Pathology-Based Diagnoses. Unable to process the form. Diffuse Axonal Injury features in Computed Tomography (CT) and present as small punctate haemorrhages to white matter. To patients climbing the uphill battle of DAI treatment, we wish you the best of luck and a speedy recovery. As the junction point of white-gray brain matter is most susceptible to lesions, the use of MRI, specifically GRE and SWI, is crucial in obtaining a diagnosis and severity of DAI [48]. Macroscopic findings include deep contusions and multiple petechial hemorrhages primarily involving cerebral white matter, basal ganglia and upper brainstem. As we have discussed previously, diffuse axonal injury (DAI) is characterized through lesions within the white matter of one’s brain; severe case lesions are present within the corpus callosum and brainstem. Conventional neuroradiological tools, such as CT and MRI, are insensitive to diffuse axonal injury (DAI) caused by trauma. These scores can be the summation of the visual, motor, and verbal scores. 32 (4): 395-402. Gaining a sense of balance while sitting and standing is also a secondary goal of therapists, allowing the patient to reestablish the necessary muscle memory and neuronal demands balance has on a human body. SWI is an MRI sequence, which is particularly sensitive to substances which disturb the magnetic field; this method of MRI is extremely useful in detecting blood [45–47]. 4. van Eijck MM, Schoonman GG, van der Naalt J, et al. Gentry LR. Trauma to any region of the head should prompt immediate concern and medical attention. Additionally, interleukin-6 (IL-6) family has also been shown to increase in expression 1–6 hours after the traumatic brain injury. It was in the early 1980s where the official term, DAI, was introduced and accepted worldwide as a pathology which played a key integral role in the posttraumatic development of the patient [87]. Help us write another book on this subject and reach those readers. (A) Arrows pointing to high-signal foci within the corpus callosum, a structure responsible for cerebral cortex communication between paralleled structures on the two hemispheres. As we mentioned above, a significant amount of damage results after the initial traumatic impact; Figure 4 illustrates the CT scan of a patient’s head for whom was diagnosed with DAI. To better understand the mechanical environment associated with closed head injury in the pediatric population, animal models that … In this chapter, we will discuss in depth the pathology of diffuse axonal injury (DAI) touching upon clinical presentation/keynote characteristics, medical diagnosis, radiological imaging, treatment, prognosis, historical outcomes, and quality of life aftercare [1]. 1995. While it was once assumed that sheer force is the responsible factor for the disconnection of axons, it is indeed false to assume that. *Address all correspondence to: paulkaloostian@hotmail.com, Traumatic Brain Injury - Pathobiology, Advanced Diagnostics and Acute Management, Edited by Nikolai V. Gorbunov and Joseph B. However, impact does in fact cause some lesions but not comparable to the damage done by biochemical cascades which follow the impact [12, 13]. While alertness and responsiveness may develop slowly over a longer course of time with intensive rehabilitation, the rate of mortality with patients presenting with DAI is extremely high, as high as 50% in severe cases. Biomechanical analysis of experimental diffuse axonal injury… Concussion can result axonal injury. White matter is composed of several bundles of myelinated axons which connects gray matter together. Image captured using the FLAIR methodology also discussed above. Assistive technology: Intelligent power wheelchair prototype for clinical applications. It is the biochemical response to the impact stimuli which causes that largest impact on axons. Although this pathology represents a mild to severe disease which complicates or often deprives patients from a normal life, implementation of effective therapy and rehabilitation treatment, along with the adaptation of novel therapy methodologies, patient course and prognosis may be substantially improved, mitigating traumatic sequelae and long-term posttraumatic outcomes. For many patients that have suffered from a severe form of DAI, adaptive assistive technologies will be essential to restoring the quality of life back for the patient. An oral examination is also conducted to ensure the strength and coordination of the muscles involved in producing speech. Many posttraumatic DAI patients buffer from immobility and are confined to the limits of a wheelchair; with technological advances such as these, we expect to see a tremendous gain in patient’s quality of life [76]. Contrary to the implication of the word "diffuse," diffuse axonal injury has a topological predilection for focal involvement of certain sites in the brain. Biochemical pathways within our bodies are greatly responsible for the axonal disconnect which occurs secondary to the traumatic impact. Axons in the white matter appear to be especially vulnerable to injury due to the mechanical loading of the brain during TBI. Same patient as above (21-year-old bicycle accident patient) presenting with traumatic brain injury and nonhemorrhagic lesions of the splenium of the corpus callosum. At the site of axon disconnect, transport products and cell debris begin to build up, causing local swelling and severe compression [15–17]. Occupational therapy is not as structured as speech or physical therapy; this form of therapy truly evaluates a patient’s quality of life and psychological state prior to beginning any form of therapy which involves movement. To date our community has made over 100 million downloads. Blooming may be seen when certain elements/compounds are present during imaging such as hemosiderin or metals (calcium). Additionally, patients who are said to be in “minimally conscious state” show beginning signs of inconsistent awareness; however, they require assistance with almost all physical movement. These forms of medical devices are crucial for the treatment of DAI in that they provide patients who otherwise would be confined to a bed the ability to be mobile again. Long, IntechOpen, DOI: 10.5772/intechopen.72828. It occurs in about half of all cases of severe head traumaand may be the primary damage tha… Secondary goals are to build cognitive skills such as attention and reduce any confusion a patient may have. 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. Primary Effects of CNS Trauma. Magnetic resonance imaging (MRI) of a 30-year-old patient which presented to medical professionals in an unconscious state of mind with a severe brain injury. Focal lesions may sometimes be only identified microscopically. Auditory stimuli must vary in frequency and tone to establish a complete understanding of the patient’s responses [29]. Additionally, patient questionnaires are utilized to gain a psychological baseline as the school of thought behind occupational therapy strongly believes in the patient’s psychological motivation. result of traumatic acceleration/deceleration or rotational injuries and a frequent cause of persistent vegetative state Trauma. Speech therapy, conducted by a licensed speech and language therapist, first completes a formal evaluation of patients cognitive and communication skills as well as their swallowing skills. In our efforts to restore quality of life back to the patient’s life, we will discuss the several modalities of therapy and their application to patients recovering from DAI. These sites, in turn, vary in functional importance. Contrary to the implication of the word "diffuse," diffuse axonal injury has a topological predilection for focal involvement of certain sites in the brain. Small petechial hemorrhages, which appear hypointense on T2*-weighted images, are characteristic but represent a minority of true diffuse axonal injury lesions 2. The susceptibility of axons to mechanical injury appears to be due to both their viscoelastic properties and their high organization in white matter tracts. This image is shown under high signal intensity at T2W1 indicating lesions within the corpus callosum of a 21-year-old patient following a traumatic brain injury resultant of a bicycle injury. In cases where MRI may demonstrate a negative result to DAI, DTI has been able to show a degree of injury to the white matter fiber tract [26]. The diagnosis of DAI is life-changing at best and is often the result of severe brain trauma. Diffuse axonal injuries are characteristic of head acceleration occurring gradually over a lengthy time period.19 Furthermore head motion in the coronal plane was found to be more damaging leading to severe axonal damage rather than the sagittal motion that produced mild or at most … Diagnosis. Oehmichen et al. Original publication within their respected journals is also cited. Brief introduction to this section that descibes Open Access especially from an IntechOpen perspective, Want to get in touch? ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 2. Previous studies … Axons in the white matter appear to be especially vulnerable to injury due to the mechanical loading of the brain during TBI. Pathology-Based Diagnoses. 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 … Neuropathological characterization of behind-helmet blunt TBI in pigs, with emphasis on meningeal and parenchymal macro- and micro-hemorrhages and diffuse axonal injury; correlations among impact severity, meningeal and parenchymal pathology and clinical outcomes While diffuse axonal injury is included within the broader category of intracranial injury, it is essential to note the physiological severity … In addition to speech therapy, patients also go through extensive physical therapy to restore the patient’s life as close to their pre-trauma life as possible. Despite the mobility, these devices can also assist with sensory such as hearing and touch, as well as safety with devices that alert the patient when an alarm may sound or a door bell may ring. Grading of diffuse axonal injury due to trauma is described according to the anatomic distribution of injury. By making research easy to access, and puts the academic needs of the researchers before the business interests of publishers. In this chapter, we will discuss in depth the pathology of diffuse axonal injury (DAI) touching upon clinical presentation/keynote characteristics, medical diagnosis, radiological imaging, treatment, prognosis, historical outcomes, and quality of life aftercare . If a CT scan shows a normal pathology, an MRI will be performed to validate those results. Primary goals are to get the patients general responses to sensory stimuli to appropriate levels, followed by education of the patient’s family and friends on proper interactions with a person going through speech therapy. Closed head injury is the leading cause of morbidity and mortality in infants and children, and results in pathologies such as diffuse axonal injury (DAI) and subarachnoid hematoma (SAH). Login to your personal dashboard for more detailed statistics on your publications. By Nino Muradashvili, Suresh C. Tyagi and David Lominadze, By Nikolai V. Gorbunov and E. Marion Schneider. Often, the Canadian Occupational Performance Measure (COPM) is used to assess the patient’s performance and life satisfaction [66]. Diffuse axonal pathology detected with magnetization transfer imaging following brain trauma in the pig. While in 1956, the human brain was not entirely understood as well as technology was not at the level it is today to have been able to radiographically or investigatingly screen for the presence of head trauma, thus the rate of mortality was strikingly high. Focal injuries are commonly associated with an injury … Within a rat model, traumatic brain injury is correlated with a rapid increase in cortical IL-1 alpha and beta sub-factors of the IL-1 family. Upon discharge from trauma and emergency centers, patients enter a long and intensive program for multiple forms of therapeutic care consisting of the following modalities: speech therapy, physical therapy, occupational therapy, recreational therapy, adaptive equipment training, and counseling [56]. Our readership spans scientists, professors, researchers, librarians, and students, as well as business professionals. A case study of five patients set the landmark for pathological investigations into brain damage and traumatic head injuries, specifically diffuse axonal injury [84]. 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 this image, the FLAIR imaging also confirms the initial diagnosis [53]. Although little is known about the pathophysiological aspects of mTBI, there is growing opinion that diffuse axonal injury (DAI) may play a key role. In the event that a patient presents difficulty utilizing muscles involved in speech or forming speech in itself, therapists will then evaluate the patient’s ability to swallow or gag in the presence of a gag stimulus. Due to the fact that there are no distinctive clinical symptoms that patients present with that allow medical professionals to immediately diagnose DAI, physicians must rely on neurological examinations and radiographic imaging to diagnose patients and predict their prognosis. Engineers today are working on the development of novel assistive technologies, such as the intelligent power wheelchair seen in Figure 10, which will allow many DAI patients who may never have the ability to walk again to be able to venture the world and be more independent. However, emerging evidence suggests that this injury is by no means mild, considering it induces persisting neurocognitive dysfunction in many individuals. The highest levels of IL-6 mRNA transcription and IL-6 cytokine expression occurred in regions where diffuse axonal damage was the greatest [93]. link. Publishing on IntechOpen allows authors to earn citations and find new collaborators, meaning more people see your work not only from your own field of study, but from other related fields too. This form of imaging is useful in suppressing the cerebrospinal fluid (CSF) effects on radiological imaging allowing the higher-intensity appearance of lesions. Newer radiographic studies such as diffusion tensor imaging (DTI) is an MRI technique, which enables radiologists to measure the diffusion of water in the tissue to then create neural tract images. The activities conducted within physical therapy sessions include a tremendous amount of both mental and physical learning, balance and coordination, as well as strength and energy [63–65]. Deficits resulting from TBI include impairments in movement, balance, and coordination, accompanied by sensory deficits, behavioral changes, cognitive defects, and communicative defects. In this section, we will discuss two forms of MRI. These therapists aim to design social outings for the patient and their friends/families to allow the patient to not only feel loved and supported but to also reintroduce key life skills such as team building and social interaction. Grading of diffuse axonal injury due to trauma is described according to the anatomic distribution of injury. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Lesions of white matter can vary in size greatly, as they typically present as 1–18 mm wide in trauma and affect the frontal and temporal lobes mostly. See the previous page. Essentially, the severity of the traumatic impact on the brain may alter or completely change the prognosis and outcome of rehabilitation efforts [34]. (A) MRI-GRE image of a 30-year-old male patient presenting with head trauma. Over the past 70 years, diffuse axonal injury (DAI) has emerged as one of the most common and important pathological features of traumatic brain injury (TBI). Factors involved in occupation therapy [69]. Check for errors and try again. The process of relearning task one learned earlier in life, involves the reconstruction of neuronal networks, is an example of the many neuronal networks and pathways within a human mind [61]. The first form is gradient-recalled echo (GRE) sequence imaging, and the second is susceptibility-weighted imaging (SWI) [44]. To try to stay consistent with the way the term is used, we will refer to it by its common name, Diffuse Axonal Injury, or DAI. Our team is growing all the time, so we’re always on the lookout for smart people who want to help us reshape the world of scientific publishing. Often hard to accomplish even for the first time, therapists work on these skills as well as social skills for life outside of the medical center. Licensee IntechOpen. With these metrics, occupational therapists are able to design personal goals for the patient to first improve self-awareness, then improve physical activity which related to daily life, and lastly to restore as much as memory recall as possible [67, 68]. Penetrating forms of TBI’s such as trauma to the head via a foreign object do also contribute to the many millions of TBI cases per year, but we will not discuss these traumatic injuries as in depth within this chapter. Developed by renowned radiologists in each specialty, STATdx provides comprehensive decision support you can rely on - Diffuse Axonal Injury. Diagnosis. The image above is an axial gradient-recalled echo (GRE) image, which indicates and draws focus to the right temporal lobe which, indicated by the white arrows, shows the resulting injury of a hemorrhagic diffuse axonal injury. Sensory-evoked potential examination studies the electrical activity within the brain and its responsiveness to stimulations such as light, sound, and touch. These sites, in turn, vary in functional importance. Mild electrical stimuli will be presented to the patients scalp via electrodes; nerves will then transfer the electrical signal to the brain through which reading can be visualized on a medical recorder device. Blooming is an artifact of radiological images which exaggerates the presence of lesions which is extremely useful in the detection of small lesions. The American Journal of Forensic Medicine and Pathology: June 1995 - p 107-114. While patients receive a tremendous amount of in-hospital care, they also receive a unique and more social form of treatment called recreational therapy. 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. Glasgow coma scale score of 6 (seeFigures 2–3). Counseling sets out to answer a series of questions regarding the patient’s life; these questions tend to deal with first, identifying the problem and then understanding the severity of the problem. The bodily response places the brain under the extreme amount of pressure and is often exposed to irreversible damage [10, 11]. (2020) Brain injury. 191 (1): 1-17. In the course of such injuries, the cerebrum goes into a back and forth gliding motion, pivoting around the upper brainstem. Through the many different modalities of therapy, the treatment for DAI is one that can span over the year with no real guarantee that progress will be made.
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