Traumatic axonal injury, a clinical-pathological correlation

Davceva, Natasha; Sivevski, Atanas; Basheska, Neli

doi:10.1016/j.jflm.2017.04.004

Cited by 18 publications

(12 citation statements)

References 19 publications

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“…Contrastingly, only widespread corticothalamic damage/disconnection can produce true DOC [35,36] based on the view that conscious states do not rely on a single cortical area or network, but rather require sustained, complex, and differentiated brain-scale communication defects [37][38][39]. Consistent with this hypothesis, we found a higher prevalence of cortical laminar necrosis and diffuse axonal injuries [40,41] among patients with DOC compared to patients with clinical CMD (data not shown). However, as we did not design this study to address imaging patterns, this finding should be regarded cautiously and requires further analysis.…”

Section: Discussionsupporting

confidence: 58%

Early discrimination of cognitive motor dissociation from disorders of consciousness: pitfalls and clues

et al. 2020

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Bedside assessment of consciousness and awareness after a severe brain injury might be hampered by confounding clinical factors (i.e., pitfalls) interfering with the production of behavioral or motor responses to external stimuli. Despite the use of validated clinical scales, a high misdiagnosis rate is indeed observed. We retrospectively analyzed a cohort of 49 patients with severe brain injury admitted to an acute neuro-rehabilitation program. Patients' behavior was assessed using the Motor Behavior Tool and Coma Recovery Scale Revised. All patients underwent systematic assessment for pitfalls including polyneuropathy and/or myopathy and/or myelopathy, major cranial nerve palsies, non-convulsive status epilepticus, aphasia (expressive or comprehensive), cortical blindness, thalamic involvement and frontal akinetic syndrome. A high prevalence (75%) of pitfalls potentially interfering with sensory afference (polyneuropathy, myopathy, myelopathy, and sensory aphasia), motor efference (polyneuropathy, myopathy, motor aphasia, and frontal akinetic syndrome), and intrinsic brain activity (thalamic involvement and epilepsy) was found. Nonetheless, the motor behavior tool identified residual cognition (i.e. a cognitive motor dissociation condition) regardless of the presence of these pitfalls in 70% of the patients diagnosed as unresponsive using the Coma Recovery Scale Revised. On one hand, pitfalls might contribute to misdiagnosis. On the other, it could be argued that they are clues for diagnosing cognitive motor dissociation rather than true disorders of consciousness given their prominent effect on the sensory-motor input-output balance.

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Section: Discussionsupporting

confidence: 58%

Early discrimination of cognitive motor dissociation from disorders of consciousness: pitfalls and clues

et al. 2020

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“…The results of the current study are, on the other hand, in line with what was found in car drivers and passengers in an autopsy study of TBI patients. 7 Also, the high TAI grades found in this group of patients are not surprising, considering the forces often involved in car accidents.…”

Section: Tai and Rtasmentioning

confidence: 61%

Association of cause of injury and traumatic axonal injury: a clinical MRI study of moderate and severe traumatic brain injury

Moe

Myhr

Moen

et al. 2020

Journal of Neurosurgery

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OBJECTIVEThe authors investigated the association between the cause of injury and the occurrence and grade of traumatic axonal injury (TAI) on clinical MRI in patients with moderate or severe traumatic brain injury (TBI).METHODSData for a total of 396 consecutive patients, aged 7–70 years, with moderate or severe TBI admitted to a level 1 trauma center were prospectively registered. Data were included for analysis from the 219 patients who had MRI performed within 35 days (median 8, IQR 4–17 days) and for whom cause of injury was known. Cause of injury was registered as road traffic accident (RTA) or fall (both with respective subcategories), alpine skiing or snowboarding accident, or violence. The MRI protocol consisted of T2*-weighted gradient echo, FLAIR, and diffusion-weighted imaging scans. TAI lesions were evaluated in a blinded manner and categorized into 3 grades, hemispheric/cerebellar white matter (grade 1), corpus callosum (grade 2), and brainstem (grade 3). The absence of TAI was analyzed as grade 0. Contusions and mass lesions on CT were also registered.RESULTSCause of injury did not differ between included and nonincluded patients. TAI was found in 83% of patients in the included group after RTAs and 62% after falls (p < 0.001). Observed TAI grades differed between the subcategories of both RTAs (p = 0.004) and falls (p = 0.006). Pedestrians in RTAs, car drivers/passengers in RTAs, and alpine skiers had the highest prevalence of TAI (89%–100%) and the highest TAI grades (70%–82% TAI grades 2–3). TAI was found in 76% of patients after falls from > own height (45% TAI grade 2–3), 63% after falls down the stairs (26% TAI grade 2–3), and 31% after falls from ≤ own height (12% TAI grade 2–3). Moreover, 53% of patients with TAI after RTAs and 68% with TAI after falls had cortical contusions or mass lesions on CT.CONCLUSIONSThis prospective study of moderate and severe TBI is to the authors’ knowledge the first clinical MRI study to demonstrate both the high prevalence and grade of TAI after most of the different types of RTAs, alpine skiing accidents, and falls from a height. Importantly, TAI was also common following more low-energy trauma such as falls down the stairs or from own height. Physicians managing TBI patients in the acute phase should be aware of the possibility of TAI no matter the cause of injury and also when the CT scan shows cortical contusions or mass lesions.

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“…It is likely that most changes reported as DAI on computed tomography (CT) or magnetic resonance (MR) imaging studies are influenced more by the vascular pathology (hemorrhage or edema) than actual axon changes. To encompass the axonal and vascular damage, the senior author prefers the more generic term “distortional brain injury.” The concept of DAI is undoubtedly useful in explaining brain dysfunction or sudden traumatic deaths in the absence of extensive contusions or hematomas (30). However, the presence of diffusely damaged axons in a victim who survives hours to days and who does not have hemorrhagic lesions is not necessarily proof of head/brain trauma.…”

Section: Discussionmentioning

confidence: 99%

Histology of Brain Trauma and Hypoxia-Ischemia

Rahaman¹,

Bigio²

2018

Academic Forensic Pathology

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Forensic pathologists encounter hypoxic-ischemic (HI) brain damage or traumatic brain injuries (TBI) on an almost daily basis. Evaluation of the findings guides decisions regarding cause and manner of death. When there are gross findings of brain trauma, the cause of death is often obvious. However, microscopic evaluation should be used to augment the macroscopic diagnoses. Histology can be used to seek evidence for TBI in the absence of gross findings, e.g., in the context of reported or suspected TBI. Estimating the survival interval after an insult is often of medicolegal interest; this requires targeted tissue sampling and careful histologic evaluation. Retained tissue blocks serve as forensic evidence and also provide invaluable teaching and research material. In certain contexts, histology can be used to demonstrate nontraumatic causes of seemingly traumatic lesions. Macroscopic and histologic findings of brain trauma can be confounded by concomitant HI brain injury when an individual survives temporarily after TBI. Here we review the histologic approaches for evaluating TBI, hemorrhage, and HI brain injury. Amyloid precursor protein (APP) immunohistochemistry is helpful for identifying damaged axons, but patterns of damage cannot unambiguously distinguish TBI from HI. The evolution of hemorrhagic lesions will be discussed in detail; however, timing of any lesion is at best approximate. It is important to recognize artifactual changes (e.g., dark neurons) that can resemble HI damage. Despite the shortcomings, histology is a critical adjunct to the gross examination of brains.

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Traumatic axonal injury, a clinical-pathological correlation

Cited by 18 publications

References 19 publications

Early discrimination of cognitive motor dissociation from disorders of consciousness: pitfalls and clues

Early discrimination of cognitive motor dissociation from disorders of consciousness: pitfalls and clues

Association of cause of injury and traumatic axonal injury: a clinical MRI study of moderate and severe traumatic brain injury

Histology of Brain Trauma and Hypoxia-Ischemia

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