Traumatic Brain Stem Injury Research Articles

TRAUMATIC BRAINSTEM INJURY DUE TO BLUNT FORCE TRAUMA: AN AUTOPSY CASE REPORT

Trauma is the leading cause of morbidity and mortality in patients under 35-years of age and the sixth leading cause of death worldwide, but primary traumatic brainstem injury after blunt force trauma to the head is a rare event. A forensic autopsy was performed on a 35 years old female who was found dead in an apartment building with both her hands and feet tied together and mouth closed with duct tape. External examination showed the victim suffered from blunt force trauma to the head, face, both arms and legs. Internal examination of the body showed hematomas on the scalp, temporal muscles and deep neck muscles and organs, subarachnoid, intraventricular and brainstem haemorrhage and contusion, along with signs of asphyxiation. Trauma to the occipital region of the head not only can cause traumatic brain injury but can also cause trauma to the brainstem as a result from acute hyperflexion of the neck. Haemorrhages and contusions of the brainstem can lead to changes in the respiratory system, depending on the location of the lesions. Cause of death was concluded to be force trauma to the occipital region causing primary brainstem injury with the mechanism of death of asphyxia.

Multi-omics analysis reveals GABAergic dysfunction after traumatic brainstem injury in rats.

Traumatic brainstem injury (TBSI) is one of the forms of brain injury and has a very high mortality rate. Understanding the molecular mechanism of injury can provide additional information for clinical treatment. In this study, we detected transcriptome, proteomics, and metabolome expression changes in the brainstem of TBSI rats, and comprehensively analyzed the underlying mechanisms of TBSI. After TBSI, there was significant diffuse axonal injury (DAI) in the brainstem of rats. A total of 579 genes, 70 proteins, and 183 metabolites showed significant changes in brainstem tissue. Through molecular function and pathway analysis, the differentially expressed genes, proteins, and metabolites of TBSI were mainly attributed to neural signal regulation, inflammation, neuroprotection, and immune system. In addition, a comprehensive analysis of transcripts, proteins, and metabolites showed that the genes, proteins, and metabolic pathways regulated in the brainstem after TBSI were involved in neuroactive ligand-receptor interaction. A variety of GCPR-regulated pathways were affected, especially GAGA's corresponding receptors GABAA, GABAB, GABAC, and transporter GAT that were inhibited to varying degrees. This study provides insights into the development of a rapid diagnostic kit and making treatment strategies for TBSI.

Excessive sacral sweating caused by autonomic dysreflexia after traumatic brainstem injury

Abstract Rationale: Autonomic dysreflexia is a release phenomenon of spinal sympathetic preganglionic neurons from supraspinal inhibition, possibly of the lower brainstem origin. It is most frequently observed in patients with severe spinal lesions above the mid-thoracic cord. Theoretically, brainstem lesions may cause autonomic dysreflexia; however, such reports are rare. The author reports a case of autonomic dysreflexia restricted to the sacral area that appeared after brainstem lesions due to a traffic accident. Patient concerns: A 36-year-old man suffered from traumatic subarachnoid hemorrhage and hematomas in the lower brainstem. After he became alert and ambulant, he presented with neurological deficits suggestive of right-sided brainstem lesions, which were visualized on magnetic resonance images. He also complained of excessive sweating in the sacral area whenever he had a desire to void. Diagnoses: On the basis of neurological and radiological findings, and results of the thermal sweating test and sweating induced by bladder or rectal distension, his sacral hyperhidrosis was attributed to autonomic dysreflexia. Interventions: Baclofen (15 mg per day) was administered for more than three months, and the sacral hyperhidrosis gradually subsided. Outcomes: After three months, the patient returned home with minor gait disturbances and sacral sweating. Lessons: This may be the first report of excessive sweating due to autonomic dysreflexia caused by traumatic brainstem lesions restricted to the sacral territory. These observations suggest possible somatotopic arrangements, even in the supraspinal inhibitory pathways. Baclofen may be one of the choices for similar cases.

Prognostic Value of Hemorrhagic Brainstem Injury on Early Computed Tomography: A TRACK-TBI Study.

Traumatic brainstem injury has yet to be incorporated into widely used imaging classification systems for traumatic brain injury (TBI), and questions remain regarding prognostic implications for this TBI subgroup. To address this, retrospective data on patients from the multicenter prospective Transforming Research and Clinical Knowledge in TBI study were studied. Patients with brainstem and cerebrum injury (BSI+) were matched by age, sex, and admission Glasgow Coma Scale (GCS) score to patients with cerebrum injuries only. All patients had an interpretable head computed tomography (CT) scan from the first 48 hours after injury and a 6-month Glasgow Outcome Scale Extended (GOSE) score. CT scans were reviewed for brainstem lesions and, when present, characterized by location, size, and type (traumatic axonal injury, contusion, or Duret hemorrhage). Clinical, demographic, and outcome data were then compared between the two groups. Mann-Whitney U-tests showed no significant difference in 6-month GOSE scores in patients with BSI+ (mean 2.7) compared with patients with similar but only cerebrum injuries (mean 3.9), although there is a trend (p=0.10). However, subclassification by brainstem lesion type, traumatic axonal injury (mean 4.0) versus Duret hemorrhage or contusion (mean 1.4), did identify a proportion of BSI+ with significantly less favorable outcome (p=0.002). The incorporation of brainstem lesion type (traumatic axonal injury vs. contusion/Duret), along with GCS into a multivariate logistic regression model of favorable outcome (GOSE score 4-8) did show a significant contribution to the prognostication of this brainstem injury subgroup (odds ratio 0.08, 95% confidence interval 0.00-0.67, p=0.01). These findings suggest two groups of patients with brainstem injuries may exist with divergent recovery potential after TBI. These data support the notion that newer CT imaging classification systems may augment traditional clinical measures, such as GCS in identifying those patients with TBI and brainstem injuries that stand a higher chance of favorable outcome.

The Interdisciplinary Stem Cell Institute's Use of Food and Drug Administration-Expanded Access Guidelines to Provide Experimental Cell Therapy to Patients With Rare Serious Diseases.

The U.S. Food and Drug Administration (FDA) provides guidance for expanded access to experimental therapies, which in turn plays an important role in the Twenty-first Century Cures Act mandate to advance cell-based therapy. In cases of incurable diseases where there is a lack of alternative treatment options, many patients seek access to cell-based therapies for the possibility of treatment responses demonstrated in clinical trials. Here, we describe the use of the FDA’s expanded access to investigational new drug (IND) to address rare and emergency conditions that include stiff-person syndrome, spinal cord injury, traumatic brain stem injury, complex congenital heart disease, ischemic stroke, and peripheral nerve injury. We have administered both allogeneic bone marrow-derived mesenchymal stem cell (MSC) and autologous Schwann cell (SC) therapy to patients upon emergency request using Single Patient Expanded Access (SPEA) INDs approved by the FDA. In this report, we present our experience with 10 completed SPEA protocols.

A Study of Traumatic Brainstem Injury – Clinical, Radiological and Pathological Correlation

A Study of Traumatic Brainstem Injury – Clinical, Radiological and Pathological Correlation

Diagnostic Imaging of Primary Brainstem Injury Using Magnetic Resonance Imaging

Traumatic primary brain stem injury is brain stem injury caused by mechanical head trauma. Before the development of diagnostic imaging, a pathological examination has been the nearly only diagnostic method of primary brain stem injury. Because magnetic resonance imaging (MRI) has a high resolution and CT demonstrates much artifact around the brain stem, MRI became a powerful tool for investigating primary brain stem injury. There are some types of primary brain stem injury. The author herein reviews the recent clinical studies of MRI of primary brain stem injury. The importance of early MRI examination appears to be a consensus. Our study demonstrated that small superficial lesion may be detected only a few days after injury. The acute phase within a few days after a head injury may show an unstable vital sign, thus intensive monitoring of the vital sign and manual or mechanical ventilation during a MRI examination should be employed. Direct brain stem contusion has a good prognosis compared with brain stem injury associated with diffuse axonal injury (DAI). Small superficial lesions are detected only within a few days after a head injury. Recent studies of MRI in patients with head injuries could not determine the pathology. However, the differentiation of the pathophysiology must be clinically important because the prognoses are different and distinguishable using only acute stage MRI.

外傷による一次性／二次性脳幹損傷のMRI 所見と予後

外傷による一次性／二次性脳幹損傷のMRI 所見と予後

Traumatic Brain Stem Injury: Evaluation by MRI

I read with great interest the article by Hilario et al.[1][1] The authors retrospectively analyzed the MR imaging data from the first 30 days after injury in 108 patients with severe head trauma and found that the presence of posterior and bilateral brain stem injuries were poor prognostic signs.

Profile of Traumatic Brain Stem Injury: An Autopsy Study of 41 Cases

It is a prospective study of 41 cases of traumatic brain stem injury cases whose medico legal autopsy was done in the Institute of Forensic Medicine, at the Madras Medical College and Government General Hospital, Chennai from December 2007 to June 2008. In the 41 cases, 16 cases, (39.02%) were primary brain stem injury and 25 cases, (60.98) were secondary brain stem injury. The mean ages of cases with primary and secondary brainstem injuries were respectively 55.7 and 36.2. Male victims outnumbered the female victims with male female sex ratio of 13:1. Road traffic accidents involving mainly pedestrians and two wheelers were the most common cause for traumatic brain injury.

The prognostic significance of traumatic brainstem injury detected on T2-weighted MRI

Magnetic resonance imaging is frequently used to evaluate patients with traumatic brain injury in the acute and subacute setting, and it can detect injuries to the brainstem, which are often associated with poor outcomes. This study was undertaken to determine which MRI and clinical factors provide prognostic information in patients with traumatic brainstem injuries. The authors performed a retrospective analysis of cases involving patients admitted to a Level I trauma center who were identified in a prospective database as having suffered traumatic brainstem injury identified on MRI. Patient outcomes were dichotomized to dead/vegetative versus functional groups. Standard demographic data, admission Glasgow Coma Scale (GCS) scores, results of the motor component of the GCS examination at admission and 24 hours later, CT scan findings, and peak intracranial pressure were collected from medical records. Volumetric analysis of each patient's injuries was performed with T2-weighted and gradient echo sequences. The T2-weighted MRI sequence for each patient was reviewed to determine the anatomical location of injury within the brainstem and whether the injury crossed the midline. Thirty-six patients who met the study inclusion criteria were identified. At 6-month follow-up, 53% of these patients had poor outcomes and 47% had recovered. Patients with injuries to the medulla or deep bilateral injuries to the pons did not recover. The T2 volumes were found superior to gradient echo sequences in regard to predicting survival (ROC/AUC 0.67, p = 0.07 vs 0.60, p = 0.29, respectively), but neither reached statistical significance. The timing of MR image acquisition did not influence the findings. The time from admission to MRI did not differ significantly between the recovered group and the poor-outcome group (p = 0.52, Mann-Whitney test), and lesion size as measured by T2 volume did not vary with time to scan (R(2) = 0.03, p = 0.3, linear regression). Performing a stepwise logistic regression with all the variables yielded the following factors related to recovery: crossing midline, p = 0.0156, OR 0.075; and 24-hour GCS motor score, p = 0.0045, OR = 2.25, c-statistic 0.913. Further examination of these 2 factors disclosed the following: none of 15 patients with midline-crossing lesions and a 24-hour GCS motor score of 4 or less recovered; conversely, 12 of 13 patients with lesions that did not cross midline recovered, regardless of GCS motor score. Bilateral injury to the pons and medulla as detected on T2-weighted MRI sequences was associated with poor outcome in patients with brainstem injuries; T2 volumes were found superior to gradient echo sequences in regard to predicting survival, but neither reached statistical significance. When MRI findings were coupled with clinical examination findings, a strong correlation existed between poor outcome and the combination of bilateral brainstem injury and a motor GCS score of 4 or less 24 hours after admission.

Focal traumatic brain stem injury is a rare type of head injury resulting from assault: A forensic neuropathological study

IntroductionBrainstem haemorrhage is common in cases of head injury when it is associated with space-occupying lesion and increases in the intracranial pressure (duret haemorrhage), in cases of diffuse axonal injury (in dorso-lateral quadrant) and diffuses vascular injury (in the periventricular tissue). However focal traumatic brainstem injury is rare. Material and methodWe identified 12 cases of focal traumatic brainstem injury from review of 319 case of head injury. The head trauma had been caused by different mechanisms of complex fall from height and assault. 10/12 are associated with skull fracture, 11/12 with contre coup contusions in the frontal and temporal lobes, 5/12 direct contusions to cerebellum, 5/12 haemorrhage in corpus callosum and 2/11 have gliding contusions. None of the cases had pathological evidence of increase in the intracranial pressure. The bleeding in the pons was at the edge in 2/12 and cross the section in 10/12. The majority of patients were unconscious immediately after the incident (10/12) and 9/12 died within one day. ConclusionFocal traumatic brainstem injury occurs most likely due to direct impact at the back of the head or stretching forces affecting the brainstem in cases of complex fall from height and after assault, particularly those associated with kicks. It is a serious and commonly fatal brain damage, which needed to be differentiated from other causes of brainstem haemorrhages.

The Prognostic Factors Related to Traumatic Brain Stem Injury

ObjectiveThis study was conducted to assess the clinical significance of traumatic brain stem injury (TBSI) reflected on Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS) by various clinical variables.MethodsA total of 136 TBSI patients were selected out of 2695 head-injured patients. All initial computerized tomography and/or magnetic resonance imaging studies were retrospectively analyzed according to demographic- and injury variables which result in GCS and GOS.ResultsIn univariate analysis, mode of injury showed a significant effect on combined injury (p<0.001), as were the cases with skull fracture on radiologic finding (p<0.000). The GCS showed a various correlation with radiologic finding (p<0.000), mode of injury (p<0.002), but less favorably with impact site (p<0.052), age (p<0.054) and skull fracture (p<0.057), in order of statistical significances. However, only GOS showed a definite correlation to radiologic finding (p<0.000). In multivariate analysis, the individual variables to enhance an unfavorable effect on GCS were radiologic finding [odds ratio (OR) 7.327, 95% confidence interval (CI)], mode of injury (OR; 4.499, 95% CI) and age (OR; 3.141, 95% CI). Those which influence an unfavorable effect on GOS were radiologic finding (OR; 25.420, 95% CI) and age (OR; 2.674, 95% CI).ConclusionIn evaluation of TBSI on outcome, the variables such as radiological finding, mode of injury, and age were revealed as three important ones to have an unfavorable effect on early stage outcome expressed as GCS. However, mode of injury was shown not to have an unfavorable effect on late stage outcome as GOS. Among all unfavorable variables, radiological finding was confirmed as the only powerful prognostic variable both on GCS and GOS.

Differential Diagnosis of T2 Hyperintense Brainstem Lesions: Part 2. Diffuse Lesions

Diffuse brainstem lesions are poorly defined, often large abnormalities and include tumors (gliomas and lymphomas) vasculitis (Behçet's disease), traumatic brainstem injury, degenerative disorders (Wallerian degeneration), infections, processes secondary to systemic conditions (central pontine myelinolysis, hypertensive or hepatic encephalopathy), and ischemic pathology (leukoaraiosis). Magnetic resonance imaging is the most appropriate imaging modality to use in evaluating lesions of this type, but often findings are nonspecific. Therefore, radiologists need to bear in mind such additional information as patient age and clinical features in making a differential diagnosis.

Mechanism-Based MRI Classification of Traumatic Brainstem Injury and Its Relationship to Outcome

While computed tomography (CT) is the appropriate technique for the urgent detection of hematomas and contusions in the cerebral hemispheres, it is much less effective at documenting diffuse injury and posterior fossa lesions, and is therefore only partially predictive of outcome. More recently, magnetic resonance imaging (MRI) has been used, particularly to examine posterior fossa structures, but the relationship between brainstem injury and outcome is unclear and the types of brainstem injury are poorly understood. The aim of this study was to use acute MRI to examine the types of brainstem injury following severe traumatic brain injury (TBI) and their relationship to supratentorial injury. We also aimed to correlate these findings with outcome at 6 months (Glasgow Outcome Scale [GOS] score). Forty-six patients (mean age, 34 years, range, 16-70 years; 76% male) admitted to a regional neurocritical care unit with TBI requiring ventilation underwent CT and MRI (T2, FLAIR, gradient echo) scanning within 3 days (median, 1 day) of injury. GOS was ascertained by outpatient interview. Brainstem lesions were detected in 13 patients by MRI, only two of which were detected by CT. Eleven out of 13 patients with brainstem injury had an unfavorable outcome (death, vegetative state, or severe disability), of whom five died. Of the 33 patients without brainstem lesions, 18 had an unfavorable outcome, of whom four died. The direct relationship between brainstem lesions and unfavorable outcome was statistically significant (p < 0.05, chi-squared test). With regard to supratentorial injury, all but two brainstem lesions were seen either in the context of severe diffuse axonal injury or a significant mass lesion, and all of these patients had a poor outcome. However, the two patients with brainstem injury and good outcome had relatively few supratentorial abnormalities. From these observations, we have devised a simple classification system that is useful clinically and has potential associations with outcome. Poor prognosis is common following major TBI but is more common in those with brainstem injury. However, brainstem injury is not an absolute indicator of poor outcome. Understanding the anatomy and extent of brainstem injury, as well as its relationship to supratentorial abnormalities, will facilitate a more accurate use of early MRI as a prognostic tool and assist in the counseling of families.

Lesión traumática del tronco cerebral diagnosticada por resonancia magnética: Reconsideración epidemiológica y pronóstica

CT-scan allows emergency surgical evaluation of head injury lesions, but does not offer a comprehensive diagnosis of the resulting brain injuries. Magnetic Resonance Imaging (MRI) can complete the evaluation of head injury, particularly in the brain stem. We attempted to estimate the frequency of traumatic primary brain stem injuries Thirty patients with moderate or severe head injury (GCS < or = 13) underwent a MRI study during the first two weeks after trauma. In order to exclude old patients with previous ischemic lesions unrelated to the head trauma, only young patients (16-40 years-old) were included. Patients with cranial surgery were also eliminated from the study. Based on previous studies, the FLAIR (8000/120/T. Inversion 2200mseg) sequence was selected. Brain stem injuries were detected in 26.6% of the patients; this was confirmed by two independent radiologists. Six patients had hyperintense lesions compatible with diffuse axonal damage, and two others showed hemorrhagic lesions. These findings were directly related to a specific neurological deficit in four patients; while in the remaining, unspecific consciousness disturbances were noted. We believe that the FLAIR sequence demonstrate a type of traumatic brain stem injury (probably corresponding to diffuse axonal injury) that is more frequent and less severe in terms of prognosis than those classically described in previous CT scan studies.

The "Cyberlink" Brain-Body Interface as an Assistive Technology for Persons with Traumatic Brain Injury: Longitudinal Results from a Group of Case Studies

A longitudinal study of traumatic brain-injured and comatose participants suggests that these individuals are able to learn to use a mental interface device to navigate a maze and perform some basic communication. The device, known as the "Cyberlink," uses electrooculargraphic, electromyographic, and electroencephlagraphic signals collected at the forehead to control cursor movement. Further details of the operation of the device and the set-up procedures are reported. Six adults, all of whom had traumatic brain injury or were believed to be comatose, participated in the study over a 7-month period. Initially, only one participant, who had previously used the device, could navigate the maze. At the end of the study all participants could navigate the maze, albeit with a high variability in success rate. Reasons for the variability obtained are postulated. The majority of participants could also use the device to type simple words. Positive behaviors and increases in attention span were also observed. The diagnosis of one participant was upgraded from coma to traumatic brain stem injury as a result of data collected during the study. Controls were built into the study in order to demonstrate intention. Further developments of the device and other applications where it may be useful are discussed.

Post-traumatic brain stem distortion: a case report

BACKGROUND Primary traumatic brain stem injury (BSI) lesions are found most frequently in the dorsal or dorsolateral midbrain, whereas distortion of the brain stem itself is exceedingly rare. CASE REPORT We present a 20-year-old woman with a rare brain stem injury caused by a violent motor vehicle collision. Magnetic resonance imaging at 2 months after injury revealed marked brain stem distortion with loss of the normal shape at the midbrain and pons, which were displaced anteriorly in association with the fracture of the clivus. Moreover, the medulla oblongata showed a loose winding configuration. At discharge about 5 months after injury, the Glasgow Outcome Scale was severe disability. CONCLUSION This BSI was caused by reciprocal actions of fracture of the clivus and the direct effect on the brain stem caused by acceleration or rotational forces.

The "Cyberlink" Brain-Body Interface as an Assistive Technology for Persons with Traumatic Brain Injury: Longitudinal Results from a Group of Case Studies

A longitudinal study of traumatic brain-injured and comatose participants suggests that these individuals are able to learn to use a mental interface device to navigate a maze and perform some basic communication. The device, known as the "Cyberlink," uses electrooculargraphic, electromyographic, and electroencephlagraphic signals collected at the forehead to control cursor movement. Further details of the operation of the device and the set-up procedures are reported. Six adults, all of whom had traumatic brain injury or were believed to be comatose, participated in the study over a 7-month period. Initially, only one participant, who had previously used the device, could navigate the maze. At the end of the study all participants could navigate the maze, albeit with a high variability in success rate. Reasons for the variability obtained are postulated. The majority of participants could also use the device to type simple words. Positive behaviors and increases in attention span were also observed. The diagnosis of one participant was upgraded from coma to traumatic brain stem injury as a result of data collected during the study. Controls were built into the study in order to demonstrate intention. Further developments of the device and other applications where it may be useful are discussed.

Classification of Computerized Tomography and Prognosis of Traumatic Primary Brain Stem Injury

Clinical signs, computerized tomography (CT), continuous monitoring of intracranial pressure (ICP), serial recording of auditory brain stem response (ABR), and autopsy were examined in 40 cases of primary brain stem injury (PBSI) which showed clinical symptoms of prolonged coma, abnormal motor responses (decorticate, decerebrate or flaccid), impaired oculocephalic and/or pupillary responses, and no evidence of focal mass lesions on initial CT scanned within 2 hours after the injury. The consciousness levels of the 40 cases of PBSI on admission were 5 or less by the Glasgow Coma Scale; 5 in 12 cases; 4 in 15 cases; 3 in 13 cases. CT findings of the brain stem region (mesencephalon, pons, and medulla oblongata) of PBSI were classified into 7 types: brain stem hemorrhage (Type I); IVth ventricle hemorrhage (Type II); subarachnoid hemorrhage in the basal cisterns (Type III); compressed basal cisterns (Type IV); pneumocephalus in the basal cisterns (Type V); combined abnormal findings in the brain stem regions (Type VI); no abnormal findings in the brain stem regions (Type VII). Those cases of PBSI with initial CT findings of Type I, Type II, Type III, Type V, and Type VI all died. On the other hand, 7 cases of PBSI (17.5%) demonstrating good recovery or moderate disability by the Glasgow Outcome Scale (6 months after injury) were of Type IV (mortality 66.7%) and Type VII (mortality 50%); 5 of these cases (71.5%) were children. It has become obvious that there are many types of CT findings in PBSI besides brain stem hemorrhage that continuous ICP monitoring is very important to protect against secondary brain damage caused by increased ICP and that serial ABR recording predicts the outcome of PBSI very well as it provides reliable information about the function of the brain stem.