(1989) Histopathology. 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. 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. 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. Non-contrast CT of the brain is routine in patients presenting with head injuries. Even severe cases of DAI can have relatively normal CT imaging. 4, 5 Up to 75% of the patients with moderate to severe head injury who survive the acute phase are diagnosed with DAI. Some point out that the Adams classification was inappropriately ported to MRI without robust study of its ability to predict outcome 3. Figure 2 – MRI imaging demonstrating diffuse axonal injury following motorcycle accident (day 3). With grade 2, there is also at least one focal lesion in the corpus callosum. Treatment options are all aimed to preventing secondary effects such as cerebral oedema or haemorrhage, however guidelines in treatment for DAI are variable. Carla and Gino were huge racing fans and saw the accident on TV. 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. Diffuse axonal injury affects nerve fibers, which can lead to a disruption in nerve communication — affecting a person's physical and cognitive abilities. Destroyed axon microtubules will align incorrectly, with Tau and amyloid precursor protein (APP) are aberrantly deposited. Last updated: January 14, 2020 With grade 1 injuries, there is histological evidence of axonal lesions in the white matter of the cerebral hemispheres. acute haemarrohage or cerebral contusions). Revisions: 6. 34 (2): 341-352. 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. Axonal disconnection and mechanical disruption to axonal cytoskeletal structure results in immediate severe brain injury. Increasing experience with fatal non-missile head injury in man has allowed the identification of three grades of diffuse axonal injury. There is a predictive correlation between the extent of brainstem DAI and likelihood of persistent vegetative state. accident, fall, assault), the rapid acceleration or deceleration of the head results in traumatic shearing forces. 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. Two drivers, Luis and James, were jockeying for position when something went terribly wrong. Lt Col Reynolds One of the most common and severe types of brain injury is known as diffuse axonal injury, or DAI. DAI usually causes coma and injury to many different parts of the brain. Grade-II Diffuse Axonal Injury: Along with widespread axonal damage, focal abnormalities are also present, particularly in the corpus callosum. 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. It is the cause of death in most cases where the patient never makes it to the hospital. (2020) Acta neurochirurgica. It happened in an instant, during a hotly contested international auto race. (2020) Brain injury. 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 … 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. 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. 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. Check for errors and try again. 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. 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. 4. van Eijck MM, Schoonman GG, van der Naalt J, et al. 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 … It is thought to be a milder type of diffuse axonal injury, because axons may be injured to a minor extent due to stretching. 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. Grading of diffuse axonal injury has been described histologically according to the anatomic distribution of injury, which correlated with outcome 1-3. 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. Severe Diffuse Axonal Injury is one of the most dangerous pathological conditions that can occur. Make the changes yourself here! Prognosis of Diffuse Axonal Injury. Several parts of the brain are affected by this type. Past Studies. Extended Anatomical Grading in Diffuse Axonal Injury Using MRI: Hemorrhagic Lesions in the Substantia Nigra and Mesencephalic Tegmentum Indicate Poor Long-Term Outcome. 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. Gentry LR. A spectrum of clinical consequences may follow DAI, dependent on the severity of the pathology ranging from very minor to extensively diffuse damage. Radiologic recognition of this entity and understanding of its sequelae can be of utmost importance in the prediction of outcome and planning for rehabilitation. 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) Diagnosing Diffuse Axonal Injury. By visiting this site you agree to the foregoing terms and conditions. Diffuse axonal shear injury is a common traumatic brain injury, with significant neurologic and behavioral impact on patients. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 2017;34: 341 … Injury occurs because the unmoving brain lags behind the movement of the skull, causing nerve structures to tear. 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. A severe diffuse axonal injury with finding as Grade 2 and additional focal lesions in the brainstem. Following any trauma, patients should be appropriately resuscitated and stabilised, prior to transfer to a neuro-trauma centre. MRI is more useful than CT for detecting characteris… Artefact regions are seen at the junctions of the grey-white matter, such as in the corpus callosum or brainstem. 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 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. This retrospective single center cohort included adult trauma patients (age > 17 years) admitted from 2006 to 2012 with TBI. Grading of diffuse axonal injury due to trauma is described according to the anatomic distribution of injury. Past Studies show that 40% to 50% of traumatic brain injuries requiring hospital admission are diffuse axonal injury (DAI). 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. (2018) Brain injury. 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 (DAI) is a form of traumatic brain injury. 3. (1994) Radiology. Other symptoms may occur even in mild cases, depending upon the area of the brain where the damage occurred. Road traffic accidents (RTAs) are the most frequent cause of DAI, with assault or falls also common aetiologies. Figure 1 – The three parts of the brainstem. 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. Figure 13a. 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 prognostic validity of the MRI-based anatomic grading of diffuse axonal injury is controversial. 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