FLAIR), T2*-weighted gradient echo (GE) imaging, and diffusion-weighted imaging (DWI) in diffuse axonal injury (DAI) patients correlate with the clinical outcome. We diagnosed patients with DAI based on the following criteria: 1) a loss of consciousness from the time of injury that persisted beyond 6 h; 2) no apparent hemorrhagic contusion on computed tomography (CT); 3) the presence of white matter injury on MRI. Twenty-one DAI patients were analyzed (19 M, 2 F, mean age 34 years) with MRI (FLAIR, T2*-weighted GE imaging, and DWI). 325 abnormalities were detected by MRI within a week after injury. The T2*-weighted GE imaging was significantly more sensitive than FLAIR and DWI in diagnosing DAI. DWI detected only 32% of all lesions, but could depict additional shearing injuries not visible on either T2*-weighted GE imaging or FLAIR. The mean number of lesions in brainstem detected by DWI in the favorable group (good recovery/moderately disabled) was significantly smaller than in the unfavorable group (severely disabled/vegetative survival/death). This trend was not observed on the T2*-weighted GE imaging and FLAIR findings. DWI cannot detect all DAI-related lesions, but is a potentially useful imaging modality for both diagnosing and assessing patients with DAI.

Reduced short latency afferent inhibition in diffuse axonal injury patients with memory impairment

The present study used short interval intracortical inhibition (SICI), intracortical facilitation (ICF), and short latency afferent inhibition (SAI) to evaluate motor cortex excitability in 16 diffuse axonal injury (DAI) patients with memory impairment and compared the data with those of 16 healthy controls. SAI was reduced in patients compared with controls (92 ± 12 versus 39 ± 11% of the test size; p < 0.0001, unpaired t-test). DAI patients tended to have a high resting motor threshold (RMT) and less pronounced SICI and ICF than controls, but these differences were not significant. A single oral dose (3 mg) of donepezil, an acetylcholinesterase inhibitor that is commonly used to treat Alzheimer's disease (AD), improved SAI in DAI patients with wide individual variations that ranged from an increase of 77–18% of test size. These findings suggest that measuring SAI may provide a means of probing the integrity of cholinergic networks in an injured human brain.

Neuropsychological sequelae of diffuse traumatic brain injury

Primary objectives: Description and analysis of neuropsychological deficits following brain trauma with diffuse lesion probably corresponding to diffuse axonal injury (DAI).Research design: A series of 111 patients suffering from traumatic brain injury could be investigated neuropsychologically within the first 4 weeks after injury and re-assessed after 5–8 months. They included 11 subjects with CT-evidence of diffuse axonal injury, but no CT-signs of focal contusions. Eleven patients with focal frontal contusions but no CT signs of DAI were matched to and compared with the DAI subjects. Seventeen TBI patients with normal CT scans served as controls.Results: When assessed within the first 4 weeks after TBI, both DAI and frontal contusion patients exhibited behavioural abnormalities and deficits in Wechsler Similarities. The DAI patients were also impaired in Digit Span backward and Stroop interference. When re-assessed, the DAI patients showed considerable deficits in the California Verbal Learning Test and in the Wisconsin Card Sorting Test.Conclusions: DAI leads to neuropsychological impairment dominated by executive and memory dysfunction.

Thyroid hormones in comatose patients with traumatic brain injury.

The objective was to study if thyroid hormones, cortisol, prolactin and brain injury marker levels were changed in traumatic brain injury (TBI) patients with changing levels of consciousness. We estimated the above named parameters in 32 patients (27 men and 5 women aged 11-55). Admission Glasgow Coma Score was < 8. Follow-up period--30 days. The length of coma was 3 to 25 days. There were significant decreases in TSH, TBG, FT3 and F_levels (p < 0.05, for each) and a T3 increase (as compared to very low preceding values) on day 1 before emergence from coma and considerable post-coma increase in TBG, FT3, TSH and F levels (p < 0.001 each) on days 1-3 in patients with diffuse axonal injury (DAI). In patients with contusions and epidural and subdural hematomas (CH) T3 and T4 levels continued to fall until 4-6 postcoma days. TSH values significantly increased up to average normal ranges (p < 0.05) on days "-" 2 and "-" 1 before emergence from coma and remained so. Significantly lower levels of TSH, F and PRL were found in patients with CH in the mostly remote period (on days "-" 12-"-" 8) before emergence from coma in comparison with DAI patients. In blood the following correlations of examined parameters were established: between NSE and T3 (r = -0.39), NSE and FT3 (r = -0.59), TNF alpha and TBG (r = -0.64), TNF alpha and T3 (r = -0.3) and S-100 and T3 (r = -0.3) (p < 0.05, for each). The results obtained confirmed a low T3 syndrome in comatose TBI patients. We demonstrated an objective and informative interdependence: the turning-point moment of the emergence from coma was accompanied by significant changes of examined hormone levels and brain injury marker levels. The results may serve as a base for recommending monitoring FT3 and T3 levels simultaneously with that of other injury markers and adequate T3 replacement therapy in the early posttraumatic period.

Diffuse axonal injury (DAI) is not associated with elevated intracranial pressure (ICP).

Traditionally, intracranial pressure (ICP) monitoring has been utilized in all patients with severe head injury (Glasgow coma score of 3-8). Ventriculostomy placement, however, does carry a 4 to 10 percent complication rate consisting mostly of hematoma and infection. The authors propose that a subgroup of patients presenting with severe head trauma and diffuse axonal injury without associated mass lesion, do not need ICP monitoring. Additionally, the monitoring data from ICP, MAP, and CPP for a comparison severe head injury group, and subgroups of DAI would be presented. Thirty-six patients sustaining blunt head trauma and fitting our strict clinical and radiographic diagnosis of DAI were enrolled in our study. Inclusion criteria were severe head injury patients who did not regain consciousness after the initial impact, and whose CT scan demonstrated characteristic punctate hemorrhages of < 10 mm diameter at the greywhite junction, basal ganglia, corpus callosum, upper brainstem, or a combination of the above. Patients with significant mass lesions and documented anoxia were excluded. Their intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were compared to a control group of 36 consecutive patients with severe non-penetrating non-operative head injury, using the Analysis for Variance method. Eighteen (50.0%), six (16.7%), and twelve (33.3%) patients had types I, II, and III DAI, respectively. The admission Glasgow Coma Score (GCS) was higher for types I and II than for type III DAI. ICP was monitored from 23 to 165 hours, with a mean ICP for 36 patients of 11.70 mmHg (SEM = 0.75) and a range from 4.3 to 17.3 mmHg. Of all ICP recordings, of which 89.7%, (2421/2698) were < or = 20 mmHg. Average mean arterial pressure (MAP) was 96.08 mmHg (SEM = 1.69), and 94.6% (2038/2154) of all MAP readings were greater than 80 mmHg. Average cerebral perfusion pressure (CPP) was 85.16 mmHg (SEM = 1.68), and 90.1% (1941/2154) of all CPP readings were greater than 70 mmHg. This is compared to the control group mean ICP, MAP, and CPP of 16.84 mmHg (p = 0.000021), 92.80 mmHg (p = 0.18), and 76.49 mmHg (p = 0.0012). No treatment for sustained elevated ICP > 20 mmHg was needed for DAI patients except in two; one with extensive intraventricular and subarachnoid hemorrhage who developed communicating hydrocephalus, and another with ventriculitis requiring intrathecal and intravenous antibiotic treatments. Two complications, one from a catheter tract hematoma, and another with Staph epidermidis ventriculitis, were encountered. All patients, except type III DAI, generally demonstrated marked clinical improvement with time. The outcome, as measured by Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS) was similarly better with types I and II than type III DAI. The authors conclude that ICP elevation in DAI patients without associated mass lesions is not as prevalent as other severe head injured patients, therefore ICP monitoring may not be as critical. The presence of an ICP monitoring device may contribute to increased morbidity. Of key importance, however, is an accurate clinical history and interpretation of the CT scan.

Pathological study of diffuse axonal injury patients who died shortly after impact.

It is generally considered that axonal injury is apparent only on electron microscopy in the very early stage after a closed head injury. To clarify the pathological findings in head injury patients dying very shortly after the impact, we analyzed 8 fatal cases of diffuse axonal injury (DAI) who underwent medicolegal autopsy at the Department of Forensic Medicine of Kyoto Prefectural University of Medicine. Seven cases died within one hour after injury and another one case died 3 days after injury. We studied these cases macroscopically, microscopically, and electron microscopically. Macroscopically all cases showed the typical findings of diffuse axonal injury. Microscopical study of the cases who died within one hour revealed no characteristic findings of DAI such as appearance of retraction balls or microglia. On the other hand, in the case who died only 3 days after injury it showed the typical retraction balls. Electron microscopic study showed the remarkable destruction of cytoskeletal structure of axons in all cases. From our results, it is reasonable to speculate that DAI may be common among head injury patients who die very soon after the impact.