Diffuse axonal injury in children: Clinical correlation with hemorrhagic lesions

An inception cohort of 40 children and adolescents with traumatic brain injury and suspected diffuse axonal injury were studied using a new high‐resolution magnetic resonance imaging susceptibility‐weighted technique that is very sensitive for hemorrhage. A blinded comparison was performed between the extent of parenchymal hemorrhage and initial clinical variables as well as outcomes measured at 6 to 12 months after injury. Children with lower Glasgow Coma Scale scores (≤8, n = 30) or prolonged coma (>4 days, n = 20) had a greater average number (p = 0.007) and volume (p = 0.008) of hemorrhagic lesions. Children with normal outcomes or mild disability (n = 30) at 6 to 12 months had, on average, fewer hemorrhagic lesions (p = 0.003) and lower volume (p = 0.003) of lesions than those who were moderately or severely disabled or in a vegetative state. Significant differences also were observed when comparing regional injury to clinical variables. Because susceptibility‐weighted imaging is much more sensitive than conventional T2*‐weighted gradient‐echo sequences in detecting hemorrhagic diffuse axonal injury, more accurate and objective assessment of injury can be obtained early after insult, and may provide better prognostic information regarding duration of coma as well as long‐term outcome. Ann Neurol 2004;56:36–50

[1]  T. W. Smith,et al.  Diffuse axonal injury in infants with nonaccidental craniocerebral trauma: enhanced detection by beta-amyloid precursor protein immunohistochemical staining. , 1999, Archives of pathology & laboratory medicine.

[2]  P. Roberson,et al.  Relationship of Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scores at pediatric intensive care unit discharge with outcome measures collected at hospital discharge and 1- and 6-month follow-up assessments , 2000, Critical care medicine.

[3]  J. Duflou,et al.  Fatal head injury in children: a new approach to scoring axonal and vascular damage , 1999, Child's Nervous System.

[4]  Gregory D. Reiber.  Fatal Falls in Childhood: How Far Must Children Fall to Sustain Fatal Head Injury? Report of Cases and Review of the Literature , 1993, The American journal of forensic medicine and pathology.

[5]  Jack M Fletcher,et al.  Magnetic Resonance Imaging in Relation to Functional Outcome of Pediatric Closed Head Injury: A Test of the Ommaya-Gennarelli Model. , 1997, Neurosurgery.

[6]  J. Goodman,et al.  Improved identification of axonal shear injuries with gradient echo MR technique. , 2000, Surgical neurology.

[7]  S. Kobayashi,et al.  [Clinical study of intracranial pressure and auditory brain stem response in the cases of diffuse axonal injury]. , 1992, No shinkei geka. Neurological surgery.

[8]  W. Orrison,et al.  Blinded comparison of cranial CT and MR in closed head injury evaluation. , 1994, AJNR. American journal of neuroradiology.

[9]  B. Holshouser,et al.  Evaluation of pediatric diffuse axonal injury using susceptibility weighted imaging ( SWI ) and MR spectroscopy , 2002 .

[10]  J. Adams,et al.  Diffuse axonal injury in head injury: Definition, diagnosis and grading , 1989, Histopathology.

[11]  B. Thompson,et al.  MR imaging of head trauma: review of the distribution and radiopathologic features of traumatic lesions. , 1988, AJR. American journal of roentgenology.

[12]  W. Lin,et al.  MR high-resolution blood oxygenation level-dependent venography of occult (low-flow) vascular lesions. , 1999, AJNR. American journal of neuroradiology.

[13]  M Galarza,et al.  Diffuse Axonal Injury (DAI) is not Associated with Elevated Intracranial Pressure (ICP) , 1998, Acta Neurochirurgica.

[14]  C. Scholtz,et al.  Diffuse axonal injury in early infancy. , 1987, Journal of clinical pathology.

[15]  M. Denckla,et al.  Depth of lesion model in children and adolescents with moderate to severe traumatic brain injury: use of SPGR MRI to predict severity and outcome , 2001, Journal of neurology, neurosurgery, and psychiatry.

[16]  H. Levin,et al.  Relationship of depth of brain lesions to consciousness and outcome after closed head injury. , 1988, Journal of neurosurgery.

[17]  M. Kurihara,et al.  [Functional outcome after diffuse axonal injury in childhood traumatic brain injury]. , 1999, No to hattatsu = Brain and development.

[18]  Stefan Golaszewski,et al.  Prediction of recovery from post-traumatic vegetative state with cerebral magnetic-resonance imaging , 1998, The Lancet.

[19]  F. Cordobés,et al.  Post-traumatic diffuse axonal brain injury. Analysis of 78 patients studied with Computed Tomography , 2005, Acta Neurochirurgica.

[20]  T. Tomberg,et al.  Computerized tomography and prognosis in paediatric head injury , 2005, Acta Neurochirurgica.

[21]  J Brown,et al.  Extent and distribution of vascular brain injury in pediatric road fatalities. , 2001, Journal of neurotrauma.

[22]  G. Tomei,et al.  Clinicoradiological and therapeutic considerations in severe diffuse traumatic brain injury in children , 1989, Child's Nervous System.

[23]  J. Fletcher,et al.  Magnetic resonance imaging after closed head injury in children. , 1989, Neurosurgery.

[24]  T A Gennarelli,et al.  Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT findings. , 1994, AJNR. American journal of neuroradiology.

[25]  A. Ommaya,et al.  Cerebral concussion and traumatic unconsciousness. Correlation of experimental and clinical observations of blunt head injuries. , 1974, Brain : a journal of neurology.

[26]  M. Piastra,et al.  [Diffuse axonal lesions in childhood]. , 1998, La Pediatria medica e chirurgica : Medical and surgical pediatrics.

[27]  G. Bonsel,et al.  Assessing the outcome of pediatric intensive care. , 1993, The Journal of pediatrics.

[28]  G. Teasdale,et al.  Diffuse brain swelling after head injury: more often malignant in adults than children? , 1994, Journal of neurosurgery.

[29]  Harvey S. Levin,et al.  Magnetic resonance imaging and computerized tomography in relation to the neurobehavioral sequelae of mild and moderate head injuries. , 1987, Journal of neurosurgery.

[30]  D. Marion,et al.  Guidelines for the management of severe head injury. Brain Trauma Foundation. , 1996, European journal of emergency medicine : official journal of the European Society for Emergency Medicine.

[31]  A. Hackshaw,et al.  Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. , 2001, Brain : a journal of neurology.

[32]  A. Karantanas,et al.  Outcome of patients with diffuse axonal injury: the significance and prognostic value of MRI in the acute phase. , 2000, The Journal of trauma.

[33]  J. Adams,et al.  Fatal head injury in children. , 1989, Journal of clinical pathology.

[34]  J. Manzano,et al.  Diffuse axonal injury with or without an evacuated intracranial hematoma in head injured patients. Are they different lesions? , 2000, Acta neurochirurgica. Supplement.

[35]  E. Bigler,et al.  Neuropsychological outcome and quantitative image analysis of acute haemorrhage in traumatic brain injury: preliminary findings. , 1994, Brain injury.

[36]  J R Reichenbach,et al.  Small vessels in the human brain: MR venography with deoxyhemoglobin as an intrinsic contrast agent. , 1997, Radiology.

[37]  J. Soustiel,et al.  Diffuse axonal injury: analysis of 100 patients with radiological signs. , 1990, Neurosurgery.

[38]  Grace Scott,et al.  Diffuse axonal injury due to nonmissile head injury in humans: An analysis of 45 cases , 1982, Annals of neurology.

[39]  E Mark Haacke,et al.  Hemorrhagic shearing lesions in children and adolescents with posttraumatic diffuse axonal injury: improved detection and initial results. , 2003, Radiology.

[40]  W Goldsmith,et al.  Biomechanics and neuropathology of adult and paediatric head injury , 2002, British journal of neurosurgery.

[41]  V. Haughton,et al.  Diffusion tensor MR imaging in diffuse axonal injury. , 2002, AJNR. American journal of neuroradiology.

[42]  E. Bigler,et al.  Quantitative magnetic resonance imaging in traumatic brain injury. , 2001, The Journal of head trauma rehabilitation.

[43]  T. Novack,et al.  Current concepts: diffuse axonal injury-associated traumatic brain injury. , 2001, Archives of physical medicine and rehabilitation.

[44]  S. Atlas,et al.  Intracranial hemorrhage: gradient-echo MR imaging at 1.5 T. Comparison with spin-echo imaging and clinical applications. , 1988, Radiology.

[45]  L. Gentry,et al.  Imaging of closed head injury. , 1994, Radiology.

[46]  D F Meaney,et al.  Diffuse axonal injury. , 2001, Journal of neurosurgery.