RESUMEN
BACKGROUND: Diffuse axonal injury (DAI) is typically associated with significant mechanisms of injury and the effects of acceleration-deceleration forces on brain tissues. The prognosis of DAI remains a matter of active investigation, but little is known about outcome differences between adult and pediatric populations with DAI. METHODS: We performed a retrospective cohort study involving blunt trauma patients with DAI between the years 1997 and 2018 from the Israeli National Trauma Registry. The patients were divided to pediatric (age <15 years) and adult (age >15 years) groups, with subsequent comparison of demographics and outcomes. RESULTS: Diffuse axonal injury was identified in 1983 patients, including 469 pediatric victims (23.6%) and 1514 adults (76.4%). Adults had higher Injury Severity Score (20.5% vs 13.2%, P = 0.0004), increased mortality (17.7% vs 13.4%, P < 0.0001), longer hospitalizations (58.4% vs 44.4%, P < 0.001), and higher rehabilitation need rates (56.4% vs 41.8%, P < 0.0001). Associated extracranial injuries were also more common in adults, particularly to the chest. CONCLUSIONS: Pediatric patients with DAI have improved outcomes and fewer associated injuries than adult counterparts.
Asunto(s)
Lesión Axonal Difusa , Heridas no Penetrantes , Adolescente , Adulto , Niño , Lesión Axonal Difusa/epidemiología , Humanos , Puntaje de Gravedad del Traumatismo , Sistema de Registros , Estudios RetrospectivosRESUMEN
BACKGROUND: Traumatic brain injury (TBI) is associated with one-third of all deaths from trauma. Preinjury exposure to cardiovascular drugs may affect TBI outcomes. Angiotensin-converting enzyme inhibitors (ACEIs) exacerbate brain cell damage and worsen functional outcomes in the laboratory setting. ß-blockers (BBs), however, appear to be associated with reduced mortality among patients with isolated TBI. OBJECTIVE: Examine the association between preinjury ACEI and BB use and clinical outcome among patients with isolated TBI. METHODS: A retrospective cohort study of patients age ≥ 40 years admitted to an academic level 1 trauma center with isolated TBI between January 2010 and December 2014 was performed. Isolated TBI was defined as a head Abbreviated Injury Scale (AIS) score ≥ 3, with chest, abdomen, and extremity AIS scores ≤ 2. Preinjury medication use was determined through chart review. All patients with concurrent BB use were initially excluded. In-hospital mortality was the primary measured outcome. RESULTS: Over the 5-year study period, 600 patients were identified with isolated TBI who were naive to BB use. There was significantly higher mortality (P = .04) among patients who received ACEI before injury (10 of 96; 10%) than among those who did not (25 of 504; 5%). A multivariate stepwise logistic regression analysis revealed a threefold increased risk of mortality in the ACEI cohort (P < .001), which was even greater than the twofold increased risk of mortality associated with an Injury Severity Score ≥ 16. A second analysis that included patients who received preinjury BBs (n = 98) demonstrated slightly reduced mortality in the ACEI cohort with only a twofold increased risk in multivariate analysis (P = .05). CONCLUSIONS: Preinjury exposure to ACEIs is associated with an increase in mortality among patients with isolated TBI. This effect is ameliorated in patients who receive BBs, which provides evidence that this class of medications may provide a protective benefit.
Asunto(s)
Antagonistas Adrenérgicos beta/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Lesiones Traumáticas del Encéfalo/mortalidad , Mortalidad Hospitalaria , Escala Resumida de Traumatismos , Adulto , Anciano , Presión Sanguínea , Craneotomía/estadística & datos numéricos , Lesión Axonal Difusa/epidemiología , Femenino , Escala de Coma de Glasgow , Hematoma Subdural/epidemiología , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Factores Protectores , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
Head trauma can injure the afferent and/or efferent visual systems, resulting in neuro-ophthalmic deficits. When assessing afferent pathway injuries, a stepwise approach to evaluating visual acuity, pupils, color perception, and visual fields is critical. Traumatic optic neuropathy is of especial importance and its management must be tailored on a case-by-case basis. Efferent pathway injuries should be assessed with attention to abnormalities of ocular alignment and motility, which may occur as isolated deficits or as part of a recognizable syndrome. Concussion or diffuse axonal injuries may also affect ophthalmologic function. Here, we review the extant literature describing the assessment and acute treatment of traumatic neuro-ophthalmic deficits.
Asunto(s)
Traumatismos Craneocerebrales/diagnóstico , Enfermedades del Sistema Nervioso/diagnóstico , Enfermedades del Nervio Óptico/diagnóstico , Vías Visuales/patología , Animales , Ensayos Clínicos como Asunto/métodos , Traumatismos Craneocerebrales/epidemiología , Lesión Axonal Difusa/diagnóstico , Lesión Axonal Difusa/epidemiología , Humanos , Enfermedades del Sistema Nervioso/epidemiología , Enfermedades del Nervio Óptico/epidemiologíaRESUMEN
OBJECTIVES: This pilot trial was conducted to establish whether Boswellia Serrata (BS), a traditional herbal medicine, could improve the outcome of patients who have diffuse axonal injury (DAI). METHODS: In total, 38 patients with pure DAI were enrolled in this 12-week, double-blind, randomized, cross-over study. The patients were randomly assigned to receive either placebo (group A, n = 20) or BS capsules (group B, n = 18) for 6 weeks and then switched to the other intervention for another 6 weeks. The disability rating scale (DRS) was used to assess the outcome at 2-, 6- and 12-weeks post-trauma. RESULTS: A non-significant trend for improvement of DRS total scores was observed after the use of BS. Regarding the DRS sub-scores, however, there was significant improvement in 'cognitive ability to self-care' during the second 6 weeks in group A on BS compared to an insignificant spontaneous recovery in group B during the same period on placebo. Moreover, both groups experienced a close-to-significant increase in the cognitive function-related items of the DRS during the periods they were on BS. The reported adverse events were all of mild quality and had similar frequency between the groups. CONCLUSION: These results suggest that BS resin does not significantly affect general outcome, but may enhance the cognitive outcome of patients with DAI.
Asunto(s)
Boswellia , Cognición/efectos de los fármacos , Lesión Axonal Difusa/tratamiento farmacológico , Fitoterapia , Preparaciones de Plantas/uso terapéutico , Autocuidado/estadística & datos numéricos , Accidentes de Tránsito/estadística & datos numéricos , Adulto , Estudios Cruzados , Lesión Axonal Difusa/epidemiología , Lesión Axonal Difusa/fisiopatología , Evaluación de la Discapacidad , Método Doble Ciego , Femenino , Escala de Coma de Glasgow , Humanos , Puntaje de Gravedad del Traumatismo , Irán/epidemiología , Masculino , Fitoterapia/métodos , Proyectos Piloto , Recuperación de la Función , Resultado del TratamientoRESUMEN
OBJECTIVE: The influence of blood alcohol level (BAL) on outcome remains unclear. This study investigated the relationships between BAL, type and number of diffuse axonal injury (DAI), intraventricular bleeding (IVB) and 6-month outcome. METHODS: This study reviewed 419 patients with isolated blunt traumatic brain injury. First, it compared clinical and radiological characteristics between patients with good recovery and disability. Second, it compared BAL among DAI lesions. Third, it evaluated the correlation between the BAL and severity of IVB, number of DAI and corpus callosum injury lesions. RESULTS: Regardless of BAL, older age, male gender, severe Glasgow Coma Scale score (<9), abnormal pupil, IVB and lesion on genu of corpus callosum were significantly related to disability. There were no significant differences between the BAL and lesions of DAI. Simple regression analysis revealed that there were no significant correlation between BAL and severity of IVB, number of DAI and corpus callosum injury lesions. CONCLUSIONS: Acute alcohol intoxication was not associated with type and number of DAI lesion, IVB and disability. This study suggested that a specific type of traumatic lesion, specifically lesion on genu of corpus callosum and IVB, might be more vital for outcome.
Asunto(s)
Intoxicación Alcohólica/complicaciones , Lesiones Encefálicas/diagnóstico , Hemorragia Cerebral Traumática/diagnóstico , Cuerpo Calloso/lesiones , Cuerpo Calloso/patología , Lesión Axonal Difusa/etiología , Heridas no Penetrantes/diagnóstico , Adulto , Factores de Edad , Anciano , Intoxicación Alcohólica/epidemiología , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/diagnóstico por imagen , Lesiones Encefálicas/epidemiología , Lesiones Encefálicas/patología , Hemorragia Cerebral Traumática/diagnóstico por imagen , Hemorragia Cerebral Traumática/epidemiología , Hemorragia Cerebral Traumática/etiología , Cuerpo Calloso/diagnóstico por imagen , Lesión Axonal Difusa/diagnóstico por imagen , Lesión Axonal Difusa/epidemiología , Lesión Axonal Difusa/patología , Evaluación de la Discapacidad , Femenino , Escala de Consecuencias de Glasgow , Humanos , Puntaje de Gravedad del Traumatismo , Japón/epidemiología , Masculino , Persona de Mediana Edad , Evaluación del Resultado de la Atención al Paciente , Pronóstico , Radiografía , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/epidemiología , Heridas no Penetrantes/patologíaRESUMEN
BACKGROUND: Dysautonomia after severe traumatic brain injury (TBI) is a clinical syndrome affecting a subgroup of survivors and is characterized by episodes of autonomic dysregulation and muscle overactivity. The purpose of this study was to determine the incidence of dysautonomia after severe TBI in an intensive care unit setting and analyze the risk factors for developing dysautonomia. METHODS: A consecutive series of 101 patients with severe TBI admitted in a major trauma hospital during a 2-year period were prospectively observed to determine the effects of age, sex, mode of injury, hypertension history, admission systolic blood pressure, fracture, lung injury, admission Glasgow Coma Scale (GCS) score, injury severity score, emergency craniotomy, sedation or analgesia, diffuse axonal injury (DAI), magnetic resonance imaging (MRI) scales, and hydrocephalus on the development of dysautonomia. Risk factors for dysautonomia were evaluated by using logistic regression analysis. RESULTS: Seventy-nine of the 101 patients met inclusion criteria, and dysautonomia was observed in 16 (20.3%) of these patients. Univariate analysis revealed significant correlations between the occurrence of dysautonomia and patient age, admission GCS score, DAI, MRI scales, and hydrocephalus. Sex, mode of injury, hypertension history, admission systolic blood pressure, fracture, lung injury, injury severity score, sedation or analgesia, and emergency craniotomy did not influence the development of dysautonomia. Multivariate logistic regression revealed that patient age and DAI were two independent predictors of dysautonomia. There was no independent association between dysautonomia and admission GCS score, MRI scales, or hydrocephalus. CONCLUSIONS: Dysautonomia frequently occurs in patients with severe TBI. A younger age and DAI could be risk factors for facilitating the development of dysautonomia.
Asunto(s)
Lesiones Encefálicas/complicaciones , Disautonomías Primarias/epidemiología , Adolescente , Adulto , Factores de Edad , Anciano , Lesiones Encefálicas/patología , Lesiones Encefálicas/fisiopatología , Niño , Estudios de Cohortes , Cuidados Críticos , Lesión Axonal Difusa/complicaciones , Lesión Axonal Difusa/epidemiología , Lesión Axonal Difusa/fisiopatología , Femenino , Humanos , Incidencia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Disautonomías Primarias/diagnóstico , Disautonomías Primarias/terapia , Factores de Riesgo , Adulto JovenRESUMEN
BACKGROUND: Diffuse axonal injury (DAI) is usually associated to severe trauma. Recent imaging advances made its diagnosis easier. Its prognosis impact is not yet well established. The aim of this article is to describe the epidemiologic, clinical, and radiologic features of posttraumatic DAI and to study its prognosis impact on mortality and outcome according to Glasgow Outcome Scale. METHODS: This is a retrospective study over a 4-year period (2004-2007) of 124 patients admitted for head trauma. Demographic, clinical, biological, and radiologic findings were recorded at admission and during intensive care unit stay. RESULTS: Mean age (±standard deviation) was 28 years±15.8 years. Cranial computed tomography scan was sufficient enough to diagnose DAI in 31 patients. Magnetic resonance imaging was performed in 105 patients with a delay of 7.7 days±8.6 days. Most patients were classified as stage II (49.5%) or stage III (44.8%) according to Gentry's classification. In a multivariate analysis, factors associated with higher mortality were dysautonomia (p=0.018; odds ratio [OR]=4.17), hyperglycemia≥8 mmol/L (p=0.001; OR=3.84) on intensive care unit admission, and subdural hematoma (p=0.031; OR=3.99), whereas factors associated to poor outcome according to Glasgow Outcome Scale score were Glasgow Coma Scale score<8 (p=0.032, OR=3.55), secondary systemic injuries score≥3 (p=0.034, OR=2.83), hyperglycemia≥8 mmol/L (p=0.002, OR=5.55), and DAI count≥6 (p=0.035, OR=3.33). In patients with pure DAI, the absence of consciousness recovery was the unique independent factor of mortality (p<0.001, OR=116.4), whereas only transfusion need was an independent factor of poor outcome (p=0.017, OR=4.44). CONCLUSION: Dysautonomia, hyperglycemia, and subdural hematoma are the main factors associated to higher mortality when DAIs are diagnosed, whereas a DAI count≥6 is associated to poor outcome. Magnetic resonance imaging classification did not have a prognosis value even in patients with pure DAI.
Asunto(s)
Traumatismos Craneocerebrales/epidemiología , Lesión Axonal Difusa/epidemiología , Adolescente , Adulto , Anciano , Encéfalo/diagnóstico por imagen , Encéfalo/patología , Niño , Preescolar , Traumatismos Craneocerebrales/diagnóstico , Lesión Axonal Difusa/diagnóstico , Lesión Axonal Difusa/diagnóstico por imagen , Lesión Axonal Difusa/patología , Femenino , Escala de Coma de Glasgow , Hematoma Subdural/epidemiología , Humanos , Hiperglucemia/epidemiología , Lactante , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Análisis Multivariante , Disautonomías Primarias/epidemiología , Pronóstico , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
PURPOSE: To assess the diagnostic value of T2 star-weighted angiography (SWAN) sequence for diffuse axonal injury (DAI) by virtue of correlation analysis between the number, volume and regional distribution of haemorrhagic lesions determined with SWAN sequence and clinical variables. METHODS: Twenty-eight DAI patients were included in our study and were divided into subgroups in compliance with dichotomized clinical variables separately. Global and regional number, volume and distribution of haemorrhagic lesions were compared between groups by non-parametric Mann-Whitney U test (two tailed) and independent samples t test. Spearman's rank correlation analysis was performed to compare the dichotomized clinical variables with the global and regional number and volume of lesions. RESULTS: Patients with lower Glasgow Coma Scale (GCS) score (≤8, nâ=â16) or prolonged coma (>4 days, nâ=â15) or abnormal pupillary light reflex (PLR, nâ=â15) had a greater global number (p ≤ 0.01) and apparent volume (p ≤ 0.01) of haemorrhagic lesions. In our study, haemorrhage extent in most brain regions, such as frontal white matter (FW), parietotemporaloccipital white matter (PTOW), corpus callosum (CC), thalamus (THAL), brain stem (BS), were greater in the lower GCS group, in the prolonged coma group and in the abnormal PLR group (p ≤ 0.05). Significant correlations were found between haemorrhage extent in global range and the dichotomized clinical variables (p ≤ 0.01). Correlations were also found between haemorrhage extent in most regions, such as FW, PTOW, CC, THAL and BS, and the dichotomized clinical variables (p ≤ 0.05). The number of involved regions was much more higher in the lower GCS group and the prolonged coma group (p < 0.0001). CONCLUSION: More accurate and objective assessment of injury can be obtained in DAI patients via SWAN sequence.
Asunto(s)
Lesión Axonal Difusa/diagnóstico , Hemorragias Intracraneales/diagnóstico , Reflejo Pupilar/fisiología , Adolescente , Adulto , Anciano , Angiografía , Encéfalo/patología , Niño , Coma/patología , Coma/fisiopatología , Interpretación Estadística de Datos , Lesión Axonal Difusa/epidemiología , Lesión Axonal Difusa/patología , Femenino , Escala de Coma de Glasgow/estadística & datos numéricos , Traumatismos Cerrados de la Cabeza/complicaciones , Humanos , Procesamiento de Imagen Asistido por Computador , Hemorragias Intracraneales/epidemiología , Hemorragias Intracraneales/patología , Imagen por Resonancia Magnética/métodos , Imagen por Resonancia Magnética/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Resistencia al Corte , Factores de Tiempo , Adulto JovenRESUMEN
The identification of children with traumatic brain injury (TBI) who are at risk of death or poor global neurological functional outcome remains a challenge. Magnetic resonance imaging (MRI) can detect several brain pathologies that are a result of TBI; however, the types and locations of pathology that are the most predictive remain to be determined. Forty-two critically ill children with TBI were recruited prospectively from pediatric intensive care units at five Canadian children's hospitals. Pathologies detected on subacute phase MRIs included cerebral hematoma, herniation, cerebral laceration, cerebral edema, midline shift, and the presence and location of cerebral contusion or diffuse axonal injury (DAI) in 28 regions of interest were assessed. Global functional outcome or death more than 12 months post-injury was assessed using the Pediatric Cerebral Performance Category score. Linear modeling was employed to evaluate the utility of an MRI composite score for predicting long-term global neurological function or death after injury, and nonlinear Random Forest modeling was used to identify which MRI features have the most predictive utility. A linear predictive model of favorable versus unfavorable long-term outcomes was significantly improved when an MRI composite score was added to clinical variables. Nonlinear Random Forest modeling identified five MRI variables as stable predictors of poor outcomes: presence of herniation, DAI in the parietal lobe, DAI in the subcortical white matter, DAI in the posterior corpus callosum, and cerebral contusion in the anterior temporal lobe. Clinical MRI has prognostic value to identify children with TBI at risk of long-term unfavorable outcomes.
Asunto(s)
Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Lesión Axonal Difusa/epidemiología , Imagen por Resonancia Magnética , Adolescente , Algoritmos , Lesiones Traumáticas del Encéfalo/mortalidad , Niño , Preescolar , Enfermedad Crítica , Lesión Axonal Difusa/diagnóstico por imagen , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Recuperación de la Función , Factores de Riesgo , Tasa de Supervivencia , Factores de TiempoRESUMEN
OBJECTIVE: To determine whether neurofilament light (NfL), glial fibrillary acidic protein (GFAP), tau, and ubiquitin C-terminal hydrolase-L1 (UCH-L1) measured in serum relate to traumatic brain injury (TBI) diagnosis, injury severity, brain volume, and diffusion tensor imaging (DTI) measures of traumatic axonal injury (TAI) in patients with TBI. METHODS: Patients with TBI (n = 162) and controls (n = 68) were prospectively enrolled between 2011 and 2019. Patients with TBI also underwent serum, functional outcome, and imaging assessments at 30 (n = 30), 90 (n = 48), and 180 (n = 59) days, and 1 (n = 84), 2 (n = 57), 3 (n = 46), 4 (n = 38), and 5 (n = 29) years after injury. RESULTS: At enrollment, patients with TBI had increased serum NfL compared to controls (p < 0.0001). Serum NfL decreased over the course of 5 years but remained significantly elevated compared to controls. Serum NfL at 30 days distinguished patients with mild, moderate, and severe TBI from controls with an area under the receiver-operating characteristic curve (AUROC) of 0.84, 0.92, and 0.92, respectively. At enrollment, serum GFAP was elevated in patients with TBI compared to controls (p < 0.001). GFAP showed a biphasic release in serum, with levels decreasing during the first 6 months of injury but increasing over the subsequent study visits. The highest AUROC for GFAP was measured at 30 days, distinguishing patients with moderate and severe TBI from controls (both 0.89). Serum tau and UCH-L1 showed weak associations with TBI severity and neuroimaging measures. Longitudinally, serum NfL was the only biomarker that was associated with the likely rate of MRI brain atrophy and DTI measures of progression of TAI. CONCLUSIONS: Serum NfL shows greater diagnostic and prognostic utility than GFAP, tau, and UCH-L1 for subacute and chronic TBI. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that serum NfL distinguishes patients with mild TBI from healthy controls.
Asunto(s)
Lesiones Traumáticas del Encéfalo/sangre , Proteína Ácida Fibrilar de la Glía/sangre , Proteínas de Neurofilamentos/sangre , Ubiquitina Tiolesterasa/sangre , Proteínas tau/sangre , Adulto , Área Bajo la Curva , Atrofia , Biomarcadores/sangre , Encéfalo/patología , Lesiones Traumáticas del Encéfalo/líquido cefalorraquídeo , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Lesiones Traumáticas del Encéfalo/epidemiología , Enfermedad Crónica , Lesión Axonal Difusa/sangre , Lesión Axonal Difusa/líquido cefalorraquídeo , Lesión Axonal Difusa/diagnóstico por imagen , Lesión Axonal Difusa/epidemiología , Imagen de Difusión Tensora , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tamaño de los Órganos , Estudios Prospectivos , Curva ROC , Recuperación de la Función , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: To determine whether serum neurofilament light (NfL) correlates with CSF NfL, traumatic brain injury (TBI) diagnosis, injury severity, brain volume, and diffusion tensor imaging (DTI) estimates of traumatic axonal injury (TAI). METHODS: Participants were prospectively enrolled in Sweden and the United States between 2011 and 2019. The Swedish cohort included 45 hockey players with acute concussion sampled at 6 days, 31 with repetitive concussion with persistent postconcussive symptoms (PCS) assessed with paired CSF and serum (median 1.3 years after concussion), 28 preseason controls, and 14 nonathletic controls. Our second cohort included 230 clinic-based participants (162 with TBI and 68 controls). Patients with TBI also underwent serum, functional outcome, and imaging assessments at 30 (n = 30), 90 (n = 48), and 180 (n = 59) days and 1 (n = 84), 2 (n = 57), 3 (n = 46), 4 (n = 38), and 5 (n = 29) years after injury. RESULTS: In athletes with paired specimens, CSF NfL and serum NfL were correlated (r = 0.71, p < 0.0001). CSF and serum NfL distinguished players with PCS >1 year from PCS ≤1 year (area under the receiver operating characteristic curve [AUROC] 0.81 and 0.80). The AUROC for PCS >1 year vs preseason controls was 0.97. In the clinic-based cohort, NfL at enrollment distinguished patients with mild from those with moderate and severe TBI (p < 0.001 and p = 0.048). Serum NfL decreased over the course of 5 years (ß = -0.09 log pg/mL, p < 0.0001) but remained significantly elevated compared to controls. Serum NfL correlated with measures of functional outcome, MRI brain atrophy, and DTI estimates of TAI. CONCLUSIONS: Serum NfL shows promise as a biomarker for acute and repetitive sports-related concussion and patients with subacute and chronic TBI. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that increased concentrations of NfL distinguish patients with TBI from controls.
Asunto(s)
Lesiones Traumáticas del Encéfalo/sangre , Hockey/lesiones , Proteínas de Neurofilamentos/sangre , Enfermedad Aguda , Adulto , Área Bajo la Curva , Atrofia , Biomarcadores/sangre , Biomarcadores/líquido cefalorraquídeo , Encéfalo/patología , Conmoción Encefálica/sangre , Conmoción Encefálica/líquido cefalorraquídeo , Conmoción Encefálica/patología , Lesiones Traumáticas del Encéfalo/líquido cefalorraquídeo , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Lesiones Traumáticas del Encéfalo/epidemiología , Enfermedad Crónica , Lesión Axonal Difusa/sangre , Lesión Axonal Difusa/líquido cefalorraquídeo , Lesión Axonal Difusa/diagnóstico por imagen , Lesión Axonal Difusa/epidemiología , Imagen de Difusión Tensora , Femenino , Humanos , Masculino , Proteínas de Neurofilamentos/líquido cefalorraquídeo , Tamaño de los Órganos , Estudios Prospectivos , Curva ROC , Recuperación de la Función , Suecia/epidemiología , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Although studies have been conducted to analyze brain injuries from motor vehicle crashes, the association of head contact has not been fully established. This study examined the association in occupants sustaining diffuse axonal injuries (DAIs). METHODS: The 1997 to 2006 motor vehicle Crash Injury Research Engineering Network database was used. All crash modes and all changes in velocity were included; ejections and rollovers were excluded; injuries to front and rear seat occupants with and without restraint use were considered. DAI were coded in the database using Abbreviated Injury Scale 1990. Loss of consciousness was included and head contact was based on medical- and crash-related data. RESULTS: Sixty-seven occupants with varying ages were coded with DAI. Forty-one adult occupants (mean, 33 years of age, 171-cm tall, 71-kg weight; 30 drivers, 11 passengers) were analyzed. Mean change in velocity was 41.2 km/h and Glasgow Coma Scale score was 4. There were 33 lateral, 6 frontal, and 2 rear crashes with 32 survivors and 9 were fatalities. Two occupants in the same crash did not sustain DAI. Although skull fractures and scalp injuries occurred in some impacts, head contact was identified in all frontal, rear, and far side, and all but one nearside crashes. CONCLUSIONS: Using a large sample size of occupants sustaining DAI in 1991 to 2006 model year vehicles, DAI occurred more frequently in side than frontal crashes, is most commonly associated with impact load transfer, and is not always accompanied by skull fractures. The association of head contact in >95% of cases underscores the importance of evaluating crash-related variables and medical information for trauma analysis. It would be prudent to include contact loading in addition to angular kinematics in the analysis and characterization of DAI.
Asunto(s)
Accidentes de Tránsito/estadística & datos numéricos , Lesión Axonal Difusa/epidemiología , Adulto , Fenómenos Biomecánicos , Índice de Masa Corporal , Diagnóstico por Imagen , Lesión Axonal Difusa/diagnóstico , Femenino , Escala de Coma de Glasgow , Humanos , Incidencia , Masculino , Factores de Riesgo , Wisconsin/epidemiologíaRESUMEN
Head injury is one of the most common injury types in vehicle-to-pedestrian collisions, which leads to death and long-term disabilities. However, detailed analysis of pedestrian head injuries in real world collisions is scarce. Thus the current study used two samples of 120 cases and 184 cases extracted from 1060 pedestrian collision cases captured during 2000-2015 from the GIDAS (German In-Depth-Accident Study) database to investigate the detailed characteristics of AIS2+ pedestrian head injuries. Firstly, the interrelationship between different head injury types (skull fracture, focal brain injury, concussion and diffuse axonal injury (DAI)) was analysed using the sample of 120 cases which each had at least one AIS2+ head injury. Then the influences of impact speed, pedestrian age and car front shape parameters on the injury risk of skull fracture, focal brain injury and concussion were assessed using the logistic regression method, based on the sample of 184 AIS1+ cases where the primary head contact location was within the windscreen glass area. The results show that: skull fractures and focal brain injuries dominate for AIS3+ head injuries and are generally associated with each other; concussion is the most important injury type for AIS2 head injuries and usually occurs in isolation. Further, for head impacts to the windscreen glass area a higher bonnet leading edge helps to reduce concussion odds, and none of the selected car front shape parameters are significant for the odds of skull fracture and focal brain injury, and vehicle impact speed and pedestrian age are insignificant for concussion. These detailed characteristics of pedestrian head injuries provide a basis for future pedestrian head injury prevention strategies with skull fractures and focal brain injuries being the most important injuries to address.
Asunto(s)
Accidentes de Tránsito/estadística & datos numéricos , Traumatismos Craneocerebrales/epidemiología , Peatones/estadística & datos numéricos , Adulto , Conmoción Encefálica/epidemiología , Bases de Datos Factuales , Lesión Axonal Difusa/epidemiología , Alemania/epidemiología , Humanos , Fracturas Craneales/epidemiología , Caminata/lesionesRESUMEN
Clinical outcome after traumatic diffuse axonal injury (DAI) is difficult to predict. In this study, three magnetic resonance imaging (MRI) sequences were used to quantify the anatomical distribution of lesions, to grade DAI according to the Adams grading system, and to evaluate the value of lesion localization in combination with clinical prognostic factors to improve outcome prediction. Thirty patients (mean 31.2 years ±14.3 standard deviation) with severe DAI (Glasgow Motor Score [GMS] <6) examined with MRI within 1 week post-injury were included. Diffusion-weighted (DW), T2*-weighted gradient echo and susceptibility-weighted (SWI) sequences were used. Extended Glasgow outcome score was assessed after 6 months. Number of DW lesions in the thalamus, basal ganglia, and internal capsule and number of SWI lesions in the mesencephalon correlated significantly with outcome in univariate analysis. Age, GMS at admission, GMS at discharge, and low proportion of good monitoring time with cerebral perfusion pressure <60 mm Hg correlated significantly with outcome in univariate analysis. Multivariate analysis revealed an independent relation with poor outcome for age (p = 0.005) and lesions in the mesencephalic region corresponding to substantia nigra and tegmentum on SWI (p = 0.008). We conclude that higher age and lesions in substantia nigra and mesencephalic tegmentum indicate poor long-term outcome in DAI. We propose an extended MRI classification system based on four stages (stage I-hemispheric lesions, stage II-corpus callosum lesions, stage III-brainstem lesions, and stage IV-substantia nigra or mesencephalic tegmentum lesions); all are subdivided by age (≥/<30 years).
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Hemorragia Cerebral/diagnóstico por imagen , Lesión Axonal Difusa/diagnóstico por imagen , Imagen por Resonancia Magnética/tendencias , Sustancia Negra/diagnóstico por imagen , Tegmento Mesencefálico/diagnóstico por imagen , Adolescente , Adulto , Hemorragia Cerebral/clasificación , Hemorragia Cerebral/epidemiología , Lesión Axonal Difusa/clasificación , Lesión Axonal Difusa/epidemiología , Femenino , Escala de Coma de Glasgow/tendencias , Humanos , Imagen por Resonancia Magnética/clasificación , Masculino , Persona de Mediana Edad , Factores de Tiempo , Tomografía Computarizada por Rayos X/clasificación , Tomografía Computarizada por Rayos X/tendencias , Resultado del Tratamiento , Adulto JovenRESUMEN
PURPOSE: This is a descriptive study of the annual incidence of brain injuries in motor vehicle crashes by type, seat belt use, and crash severity (delta V) using national accident data. The risk for concussion, diffuse axonal injury (DAI), and severe head injury was determined. METHODS: 1994-2011 NASS-CDS was analyzed to estimate the number of brain injuries annually in nonejected adults involved in motor vehicle crashes. Crashes were grouped by front, side, rear, and rollover, and the effect of belt use was investigated. Light vehicles were included with model year 1994+. Head injuries were identified as concussion, DAI, severe head injury (Abbreviated Injury Scale [AIS] 4+), and skull fracture. The annual incidence, risk, and rate for different types of head injury were estimated with standard errors. RESULTS: Motor vehicle crashes involved 33,191 ± 7,815 occupants with concussion, 5,665 ± 996 with AIS 4+ head injuries, 986 ± 446 with DAI, and 3,300 ± 531 with skull fracture annually. The risk was 1.64 ± 0.39% for concussion, 0.28 ± 0.05% for severe head injury (AIS 4+), 0.05 ± 0.02% for DAI, and 0.16 ± 0.03% for skull fracture in tow-away crashes. The risk for severe head injury (AIS 4+) was highest in rollovers (0.74 ± 0.16%) and lowest in rear impacts (0.17 ± 0.05%). Head injury risk depended on seat belt use, crash type, and crash severity (delta V). Seat belt use lowered the risk for AIS 4+ head injury by 74.8% and skull fracture by 73.2%. CONCLUSIONS: Concussions occur in about one out of 61 occupants in tow-away crashes. The risk was highest in rollover crashes (4.73 ± 1.09%) and it was reduced 69.2% by seat belt use. Severe brain injuries occurred less often and the risk was also reduced by seat belt use.
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Accidentes de Tránsito/estadística & datos numéricos , Conmoción Encefálica/epidemiología , Traumatismos Craneocerebrales/epidemiología , Lesión Axonal Difusa/epidemiología , Escala Resumida de Traumatismos , Adulto , Bases de Datos Factuales , Femenino , Humanos , Incidencia , Masculino , Cinturones de Seguridad/estadística & datos numéricos , Índices de Gravedad del Trauma , Estados Unidos/epidemiologíaRESUMEN
The authors have reported a macro- and microscopic study of brain lesions in 120 victims of fatal road traffic accidents, independent of the survival time. Diffuse vascular injury (DVI) was found in 14 patients (11.7%). All patients with DVI died within 24 h after the accident. The 14 patients with DVI also showed severe (Grade 2 or 3) diffuse axonal injury (DAI). Since DVI is restricted to road traffic accidents and incompatible with life, the high frequency observed in our series could be explained by the fact that all 120 patients were victims of road traffic accidents, and 69.2% had died within 24 h after the accident. The association between DVI and severe DAI (Grades 2 and 3) suggests that both lesions depend on the same mechanism, with the degree of axonal and vascular damage being determined by the intensity of the head acceleration. Our results show a relationship between DVI and DAI that suggest there may be a spectrum or at least a continuum between these entities as distinct from DVI being a separate entity.
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Accidentes de Tránsito , Hemorragia Encefálica Traumática/patología , Encéfalo/irrigación sanguínea , Traumatismos Craneocerebrales/patología , Lesión Axonal Difusa/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Encéfalo/patología , Hemorragia Encefálica Traumática/epidemiología , Brasil/epidemiología , Niño , Preescolar , Traumatismos Craneocerebrales/epidemiología , Lesión Axonal Difusa/epidemiología , Femenino , Medicina Legal , Escala de Coma de Glasgow , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Objectives To determine the relationship between alcohol consumption and the incidence of traumatic brain injury (TBI) with diffuse axonal injury (DAI), determining these indices, checking acquired comorbidities and characterizing the patients by gender, age and race/color, as well as describing the characteristics of the motor vehicle collision (vehicle, period of the day, day of the week and site) in people admitted to an emergency hospital in the city of Teresina, in the state of Piauí, Brazil. Methods We have analyzed the data contained in the medical records of patients admitted with a history of motor vehicle collision and severe TBI in intensive care units, based on the forms provided by the Mobile Emergency Care Service (SAMU, in the Portuguese acronym) in the period between February 28 and November 28, 2013. Results In the period covered by the present study, 200 individuals were analyzed, and 54 (27%) had consumed alcohol; of these 11 had DAI. Of the total sample, 17% (34) presented DAI, however, with unknown data regarding the consumption of alcoholic beverages. Conclusion Considering the data, we observed that the profile of the head trauma patients are brown men, mostly (53.5%) aged between 15 and 30 years. The collisions occurred mostly on weekends and at night (55%), and 89.5% of the crashes involved motorcycles.
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Humanos , Masculino , Femenino , Adolescente , Adulto , Persona de Mediana Edad , Anciano , Adulto Joven , Consumo de Bebidas Alcohólicas/epidemiología , Accidentes de Tránsito/estadística & datos numéricos , Lesión Axonal Difusa/epidemiología , Lesiones Traumáticas del Encéfalo/epidemiología , Factores de Tiempo , Brasil/epidemiología , Consumo de Bebidas Alcohólicas/efectos adversos , Registros Médicos , Epidemiología Descriptiva , Interpretación Estadística de Datos , Lesiones Traumáticas del Encéfalo/etiologíaRESUMEN
White matter injury may be secondary to a range of neurodegenerative disorders, such as the common dementing disorders of the elderly, or may be a consequence of specific white matter disorders, such as multiple sclerosis and the rare leukodystrophies. This article will focus on two relatively common primary groups of disorders of the white matter, traumatic white matter injury and toxic leukoencephalopathies. Traumatic axonal injury may be focal or diffuse, and is associated with a clinical spectrum ranging from concussion through to coma and death. The molecular mechanisms underlying axonal degeneration secondary to traumatic axonal degeneration are being elucidated and may give an insight into potential therapeutic targets. Toxic leukoencephalopathy may be secondary to exposure to a wide range of compounds, including chemotherapeutic drugs. These toxins may produce white matter injury through a range of mechanisms, and the potential toxic effects of compounds need to be considered when assessing a patient with a nonspecific leukoencephalopathy.
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Axones/patología , Encéfalo/fisiopatología , Lesión Axonal Difusa/fisiopatología , Leucoencefalopatías/fisiopatología , Síndromes de Neurotoxicidad/fisiopatología , Axones/metabolismo , Encéfalo/patología , Lesión Axonal Difusa/epidemiología , Humanos , Leucoencefalopatías/epidemiología , Síndromes de Neurotoxicidad/epidemiología , Síndromes de Neurotoxicidad/inmunologíaRESUMEN
OBJECT: In this prospective cohort study the authors examined patients with moderate to severe head injuries using MR imaging in the early phase. The objective was to explore the occurrence of diffuse axonal injury (DAI) and determine whether DAI was related to level of consciousness and patient outcome. METHODS: One hundred and fifty-nine patients (age range 5-65 years) with traumatic brain injury, who survived the acute phase, and who had a Glasgow Coma Scale (GCS) score of 3-13 were admitted between October 2004 and August 2008. Of these 159 patients, 106 were examined using MR imaging within 4 weeks postinjury. Patients were classified into 1 of 3 stages of DAI: Stage 1, in which lesions were confined to the lobar white matter; Stage 2, in which there were callosal lesions; and Stage 3, in which lesions occurred in the dorsolateral brainstem. The outcome measure used 12 months postinjury was the Glasgow Outcome Scale-Extended (GOSE). RESULTS: Diffuse axonal injury was detected in 72% of the patients and a combination of DAI and contusions or hematomas was found in 50%. The GCS score was significantly lower in patients with "pure DAI" (median GCS Score 9) than in patients without DAI (median GCS Score 12; p < 0.001). The GCS score was related to outcome only in those patients with DAI (r = 0.47; p = 0.001). Patients with DAI had a median GOSE score of 7, and patients without DAI had a median GOSE score of 8 (p = 0.10). Outcome was better in patients with DAI Stage 1 (median GOSE Score 8) and DAI Stage 2 (median GOSE Score 7.5) than in patients with DAI Stage 3 (median GOSE Score 4; p < 0.001). Thus, in patients without any brainstem injury, there was no difference in good recovery between patients with DAI (67%) and patients without DAI (66%). CONCLUSIONS: Diffuse axonal injury was found in almost three-quarters of the patients with moderate and severe head injury who survived the acute phase. Diffuse axonal injury influenced the level of consciousness, and only in patients with DAI was GCS score related to outcome. Finally, DAI was a negative prognostic sign only when located in the brainstem.
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Lesiones Encefálicas/epidemiología , Traumatismos Craneocerebrales/epidemiología , Lesión Axonal Difusa/epidemiología , Adolescente , Adulto , Anciano , Encéfalo/patología , Lesiones Encefálicas/diagnóstico , Lesiones Encefálicas/patología , Niño , Preescolar , Enfermedad Crónica , Estudios de Cohortes , Estado de Conciencia , Traumatismos Craneocerebrales/diagnóstico , Traumatismos Craneocerebrales/patología , Lesión Axonal Difusa/diagnóstico , Lesión Axonal Difusa/patología , Humanos , Imagen por Resonancia Magnética , Persona de Mediana Edad , Prevalencia , Pronóstico , Estudios Prospectivos , Recuperación de la Función , Índice de Severidad de la Enfermedad , Factores de Tiempo , Adulto JovenRESUMEN
Fifty-three cases of non-accidental head injury in children were subjected to detailed neuropathological study, which included immunocytochemistry for microscopic damage. Clinical details were available for all the cases. There were 37 infants, age at head injury ranging from 20 days to 9 months, and 16 children (range 13 months to 8 years). The most common injuries were skull fractures (36% of cases), acute subdural bleeding (72%) and retinal haemorrhages (71%); the most usual cause of death was raised intracranial pressure secondary to brain swelling (82%). On microscopy, severe hypoxic brain damage was present in 77% of cases. While vascular axonal damage was found in 21 out of 53 cases, diffuse traumatic axonal injury was present in only three. Eleven additional cases, all of them infants, showed evidence of localized axonal injury to the craniocervical junction or the cervical cord. When the data were analysed by median age at head injury, statistically significant patterns of age-related damage emerged. Our study shows that infants of 2-3 months typically present with a history of apnoea or other breathing abnormalities, show axonal damage at the craniocervical junction, and tend also to have a skull fracture, a thin film of subdural haemorrhage, but lack extracranial injury. Children over 1 year are more likely to suffer severe extracranial, particularly abdominal, injuries. They tend to have larger subdural haemorrhages, and where traumatic axonal injury is present, show patterns of hemispheric white matter damage more akin to those reported in adults. Diffuse axonal injury is an uncommon sequel of inflicted head injury in children.