Reliability of Magnetic Resonance Tractography in Predicting Early Clinical Improvements in Patients with Diffuse Axonal Injury Grade III.

Diffuse axonal injury (DAI) grade III forms a distinct subset of traumatic brain injury wherein it is difficult to predict the outcome and the time taken for early recovery in terms of sustained eye opening and standing with minimal assistance. This study seeks to determine differences in the fractional anisotropy (FI) and diffusion-weighted image (DWI) values obtained from the seeds placed at an appropriate region of interest (ROI) within the magnetic resonance (MR) tractography of the brainstem of brain-injured patients. We found that differences in the DWI values along the corticospinal tract were associated with the days required for early recovery. Moreover, dysautonomia was an independent variable governing a delayed recovery in these patients. The lesions posterior to the corticospinal tract in the brainstem conferred increased odds for the subsequent development of dysautonomia. We conclude that MR tractography, in addition to depicting the anatomical integrity of the concerned tracts, has the potential of becoming a surrogate clinical imaging marker for effectively predicting days for early recovery among patients with DAI grade III.

Repetitive TMS does not improve cognition in patients with TBI: A randomized double-blind trial.

OBJECTIVE: To determine whether high-frequency repetitive transcranial magnetic stimulation (rTMS) improves cognition in patients with severe traumatic brain injury. METHODS: A single-center, randomized, double-blind, placebo-controlled study of rTMS was conducted in patients aged 18-60 years with chronic (>12 months postinjury) diffuse axonal injury (DAI). Patients were randomized to either a sham or real group in a 1:1 ratio. A 10-session rTMS protocol was used with 10-Hz stimulation over the left dorsolateral prefrontal cortex (DLPFC). Neuropsychological assessments were performed at 3 time points: at baseline, after the 10th rTMS session, and 90 days after intervention. The primary outcome was change in executive function evaluated using the Trail Making Test Part B. RESULTS: Thirty patients with chronic DAI met the study criteria. Between-group comparisons of performance on TMT Part B at baseline and after the 10th rTMS session did not differ between groups (p = 0.680 and p = 0.341, respectively). No significant differences were observed on other neuropsychological tests. No differences in adverse events between treatment groups were observed. CONCLUSIONS: Cognitive function in individuals with chronic DAI is not improved by high-frequency rTMS over the left DLPFC, though it appears safe and well-tolerated in this population. CLINICALTRIALSGOV IDENTIFIER: NCT02167971. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for individuals with chronic DAI, high-frequency rTMS over the left DLPFC does not significantly improve cognition.

Mechanisms of axon regeneration: The significance of proteoglycans.

BACKGROUND: Therapeutics specific to neural injury have long been anticipated but remain unavailable. Axons in the central nervous system do not readily regenerate after injury, leading to dysfunction of the nervous system. This failure of regeneration is due to both the low intrinsic capacity of axons for regeneration and the various inhibitors emerging upon injury. After many years of concerted efforts, however, these hurdles to axon regeneration have been partially overcome. SCOPE OF REVIEW: This review summarizes the mechanisms regulating axon regeneration. We highlight proteoglycans, particularly because it has become increasingly clear that these proteins serve as critical regulators for axon regeneration. MAJOR CONCLUSIONS: Studies on proteoglycans have revealed that glycans not only assist in the modulation of protein functions but also act as main players-e.g., as functional ligands mediating intracellular signaling through specific receptors on the cell surface. By regulating clustering of the receptors, glycans in the proteoglycan moiety, i.e., glycosaminoglycans, promote or inhibit axon regeneration. In addition, proteoglycans are involved in various types of neural plasticity, ranging from synaptic plasticity to experience-dependent plasticity. GENERAL SIGNIFICANCE: Although studies on proteins have progressively facilitated our understanding of the nervous system, glycans constitute a new frontier for further research and development in this field. This article is part of a Special Issue entitled Neuro-glycoscience, edited by Kenji Kadomatsu and Hiroshi Kitagawa.

Robotic gait assistive technology as means to aggressive mobilization strategy in acute rehabilitation following severe diffuse axonal injury: a case study.

INTRODUCTION: Diffuse axonal injury is a prominent cause of disablement post-traumatic brain injury. Utilization of the rapid expansion of our current scientific knowledge base combined with greater access to neurological and assistive technology as adjuncts to providing sensorimotor experience may yield innovative new approaches to rehabilitation based upon a dynamic model of brain response following injury. CASE DESCRIPTION: A 24-year-old female who sustained a traumatic brain injury, bilateral subdural hemorrhage, subarachnoid hemorrhage and severe diffuse axonal injury secondary to a motor vehicle collision. DISCUSSION AND CONCLUSIONS: Evidence-based appraisal of present literature suggests a link between graded intensity of aerobic activity to facilitation of neuro-plastic change and up-regulation of neurotrophins essential to functional recovery post-diffuse axonal injury. Following resolution of paroxysmal autonomic instability with dystonia, aggressive early mobilization techniques were progressed utilizing robotic assistive gait technology in combination with conventional therapy. This approach allowed for arguably greater repetition and cardiovascular demands across a six-month inpatient rehabilitation stay. Outcomes in this case suggest that the use of assistive technology to adjunct higher level and intensity rehabilitation strategies may be a safe and effective means towards reduction of disablement following severe traumatic brain and neurological injury. Implications for Rehabilitation Functional recovery and neuroplasticity following diffuse neurological injury involves a complex process determined by the sensorimotor experience provided by rehabilitation clinicians. This process is in part modulated by intrinsic brain biochemical processes correlated to cardiovascular intensity of the activity provided. It is important that rehabilitation professionals monitor physiological response to higher intensity activities to provide an adaptive versus maladaptive response of central nervous system plasticity with activity. Identification of early mobilization parameters and skill acquisition may assist selection of gait assistive technology adjunct in progressing early optimal physical rehabilitation outcomes in the acute inpatient setting.

Sleep Modulation Alleviates Axonal Damage and Cognitive Decline after Rodent Traumatic Brain Injury.

Traumatic brain injury (TBI) is a major cause of death and disability worldwide. It produces diffuse axonal injury (DAI), which contributes to cognitive impairment, but effective disease-modifying treatment strategies are missing. We have recently developed a rat model of closed skull TBI that reproduces human TBI consequences, including DAI and clinical sequelae such as memory impairment. Here, we investigated whether sleep modulation after trauma has an impact on DAI and memory outcome. We assessed cognition with the novel object recognition test and stained for amyloid precursor protein, a DAI marker. We found that both sleep induction and restriction acutely after TBI enhanced encephalographic slow-wave activity, markedly reduced diffuse axonal damage in the cortex and hippocampus, and improved memory impairment 2 weeks after trauma. These results suggest that enhancing slow-wave sleep acutely after trauma may have a beneficial disease-modifying effect in subjects with acute TBI. SIGNIFICANCE STATEMENT: Traumatic brain injury (TBI) is a clinically important entity. Cognitive deficits belong to the most prevalent chronic posttraumatic symptoms, most likely due to diffuse axonal injury (DAI). A growing body of evidence suggests a role of sleep in the clearance of waste products in the brain, possibly including amyloid precursor protein (APP), a marker of DAI. In this study, we provide evidence that enhancement of slow-wave oscillatory activity in the delta-frequency range decreases the APP-immunoreactivity and preserves cognitive abilities after trauma, potentially offering novel, noninvasive treatment options for traumatic injury.

Behavioral and electrophysiological auditory processing measures in traumatic brain injury after acoustically controlled auditory training: a long-term study.

OBJECTIVE: To investigate the long-term efficacy of acoustically controlled auditory training in adults after tarumatic brain injury. METHODS: A total of six audioogically normal individuals aged between 20 and 37 years were studied. They suffered severe traumatic brain injury with diffuse axional lesion and underwent an acoustically controlled auditory training program approximately one year before. The results obtained in the behavioral and electrophysiological evaluation of auditory processing immediately after acoustically controlled auditory training were compared to reassessment findings, one year later. RESULTS: Quantitative analysis of auditory brainsteim response showed increased absolute latency of all waves and interpeak intervals, bilaterraly, when comparing both evaluations. Moreover, increased amplitude of all waves, and the wave V amplitude was statistically significant for the right ear, and wave III for the left ear. As to P3, decreased latency and increased amplitude were found for both ears in reassessment. The previous and current behavioral assessment showed similar results, except for the staggered spondaic words in the left ear and the amount of errors on the dichotic consonant-vowel test. CONCLUSION: The acoustically controlled auditory training was effective in the long run, since better latency and amplitude results were observed in the electrophysiological evaluation, in addition to stability of behavioral measures after one-year training.

Behavioral and electrophysiological auditory processing measures in traumatic brain injury after acoustically controlled auditory training: a long-term study / Medidas comportamentais e eletrofisiológicas do processamento auditivo em traumatismo craniencefálico após treinamento auditivo acusticamente controlado: estudo de longo prazo

ABSTRACT Objective To investigate the long-term efficacy of acoustically controlled auditory training in adults after tarumatic brain injury. Methods A total of six audioogically normal individuals aged between 20 and 37 years were studied. They suffered severe traumatic brain injury with diffuse axional lesion and underwent an acoustically controlled auditory training program approximately one year before. The results obtained in the behavioral and electrophysiological evaluation of auditory processing immediately after acoustically controlled auditory training were compared to reassessment findings, one year later. Results Quantitative analysis of auditory brainsteim response showed increased absolute latency of all waves and interpeak intervals, bilaterraly, when comparing both evaluations. Moreover, increased amplitude of all waves, and the wave V amplitude was statistically significant for the right ear, and wave III for the left ear. As to P3, decreased latency and increased amplitude were found for both ears in reassessment. The previous and current behavioral assessment showed similar results, except for the staggered spondaic words in the left ear and the amount of errors on the dichotic consonant-vowel test. Conclusion The acoustically controlled auditory training was effective in the long run, since better latency and amplitude results were observed in the electrophysiological evaluation, in addition to stability of behavioral measures after one-year training.

RESUMO Objetivo Investigar a eficácia de longo prazo do treinamento auditivo acusticamente controlado em indivíduos adultos após traumatismo craniencefálico. Métodos Foram estudados seis indivíduos audiologicamente normais com idades entre 20 e 37 anos, que sofreram traumatismo craniencefálico grave com lesão axional difusa, submetidos a um programa de treinamento auditivo acusticamente controlado aproximadamente um ano antes. Foram comparados os resultados obtidos nas avaliações comportamental e eletrofisiológica do processamento auditivo imediatamente após o treinamento auditivo acusticamente controlado e a reavaliação, um ano após. Resultados Quanto ao potencial de tronco encefálico, observou-se aumento da latência absoluta de todas as ondas e os intervalos interpicos, na comparação entre as avaliações, bilateralmente, bem como aumento da amplitude de todas as ondas, sendo a onda V estatisticamente significativa, para a orelha direita e a onda III para a orelha esquerda. Quanto ao P3, observaram-se diminuição da latência e aumento da amplitude do P3 na avaliação atual em ambas as orelhas. A avaliação comportamental atual evidenciou desempenho semelhante nas duas avaliações, exceto no teste dicótico de dissílabos alternados na orelha esquerda e a quantidade de erros no teste dicótico consoante-vogal. Conclusão O treinamento auditivo acusticamente controlado mostrou-se eficaz em longo prazo, uma vez que foram observados resultados melhores de latência e amplitude na avaliação eletrofisiológica, bem como estabilidade das medidas comportamentais após um ano de treinamento.

Repetitive Transcranial Magnetic Stimulation (rTMS) for the cognitive rehabilitation of traumatic brain injury (TBI) victims: study protocol for a randomized controlled trial.

BACKGROUND: Repetitive Transcranial Magnetic Stimulation (rTMS) has been proposed as a new tool in neurological rehabilitation of victims of traumatic brain injury (TBI). However, its usefulness to treat this condition has never been tested rigorously. The primary goal is to conduct a study protocol to determine whether rTMS used to cognitive rehabilitation of victims of TBI with diffuse axonal injury (DAI) is a safe instrument and if it enhances cognitive function recovery. METHODS: Double-blind randomized controlled trial of patients with diffuse axonal injury. Thirty-six patients will be randomized to either an active coil group or sham group in a 1:1 ratio. rTMS protocol: 10 sessions of high-frequency rTMS (10 Hz) over the left dorsolateral prefrontal cortex (DLPFC). Cortical Excitability measures will be obtained. Neuropsychological evaluations will be performed 1 week before, 1 week and 3 months after rTMS. There are 2 study hypotheses: (1) rTMS over the left DLPFC in patients with DAI will improve cognitive function and (2) whether rTMS is safe in TBI patients. DISCUSSION: This study evaluates the immediate and delayed effects of rTMS over the DLPFC on the cognitive domain of patients with DAI following TBI. rTMS has shown good results in treating major depression and may be promising for patients with TBI. As such, the results of this study can greatly modify the cognitive rehabilitation strategies. TRIAL REGISTRATION: This trial was registered in clinicaltrials.gov ( NCT02167971 ) on 17 June 2014.

Oxyhemoglobin changes during cognitive rehabilitation after traumatic brain injury using near infrared spectroscopy.

To investigate cerebral reactions to cognitive rehabilitation tasks, oxyhemoglobin changes were compared in 9 patients with cognitive impairments after traumatic brain injury (TBI) and 47 healthy controls using functional near infrared spectroscopy (fNIRS) during nine cognitive rehabilitation tasks employed at Nagoya City Rehabilitation Center. Forty-seven measurement channels were placed on the frontal to temporal cortices, and organized into seven channel regions. Oxyhemoglobin changes were normalized based on the mean oxyhemoglobin value at the resting state, and integrated throughout a task. Statistical analyses of the differences between the TBI patients and controls were performed with the two-sided Mann-Whitney U test. Oxyhemoglobin changes were high for both controls and TBI patients in the lateral frontal regions. Oxyhemoglobin changes in TBI patients tended to be higher than controls in the medial frontal regions for most training tasks, and significant differences (p < 0.05) were seen for two tasks in the medial frontal regions. Different regions were activated during the tasks in TBI patients compared to controls. fNIRS measurement is useful in the evaluation of changes of neuronal activities during rehabilitation tasks in TBI patients.

Cognitive impact of traumatic axonal injury (TAI) and return to work.

OBJECTIVE: Axonal injury (AI) after traumatic brain injury (TBI) is often overlooked as an explanation for cognitive complaints when no damage is detected by computed tomography. The purpose was to assess cognition during the 12 months following a TBI and suspected traumatic axonal injury (TAI). METHODS: The sample included 17 patients younger than 65 years old, however one died. In the acute phase and at 6 and 12 months, cognition, reaction time, psychomotor performance and finger tapping speed were assessed. Working memory and work status were added at 12 months. Acute MRI findings were recorded. RESULTS: After 1 year, all patients still showed cognitive dysfunction. A recovery had been noted at 6 months, but a cognitive decline was indicated for the majority at 12 months. The sick-listed patients had TAI located in the corpus callosum and the brainstem. They were cognitively more impaired and in more areas than the four patients who had returned to work. CONCLUSION: Cognitive screening can identify the long-term impact of TAI identified by conventional MRI, used as a routine clinical technique. For rehabilitation and for insurance-related matters, these injuries must be taken seriously, as a deterioration over time might occur. Further research is needed.

How can investigation of network function inform rehabilitation after traumatic brain injury?

PURPOSE OF REVIEW: Traumatic brain injury (TBI) often results in long-term cognitive impairments. This is often due to the disruption of brain networks that support cognition. Major advances have recently been made in our understanding of these networks. Here we review work that investigates the effect of TBI on brain networks, and discuss the potential importance of these findings for rehabilitation. RECENT FINDINGS: Large-scale brain networks, which we refer to as intrinsic connectivity networks (ICNs), have been identified. Traumatic axonal injury disrupts their white-matter connections, and altered brain activity within the networks is frequently observed after TBI. These changes relate to the pattern of cognitive impairment, and are useful for predicting clinical outcome. The effect of drugs such as methylphenidate, which can be used to augment rehabilitation, are beginning to be studied in the context of their effect on network function after TBI. SUMMARY: The assessment of brain network function after TBI provides insights into the pathophysiology of cognitive dysfunction and the mechanisms involved in recovery. These advances should provide the basis for a more detailed understanding of rehabilitation, and ultimately guide the development of targeted individualized therapy after TBI.

Neuroimaging of anoxic injury: implications for neurorehabilitation.

Anoxic brain injury is common and occurs in a wide variety of disorders. The anoxic injury has characteristic pathologies in particular affecting the medial temporal lobe, basal ganglia and deep white matter. The neural injury is associated with significant and persistent cognitive impairments and poor functional outcomes, related in part to the severity of anoxia and assumed to relate to the degree of structural damage evidenced on neuroimaging during the chronic stage. To date neuroimaging following ABI has been used diagnostically with less research focused on guiding or predicting rehabilitation outcome. Because of the distribution of these lesions/abnormalities the degree of damage has practical implications for rehabilitation outcome. Research is needed to understand cognitive and functional outcomes following ABI as well as whether specific rehabilitation techniques or strategies will result in better outcomes.

Independence in managing one's finances after traumatic brain injury.

PRIMARY OBJECTIVE: To establish whether the budgeting task of the Instrumental Activities of Daily Living (IADL) Profile discriminates individuals with a traumatic brain injury (TBI) from healthy controls and to identify the nature of the observed difficulties. METHOD: This study tested 27 adults with moderate or severe TBI and 27 controls matched for age, sex and education on the budgeting task of the IADL Profile. The budgeting task is a complex real-world problem involving the preparation of a yearly budget for an individual living on a fixed income with the goal of saving money to purchase a car. MAIN RESULTS: The results showed that TBI subjects, the majority of whom had documented frontal lesions and/or diffuse axonal injury based on CT scan reports, were more likely than control subjects to experience difficulties on all task-related operations (planning, carrying out and verifying attainment of goal), with planning being particularly affected. These deficits were shown to impact on financial abilities, an issue of particular concern for TBI individuals reporting full responsibility of their finances. CONCLUSIONS: The budgeting task of the IADL Profile discriminates TBI subjects from controls. Planning was shown to be the most significant difficulty underlying reduced independence in the task.

[Care continuity for pediatric patients with higher cortical dysfunction after traumatic brain injury].

Higher cortical dysfunction after traumatic brain injury(TBI) is one of the most important aspects for rehabilitation. Main etiology is traffic accidents and classification after TBI is diffuse axonal injury, cerebral contusion, etc. Though Wechsler Intelligence Scale for Children-III, Kaufman assessment battery for children, Trail Making Test, etc. are used for assessing higher cortical dysfunction in children, the most important evaluation method is to get information precisely from his/her families and teachers. Memory disturbance, attention deficit and dyscontrol of feeling are the top 3 symptoms of higher cortical dysfunction in children with TBI. Support for re-entrance to schools should be begun as fast as possible with cooperation among hospitals, schools and homes. As many problems are observed in the aspects of study, behavior, communication, etc, a lot of support from the professional staffs is necessary. After the school age, support should be continued by stuffs for adult cases.

Long-term recovery of motor function in a quadriplegic patient with diffuse axonal injury and traumatic hemorrhage: a case report.

There have been no studies on motor recovery in severe quadriplegic patients with traumatic brain injury (TBI) resulting from combined causes of weakness; this type of patient is often seen in rehabilitation clinics. We report on a quadriplegic patient who showed long-term motor recovery from severe weakness caused by a diffuse axonal injury (DAI) on the brainstem and a traumatic intracerebral hemorrhage (ICH) on left cerebral peduncle, as evaluated by diffuse tensor imaging (DTI) and functional MRI (fMRI). A 17-year-old male patient presented with quadriparesis at the onset of TBI. Over the 28-month period following the onset of the injury, the motor function of the four extremities slowly recovered to a range that was nearly normal. Two longitudinal DTIs (at 11 and 28 months from onset) and fMRI (at 28 months) were performed. Fractional anisotropy and an apparent diffusion coefficient were measured using the region of interest method, and diffusion tensor tractography was conducted using a DTI/fMRI combination. Fractional anisotrophy values in the brainstem, which were markedly decreased on the 11-month DTI, were increased on the 28-month DTI. On the fMRI performed at 28 months, the contralateral primary sensori-motor cortex was activated by the movement of either the right or left hand. Diffusion tensor tractography showed that fiber tracts originating from the motor-sensory cortex passed through the known corticospinal tract pathway to the pons. It seems that the weakness of this patient recovered due to the recovery of the damaged corticospinal tracts.

Challenges of diffuse axonal injury diagnosis.

"This can't be right. Jay is in a vegetative state following a severe traumatic brain injury (TBI), but his computed tomography scan is essentially normal. How am I going to explain this to his mom?" This is a conversation I overhear among my rehabilitation nurse colleagues from time to time. Jay has a type of brain trauma called diffuse axonal injury (DAI). Recent statistics from the National Centers for Injury Prevention and Control (NCIPC, 2006) indicate 1.4 million people sustain a TBI each year in the United States. The leading causes of TBI are falls (28%), motor vehicle accidents (20%), being struck by or against an object (19%), and assaults (11%; NCIPC). DAI, one of the most important causes of cognitive dysfunction after TBI (Sugiyama et al., 2007), occurs in a more widespread pattern in certain regions of the brain than the localized zone of focal injuries. It is one of the most devastating forms of TBI and a common cause of vegetative state and severe disability. DAI occurs in 40%-50% of all patients who are hospitalized from TBI (Meythaler, Peduzzi, Eleftheriou, & Novack, 2001).

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.

Oral diadochokinesis and velocity of narrative speech: a prognostic parameter for the outcome of diffuse axonal injury in severe head trauma.

AIM: To investigate dysarthria in severe traumatic brain injury following an acceleration/deceleration trauma and to correlate results with the severity of head trauma. METHODS: Oral diadochokinesis by testing alternating (/pa/, /ta/and/ka/) and sequential motion rates (/pataka/and/tana/) and contextual speech, which comprises narrative speech and text reading, were examined in 15 patients in the chronic stage after severe closed head trauma with diffuse axonal injury. A possible influence of the severity of brain injury, expressed by the duration of post-traumatic amnesia, was examined. RESULTS: Oral diadochokinesis of alternating motion rates and velocity of narrative speech were significantly reduced in traumatic brain injury. Both parameters correlated highly significantly with each other and correlated with the severity of brain injury described by the duration of post-traumatic amnesia. Reading speed was not comparable with narrative speech. Reading speed did not correlate with diffuse axonal injury but was strongly influenced by parameters that also influenced mental abilities. CONCLUSION: Oral diadochokinetic abilities of alternating motion rates and velocity of narrative speech represent a possible additional prognostic parameter for the outcome of traumatic brain injury in diffuse axonal injury.

The predictive brain state: timing deficiency in traumatic brain injury?

Attention and memory deficits observed in traumatic brain injury (TBI) are postulated to result from the shearing of white matter connections between the prefrontal cortex, parietal lobe, and cerebellum that are critical in the generation, maintenance, and precise timing of anticipatory neural activity. These fiber tracts are part of a neural network that generates predictions of future states and events, processes that are required for optimal performance on attention and working memory tasks. The authors discuss the role of this anticipatory neural system for understanding the varied symptoms and potential rehabilitation interventions for TBI. Preparatory neural activity normally allows the efficient integration of sensory information with goal-based representations. It is postulated that an impairment in the generation of this activity in traumatic brain injury (TBI) leads to performance variability as the brain shifts from a predictive to reactive mode. This dysfunction may constitute a fundamental defect in TBI as well as other attention disorders, causing working memory deficits, distractibility, a loss of goal-oriented behavior, and decreased awareness.

Recovery of corticospinal tract with diffuse axonal injury: a diffusion tensor image study.

OBJECTIVES: The purpose of this study is to identity the recovery process of the corticospinal tract with diffuse axonal injury (DAI) using diffusion tensor imaging (DTI). DESIGN: A 47-year-old female patient and six age-matched control subjects were evaluated. The patient presented with quadriparesis (more severe in the right extremities than the left ones) due to DAI at the onset of traumatic brain injury. Over the 24-month period following the onset of the injury, motor function of the four extremities slowly recovered to range which was close to normal. Two longitudinal DTIs were acquired from the patient (at 10 weeks and 24 months from onset) and from the control subjects. Fractional anisotropy (FA) and an apparent diffusion coefficient were measured using the region of interest (ROI) method. RESULTS: On the 10-week DTI, FAs of ROIs of the brainstem in both hemispheres of the patient were significantly lower than those of the control subjects. Compared to normal controls, the patient showed significantly increased FA in both sides of the brainstem at 24 months after the onset, which occurred in parallel with the improvement in motor function. CONCLUSIONS: Recovery in this patient could be attributed to the recovery of the corticospinal tract with diffuse axonal injury.