Non-contrast CT of the brain is routine in patients presenting with head injuries. The pathognomonic histological findings of axons with DAI are: Patients will have loss of consciousness at the time of injury with a prolonged post-traumatic coma (often attributed to co-existent injury, e.g. 15 (1): 49-59. most common sites: parasagittal regions of frontal lobes, periventricular temporal lobes, less common sites: parietal and occipital lobes, internal and external capsules, cerebellum, most common sites: posterior body and splenium of corpus callosum, less common sites: anterior body and rostrum of corpus callosum (usually in conjunction with posterior involvement), usually unilateral and eccentric but may be bilateral and symmetric, most common sites: dorsolateral midbrain, upper pons, and superior cerebellar peduncles. 1. This chapter will summarize an important aspect of TBI pathology—diffuse axonal injury (DAI)—that is increasingly recognized as an important cause of long-term disability and mortality. Unconsciousness, which lasts several hours or more, is a leading symptom of diffuse axonal injury. Management via steroids and short-term anticonvulsant therapy can be considered on a case by case basis. Once you've finished editing, click 'Submit for Review', and your changes will be reviewed by our team before publishing on the site. Figure 13a. A severe diffuse axonal injury with finding as Grade 2 and additional focal lesions in the brainstem. It happened in an instant, during a hotly contested international auto race. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Diffuse axonal injury after traumatic brain injury is a prognostic factor for functional outcome: a systematic review and meta-analysis. 2. Even severe cases of DAI can have relatively normal CT imaging. The onset of diffuse axonal injury will vary on a per-patient basis from mild to severe, based on a standardized neurological examination rated on the Glasgow Coma Scale (GCS), which indicates the severity of brain damage present. 6 Imaging of closed head injury. Others have found supportive evidence for its prognostic utility: a meta-analysis including 5 studies of 258 patients with diffuse axonal injury found an unfavorable functional outcome in 17% of patients with grade 1 diffuse axonal injury on MRI, 40% of grade 2, and 63% of grade 3 4. 191 (1): 1-17. Radiologic recognition of this entity and understanding of its sequelae can be of utmost importance in the prediction of outcome and planning for rehabilitation. Bruggeman GF, Haitsma IK, Dirven CMF, Volovici V. Traumatic axonal injury (TAI): definitions, pathophysiology and imaging-a narrative review. However, there are characteristics typical of DAI that may or may not show up on a CT scan. The prognostic validity of the MRI-based anatomic grading of diffuse axonal injury is controversial. Road traffic accidents (RTAs) are the most frequent cause of DAI, with assault or falls also common aetiologies. Diagnosing Diffuse Axonal Injury. The amount you recover from diffuse axonal injury depends on the severity of the injury itself. A spectrum of clinical consequences may follow DAI, dependent on the severity of the pathology ranging from very minor to extensively diffuse damage. Determine the prognostic impact of magnetic resonance imaging (MRI)-defined diffuse axonal injury (DAI) after traumatic brain injury (TBI) on functional outcomes, quality of life, and 3-year mortality. The main differential in cases of head injury are cortical contusions, typically found superficially at the cortical level, not concentrated to the grey-white matter junction. Treatment options are limited to preventing secondary effects such as cerebral oedema or haemorrhage. J Neurotrauma. Treatment options are all aimed to preventing secondary effects such as cerebral oedema or haemorrhage, however guidelines in treatment for DAI are variable. Axonal disconnection and mechanical disruption to axonal cytoskeletal structure results in immediate severe brain injury. Grade 2 and 3 injury is considered severe if the focal lesions are macroscopically apparent. (2020) Brain injury. A DAI is caused by shaking or strong rotation of the head by physical forces, such as with a car crash. Contrary to the implication of the word "diffuse," diffuse axonal injury has a topological predilection for focal involvement of certain sites in the brain. (1989) Histopathology. 4, 5 Up to 75% of the patients with moderate to severe head injury who survive the acute phase are diagnosed with DAI. Grading of diffuse axonal injury due to trauma is described according to the anatomic distribution of injury. DAI is difficult to detect since it does not show up well on CT scans or with other macroscopic imaging techniques, though it shows up microscopically. Past Studies. It is always severe thus it becomes life-threatening. In mild to moderate forms of diffuse axonal injury, recovery is possible, with the mildest forms of diffuse axonal injury often resulting in few if any long-term issues. It is the cause of death in most cases where the patient never makes it to the hospital. Diffuse Axonal Injury (DAI) is considered one of the most common and detrimental forms of traumatic brain injury (TBI). However, many smaller studies have found weak or nonexistent correlations between MRI grading and outcome, suggesting that clinical applicability in individual patients is likely poor 5,6. Grade 1: Diffuse axonal damage within the white matter of the cerebral hemispheres and grey-white matter interfaces: Brief loss of consciousness: Grade 2: Tissue tear haemorrhages present; axonal damage of the white matter including grade 1 regions and the territory of the corpus callosum Grading of diffuse axonal injury has been described histologically according to the anatomic distribution of injury, which correlated with outcome 1-3. Is our article missing some key information? Abu Hamdeh S, Marklund N, Lannsjö M, Howells T, Raininko R, Wikström J, et al. A diffuse axonal injury (DAI) is a type of brain injury which involves damages to the axons, caused by shearing forces which push tissues in the brain past each other. The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. The diagnosis is often only suspected when patients do not make a neurological recovery, based on initial imaging. The primary aim of this cross-sectional cohort study was to assess the long-term functional outcome in patients with DAI and to identify prognostic factors. acute haemarrohage or cerebral contusions). This retrospective single center cohort included adult trauma patients (age > 17 years) admitted from 2006 to 2012 with TBI. Diffuse axonal injury was identified in 122 of a series of 434 fatal non‐missile head injuries–‐10 grade 1, 29 grade 2 and 83 grade 3. It happens when the brain rapidly shifts inside the skull as an injury is occurring. Following any trauma, patients should be appropriately resuscitated and stabilised, prior to transfer to a neuro-trauma centre. Long-term vegetative state appears at the severe end of the spectrum. METHODS . 2017;34: 341 … Gentry LR. In grade 1 there is histological evidence of axonal injury in the white matter of the cerebral hemispheres, the corpus callosum, the brain stem and, less commonly, the cerebellum; in grade 2 there is also a focal lesion in the corpus callosum; and in grade 3 there is in … Results: Diffuse axonal injury (DAI) (OR 9.06, 95% CI 0.99 to 82.7) and frontal lobe injury of any type (OR 6.68, 95% CI 1.1 to 39.3) are independently predictive of … (2018) Brain injury. Diffuse damage to axons can only be detected micro- scopically inappropriatelystainedtissue;ittakestheformsof axonal retraction balls (RB) in short survivors (hours to Whilst non-contrast CT imaging of the head is the mainstay initial investigation following head injury, DAI is poorly picked up through this modality. Midline traumatic SAH (in the interhemispheric fissure or perimesencephalic cisterns) on initial head CT images is a marker of diffuse axonal injury (DAI) at subsequent MRI, with a 61% sensitivity and 82% specificity for severe DAI in one study . Other symptoms may occur even in mild cases, depending upon the area of the brain where the damage occurred. With grade 2, there is also at least one focal lesion in the corpus callosum. The patient population most susceptible to DAI is the equivalent cohort most vulnerable to traumatic brain injury, thus young males are often significantly over-represented. (2017) Journal of neurotrauma. By OpenStax College [CC BY 3.0], via Wikimedia Commons, By Hellerhoff [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], from Wikimedia Commons, [caption id="attachment_18740" align="aligncenter" width="364"], [caption id="attachment_18739" align="aligncenter" width="324"], Endovascular Abdominal Aortic Aneurysm Repair, Diffuse axonal damage within the white matter of the cerebral hemispheres and grey-white matter interfaces, Tissue tear haemorrhages present; axonal damage of the white matter including grade 1 regions and the territory of the corpus callosum, Variable recovery process, coma of unclear duration, Grade 2 findings in addition to tissue tear haemorrhages within the brainstem, Instant coma with posturing and incomplete recovery, Diffuse Axonal Injury is often fatal and one of the major causes of morbidity and mortality following traumatic brain injury, Diffuse white matter tract lesions are histopathological and neuroimaging hallmarks of DAI, A spectrum of severity for DAI exists, ranging from concussion in milder forms to coma in cases involving widespread axonal damage. Destroyed axon microtubules will align incorrectly, with Tau and amyloid precursor protein (APP) are aberrantly deposited. Several parts of the brain are affected by this type. Diffuse axonal injury (DAI) is a form of traumatic brain injury. Diffuse axonal injury affects nerve fibers, which can lead to a disruption in nerve communication — affecting a person's physical and cognitive abilities. Injury occurs because the unmoving brain lags behind the movement of the skull, causing nerve structures to tear. 6. van Eijck MM, Herklots MW, Peluso J, Schoonman GG, Oldenbeuving AW, de Vries J, van der Naalt J, Roks G. Accuracy in prediction of long-term functional outcome in patients with traumatic axonal injury: a comparison of MRI scales. Figure 1 – The three parts of the brainstem. Past Studies show that 40% to 50% of traumatic brain injuries requiring hospital admission are diffuse axonal injury (DAI). Increasing experience with fatal non-missile head injury in man has allowed the identification of three grades of diffuse axonal injury. Diffuse axonal injury is injury to the axons and axonal tracts, which criss-cross different layers of the brain.See our pages on Neuron and Axon starting here. The survival rate depends on a lot of factors such as the brain regions that are affected, the health of the patient, the quality of care available and the accessibility to this type of quality care. Unable to process the form. Grade-III Diffuse Axonal Injury: There is widespread axonal damage, focal abnormalities along with injury to the rostral brainstem which often results in … The delayed secondary axonal disconnection develops in a progressive manner, accounting for a significant proportion of DAI damage. Grade : Pathology: Effect on Consciousness. Carla and Gino were huge racing fans and saw the accident on TV. Focal lesions may sometimes be only identified microscopically. (2020) Acta neurochirurgica. Diffuse axonal injury is characterized by multiple focal lesions with a characteristic distribution: typically located at the grey-white matter junction, in the corpus callosum and in more severe cases in the brainstem (see: grading of diffuse axonal injury). Extended Anatomical Grading in Diffuse Axonal Injury Using MRI: Hemorrhagic Lesions in the Substantia Nigra and Mesencephalic Tegmentum Indicate Poor Long-Term Outcome. Grade-II Diffuse Axonal Injury: Along with widespread axonal damage, focal abnormalities are also present, particularly in the corpus callosum. A diffuse axonal brain injury is a traumatic brain injury (TBI) … DAI may also present as a consequence of child abuse, particularly in shaken baby syndrome and abusive head trauma. Extended anatomical grading in diffuse axonal injury using MRI: Hemorrhagic lesions in the substantia nigra and mesencephalic tegmentum indicate poor long-term outcome. The resistant inertia that occurs to the brain at the time of injury, preceding and following its sudden acceleration against the solid skull, causes shearing of the axonal tracts of the white matter. MRI is more useful than CT for detecting characteris… Check for errors and try again. Background: Determine the prognostic impact of magnetic resonance imaging (MRI)-defined diffuse axonal injury (DAI) after traumatic brain injury (TBI) on functional outcomes, quality of life, and 3-year mortality. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Diffuse Axonal Injury. The grey and white matter of the axons are of distinct specific gravities, therefore the axons present at the grey-white matter junction are particularly susceptible to injury. Both their cars spun wildly out of control and crashed. Make the changes yourself here! It is thought to be a milder type of diffuse axonal injury, because axons may be injured to a minor extent due to stretching. Diffuse axonal shear injury is a common traumatic brain injury, with significant neurologic and behavioral impact on patients. Last updated: January 14, 2020 Two drivers, Luis and James, were jockeying for position when something went terribly wrong. Racing fans watched in horror as the two were carefully removed from the wreckage of their vehicles and rushed away in ambulances. Lindell Gentry translated the histopathologic grading system to imaging in the following manner in a review article in 1994 published in Radiology 2: Diffuse axonal injury lesions were not clearly defined in this article by their MR appearance aside from being multiple, small, elliptical "lesions" located in characteristic areas of white matter. Found an error? With grade 3, there is also a focal lesion in the dorsolateral quadrant or in … MRI imaging serves as the best imaging modality for DAI detection. Diffuse axonal injury (DAI) is defined as a prolonged consciousness disturbance, more than 6 h after head injury, without demonstrable swelling or ischemic brain lesions. 5. 32 (4): 395-402. accident, fall, assault), the rapid acceleration or deceleration of the head results in traumatic shearing forces. Secondary physiological alterations include disrupted axonal transport, diffuse swelling, and axonal degeneration. A diffuse axonal injury affects many areas of the brain at once, which is what makes them more difficult to treat than other brain injuries. With grade 1 injuries, there is histological evidence of axonal lesions in the white matter of the cerebral hemispheres. Figure 2 – MRI imaging demonstrating diffuse axonal injury following motorcycle accident (day 3). A classification for grading of DAI characterises into 3 distinct categories, based upon histological findings in the anatomical distribution of injury: From the initial event or insult (e.g. lacerations or punctate contusions at the interface between grey and white matter; caused by a rotational vector of injury; common cause of persistent vegetative state or prolonged coma; Marshall Classification of DAI on CT: I – no CT abnormalities (normal) 34 (2): 341-352. These sites, in turn, vary in functional importance. Artefact regions are seen at the junctions of the grey-white matter, such as in the corpus callosum or brainstem. Diffuse axonal injury is the shearing (tearing) of the brain's long connecting nerve fibers (axons) that happens when the brain is injured as it shifts and rotates inside the bony skull. Methods: This retrospective single center cohort included adult trauma patients (age > 17 years) admitted from 2006 to 2012 with TBI. Severe Diffuse Axonal Injury is one of the most dangerous pathological conditions that can occur. Some point out that the Adams classification was inappropriately ported to MRI without robust study of its ability to predict outcome 3. 3. Abu Hamdeh S, Marklund N, Lannsjö M, et al. Physiotherapy, speech therapy, and occupational therapy within brain injury rehabilitation programs should be provided to optimise patient follow-up. 4. van Eijck MM, Schoonman GG, van der Naalt J, et al. A classification based on histopathology was first proposed by J Hume Adams and colleagues in 1989 1: The features of diffuse axonal damage vary by time: axonal bulbs are present within days, microglia clusters and astrocytosis develop after weeks, and Wallerian degeneration of the white matter tracts sets in after months. Diffuse injury has more microscopic injury than macroscopic injury and is difficult to detect with CT and MRI, but its presence can be inferred when small bleeds are visible in the corpus callosum or the cerebral cortex. Diffuse Axonal Injury and Oxidative Stress: A Comprehensive Review. As the “diffuse” in the name implies, a diffuse axonal injury can cover a large area of the brain, as opposed to a focal injury, in which the damage is concentrated in one region. If you do not agree to the foregoing terms and conditions, you should not enter this site. Unfortunately, it is not sensitive to subtle diffuse axonal injury and as such, some patients with relatively normal CT scans may have significant unexplained neurological deficit 4,5… Some DAIs are … This information is intended for medical education, and does not create any doctor-patient relationship, and should not be used as a substitute for professional diagnosis and treatment. Concussion involves diffuse (as opposed to focal) brain injury, meaning that the dysfunction occurs over a widespread area of the brain rather than in a particular spot. Functional outcome and quality of life are difficult to predict in patients with diffuse axonal injury (DAI) after traumatic brain injury (TBI). Some investigators have proposed alternative MRI location-based grading scales that may perform as well or better than the original Gentry classification, including those with added emphasis on the basal ganglia, thalamus, substantia nigra, and/or midbrain tegmentum 5,6. Therapeutic interventions for DAI are limited. The classification was first proposed by Adams in 1989 4 and divides diffuse axonal injury (DAI) into three grades: grade I: involves grey-white matter interfaces. What Is a Diffuse Axonal Brain Injury? Diffuse axonal injury (DAI) is a frequent form of traumatic brain injury in which a clinical spectrum of in creasing injury severity is paralleled by progressively increasing amounts of axonal damage in the brain. 34 (5): 595-601. Adams JH, Doyle D, Ford I, et al. DAI usually causes coma and injury to many different parts of the brain. It is thought that diffuse axonal injury can occur in just about every level of severity, with concussion thought to be one of the milder forms. By visiting this site you agree to the foregoing terms and conditions. With DAI, the damage to the brain occurs over a large area, and is one of the major causes of unconsciousness and long-term coma after traumatic brain injury. There is a predictive correlation between the extent of brainstem DAI and likelihood of persistent vegetative state. (1994) Radiology. Other differential diagnoses, from imaging, include diffuse vascular injury, amyloid angiopathy, and chronic hypertensive encephalopathy. It is unclear whether the variable sensitivity of different MRI techniques to detect diffuse axonal injury affects the predictive validity of anatomic grading (eg, SWI rather than T2* GRE, 3T rather than 1.5T) 5. In 24 of these cases the diagnosis could not have been made without microscopical examination, while in a further 31 microscopical examination was … Lt Col Reynolds One of the most common and severe types of brain injury is known as diffuse axonal injury, or DAI. Diffuse axonal injury after traumatic brain injury is a prognostic factor for functional outcome: a systematic review and meta-analysis Marleen Maria van Eijck Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands; Trauma TopCare, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands Correspondence m.vaneijck@etz.nl Focal lesions include infarct and hemorrhage. Prognosis of Diffuse Axonal Injury. Patients will warrant close monitoring, including intracranial pressure monitoring, however the role of surgical intervention is also variable. {"url":"/signup-modal-props.json?lang=us\u0026email="}, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":10020,"mcqUrl":"https://radiopaedia.org/articles/diffuse-axonal-injury-grading-1/questions/1524?lang=us"}. Revisions: 6. Diffuse axonal injury in head injury: definition, diagnosis and grading. Small petechial hemorrhages, which appear hypointense on T2*-weighted images, are characteristic but represent a minority of true diffuse axonal injury lesions 2. The Diffuse Axonal Injury is a severe form of brain injury and is usually diagnosed after a traumatic brain injury with Glasgow Coma Scale (GCS) < 8 for more than six consecutive hours. 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