Hospital: Hospital universitario la Paz.
Ciudad:
Nº:
Aut@r o Autores: S. Ossaba Vélez, Y. Navarro Monforte, M. Nogueras Carrasco.,
Presentación:
A 19-year-old male enters with multiple injuries after a traffic accident (high-speed frontal collision on the highway). Neurological examination upon arrival: GCS 6 (O1 V1 M4). Miotic and normorreactive pupils. A cranial CT is performed where multiples microhemorrhages are observed in corticosubcortical union of both cerebral hemispheres, in the splenium of the corpus callosum, ganglia of the base and right dorsolateral region of the pons, compatible with diffuse axonal damage, grade III. A CT body was also performed where pulmonary contusions, hepatic laceration and right femoral fracture were observed.
Discusión:
Diffuse axonal injury (DAI) is a frequent result of traumatic acceleration/deceleration or rotational injuries and a frequent cause of persistent vegetative state in patients. From the clinical point of view, the DAI produces confusion, loss of consciousness or coma depending on the severity of the trauma. Post-traumatic coma may last a considerable time and is often attributed to coexistent more visible injury (e.g. cerebral contusions) 1. As such the diagnosis is often not suspected until later when patients fail to recover neurologically as expected. Radiographically, computed tomography (CT) is characterized by multiple focal lesions under 15mm. Hemorrhagic lesions will be hyperdense and non-hemorrhagic lesions are hypodense, with a characteristic distribution: typically located at the grey-white matter junction, in the corpus callosum and in more severe cases in the brainstem. Grade I: involves grey-white matter interfaces Grade II: involves corpus callosum in addition to grade I locations. Grade III: involves brainstem in addition to grade I and II locations. Less often the basal ganglia can be affected and thalamus. CT findings can be normal or subtle, since we usually only see hemorrhagic lesions. MRI has been shown to be superior to CT in the identification of DAI 2-3.
Conclusión:
Diffuse axonal injury (DAI) is a frequent result of traumatic acceleration/deceleration or rotational injuries and a frequent cause of persistent vegetative state in patients. From the clinical point of view, the DAI produces confusion, loss of consciousness or coma depending on the severity of the trauma. Post-traumatic coma may last a considerable time and is often attributed to coexistent more visible injury (e.g. cerebral contusions) 1. As such the diagnosis is often not suspected until later when patients fail to recover neurologically as expected. Radiographically, computed tomography (CT) is characterized by multiple focal lesions under 15mm. Hemorrhagic lesions will be hyperdense and non-hemorrhagic lesions are hypodense, with a characteristic distribution: typically located at the grey-white matter junction, in the corpus callosum and in more severe cases in the brainstem. Grade I: involves grey-white matter interfaces Grade II: involves corpus callosum in addition to grade I locations. Grade III: involves brainstem in addition to grade I and II locations. Less often the basal ganglia can be affected and thalamus. CT findings can be normal or subtle, since we usually only see hemorrhagic lesions. MRI has been shown to be superior to CT in the identification of DAI 2-3.
Bibliografía:
– Gentry LR, Godersky JC, Thompson B et-al. Prospective comparative study of intermediate-field MR and CT in the evaluation of closed head trauma. AJR Am J Roentgenol. 1988,150 (3): 673-82. – Davis PC. Head trauma. AJNR Am J Neuroradiol. 2007,28 (8): 1619