Diffuse axonal injury: a study of patients in neurological

intensive care unit, with emphasis on follow up and value of

diffusion weighted imaging.

Poster No.: C-1692

Congress: ECR 2011
Type: Scientific Exhibit
Authors: 1 2 3
L. Amaral , A. A. S. M. Santos , V. E. C. Oliveira , C. A. P.
2 2 4 2
Fontes , T. C. R. S. SANTOS , M. H. Santos , M. L. O. Santos ;
1 2
Vila Velha - Espirito Santo, E.S./BR, Niteri - Rio de Janeiro, RJ/
3 4
BR, Niteroi-Rio de Janeiro, RJ/BR, Niteri-Rio de Janeiro, RJ/BR
Keywords: Observer performance, MR-Diffusion/Perfusion, MR, CT, Trauma,
Neuroradiology brain, Outcomes analysis
DOI: 10.1594/ecr2011/C-1692

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www.myESR.org

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Purpose

Description of characteristics of lesions in CT and MRI of patients after

traumatic brain injury with Diffuse Axonal Injury (DAI) clinically proven and
admitted to the Intensive Care Unit neurological.
To detect diffuse axonal injury (DAI) lesions by diffusion-weighted imaging
(DWI), as compared with fluid-attenuated inversion recovery (FLAIR)
imaging and to evaluate hemorrhagic DAI lesions with gradient-echo (GRE)
imaging.
Review the sensitivity and specificity of the sequences of Diffusion and
T2*GRE/SWI in Diffuse Axonal Injury, when compared to other sequences
of MRI.

Methods and Materials

Cross-sectional study, observational and retrospective, on Diffuse Axonal

Injury, in Hospital de Clinicas de Niteri (HCN), State of Rio de Janeiro,
Brazil,from January 2007 to June 2010.
CT scans were performed on Spiral CT and Multidetector CT with 64
channels and MRI at 1.5 T scanner, with specific protocols of the service
without intravenous contrast.
We initially used sequences in DWI, axial FLAIR, axial GRE T2, assessment
of urgency, and later added T1 sagital and T2 coronal sequences.
There was no standardization of time between the initial request of
computed tomography and magnetic resonance imaging, with a variance of
5 hours to 30 days between these examinations. This temporal difference
depended on the patient's clinical condition and request for further
examination by a neurologist of the Neurological Intensive Care Unit.
We reviewed MR images of 18 patients with a diagnosis of DAI. MR imaging
was performed 5 h to 30 days, after traumatic brain injury. We evaluated:
lesions on DWI and FLAIR and GRE imaging.
We also made a comparative analysis of the quality of images in different
sequences, correlating with the literature data.
All examinations were evaluated by two radiologists and discordant results
were resolved by consensus and was made follow up of patients who were
hospitalized and underwent CT/ MRI control.

Results

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 We selected 18 patients with clinical and radiological diagnosis of Diffuse
Axonal Injury (DAI) and were followed in the Neuro-intensive care unit of
Hospital de Clinicas de Niteri, state of Rio de Janeiro, Brazil.
There was male predominance (16 men and 2 women).
All patients suffered an automobile accident and were treated in the
emergency department and subsequently admitted to the Neurological
Intensive Care Unit of our hospital.
The CT scan was performed as initial examination in all 18 patients.
Only 11 of 18 CT scans were suggestive of diffuse axonal injury. Of the 7
CT scans as normal on admission of patients in all were identified signs
suggestive of DAI on MRI performed later. The findings in CT scans were
diffuse cerebral edema with only 38% patients with petechial hemorrhagic
foci (FIG 1).
In relation to topography, a predominance of lesions suggestive of LAD
on CT without contrast (in descending order) were: fronto-parietal lobe>
temporal lobe> occipital lobe> corona radiata> basal ganglia and midbrain
In all exams with DAI on CT and MRI, 18% occurred in the frontal lobe,
parietal Lobe in 14% and 14% in the corpus callosum, 10% in temporal
lobe> radiated crown 7%> 5% Lobo Occipital / 5% cingulate / midbrain 5%>
22% others (FIG 2).
The right and left hemispheres were affected with the same frequency
without predominance.
Regarding the topography of the lesions were seen in our MRI studies, a
total of 109 lesions. There was a clear predominance in the corticomedullary
junction and only 5% in upper brainstem (FIG 3).
In all cases MRI showed hemorrhagic foci well demonstrated in the GRE-
T2*/ SWI and hyperintense foci of restricted diffusion, especially in gray/
white matter junction (FIG. 4).
At the Gray/white matter junction, more lesions were found in the GRE
sequence (FIG. 5-7).
In six patients, lesions were observed in the corpus callosum, which were
well demonstrated in the diffusion and FLAIR sequences (FIG.8,9).
The GRE showed no focal lesions identified in other MRI sequences (FIG.
10,11).
In the brainstem, the number of injuries was the same in FLAIR and GRE
sequences (FIG. 12,13).
Nine patients in the study had some type of intracranial bleeding
(hematomas, subarachnoid hemorrhage, acute subdural hematoma) or
extra-cranial (subgaleal hematoma).
Of these, 5 patients with LAD showed signs suggestive of acute subdural
hematoma (SAH) confirmed by CT and MRI.
There was only one case with lesions in the right thalamus (FIG. 14).
In many cases had multiple DAI lesions in multiple locations, exacerbating
the patient's neurological status (FIG 15).

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 Assessing the lesion conspicuity between DWI and FLAIR and comparing
our results with the referenced article, we had more lesions identified on
DWI at the Gray/white matter junction (FIG.16).
In the FLAIR sequence we had the highest percentage of injuries at the
Gray/white matter junction and lower in other locations, comparatively
(FIG.17).
The DWI sequence is very useful in the evaluation of DAI lesions, especially
in the acute phase, being better than FLAIR in many cases and can serve to
follow up the patient (FIG. 18). Should be assessed in conjunction with the
GRE, especially for patients in neurological intensive care units, whereas in
subacute and chronic stages the GRE sequence becomes more important
than others in the evaluation of DAI lesions.

Images for this section:

Fig. 1: CT scan showing foci of bleeding in the right frontal lobe, left parietal lobe, basal
ganglia and thalamus in the right hemisphere.

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Fig. 2: Graph 1: Prevalence of the main regions affected by Diffuse Axonal Injury in CT
and MRI.

Fig. 3: Table 1: Regarding the topography of the lesions were seen in our MRI studies, a
total of 109 lesions.We had a clear predominance of lesions in gray/white matter junction
(n=98)

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Fig. 4: Male 23 years old. Car accident with head trauma. Multiple diffuse small foci at
gray/white matter junction in GRE sequence

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Fig. 5: Graph 2: At the Gray/white matter junction, more lesions were found in the GRE
sequence

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Fig. 6: Same patient figure 4. FLAIR sequence showing multiple foci of hyperintensity.

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Fig. 7: Same patient in the previous figure. DWI showing small foci of restricted diffusion
(arrows.

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Fig. 8: Graph 3: DAI lesions in corpus callosum. The number of injuries was the same
in DWI and FLAIR

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Fig. 9: DAI Lesion in the corpus callosum: hypointense on sagittal T1, hyperintense on
FLAIR axial and coronal T2, with no signal on GRE and restricted diffusion on DWI.

Fig. 10: Same patient in figure 9: It was also observed foci of with no signal on GRE in
the frontal lobes and right parietal (arrows), all at gray/white matter junction, not shown
on DWI and FLAIR sequences.

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Page 13 of 23
Fig. 11: DAI lesions: small focus most clearly shown (or only shown) in the GRE
sequence than on FLAIR

Fig. 12: DAI lesions: brainstem

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Fig. 13: DAI lesion in the right cerebral peduncle, as evidenced in DWI and GRE
sequences. It was also observed left parietal subgaleal hematoma.

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Page 16 of 23
Fig. 14: Male 30 years old. Head injury by high-impact car accident. Comatose
patient.DAI lesion: in the right thalamus.

Fig. 15: Same patient in the previous figure, showing the thalamic lesion, lesion in the
splenium of the corpus callosum (DWI, FLAIR), and multiple foci DAI lesions in GRE
sequences at gray/white matter junction.

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Fig. 16: We had a higher percentage of DAI lesions in the gray/white matter junction
visualized in the DWI sequences.

Fig. 17: Graph comparing FLAIR sequences

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Fig. 18: DAI lesion in the splenium of the corpus callosum: best seen on DWI than on
FLAIR

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Conclusion

After a review of 18 proven cases of Diffuse Axonal Injury, we conclude that:

MRI is the best exam for the identification and follow-up of the DAI, with the
DWI the most sensitive and specific sequence in the acute phase.
DWI is as useful as FLAIR in detecting DAI lesions. GRE imaging is still the
superior tool for the evaluation of hemorrhagic DAI.
A limitation of our study was that DWI and FLAIR images were compared in
a small number of patients.
There was agreement to our findings with those described in the literature.

References

1. Adams JH, Graham DI, Gennarelli TA, et al. Diffuse axonal injury in non
missile head injury. J Neurol Neurosurg Psychiatry, 1991; 54: 481-3.
2. Pitella JEH, Gusmao SNS, et al. The conformation of the brain plays an
important rolein in the distribution of diffuse axonal injury in Fatal road traffic
accident. Arq Neuropsiquiatr 2004;62(2-B):406-413.
3. Pitella JEH, Gusmao SNS, et al. Acute subudral hematoma and diffuse
axonal injury in fatal road traffic accident victims. Arq Neuropsiquiatr
2003;61(3-B):746-750 .
4. Li XY, Feng DF, et al. Diffuse axonal injury: Novel insights into detection and
treatment. Journal of Clinical Neuroscience 16 (2009) 614-619.
5. Morais DF, Spotti AR, Tognola WA, et al. Clinical Applicatio of Magnetic
Resonance in Acute Traumatic Brain Injury. Arq Neuropsiquiatr
2008;66(1):53-58.
6. Ding K, Plata CM, Wang JY, et al. Cerebral Atrophy after Traumatic White
Matter Injury: Correlation with Acute Neuroimaging and Outcome. Journal of
Neurotrauma 25:1433-1440 (2008).
7. Gasparovic C, Yeo R, Mannell M, et al. Neurometabolite Concentrations
in Gray and White Matter in Mild Traumatic Brain Injury: An 1H-Magnetic
Resonance Spectroscopy Study . Journal of Neurotrauma 26:1635-1643
(2009).
8. Plata CM, Ardelean A, Koovakkattu D, et al. Magnetic Resonance Imaging
of Diffuse Axonal Injury: Quantitative Assessment of White Matter Lesion
Volume. Journal of Neurotrauma Volume 24, Number 4, 2007.
9. Yanagawa Y, Toshihisa S, Akira T, et al. Relationship Between Maximum
Intracranial Pressure and Traumatic Lesions Detected by T2*-Weighted
Imaging in Diffuse Axonal Injury. The Journal of Trauma, June 2007.

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 10. Park SJ; Hur JW; Kwon KY; et al. Time to recover consciousness in
patients with diffuse axonal injury : assessment with reference to magnetic
resonance grading. J Korean Neurosurg Soc;46(3):205-9, 2009.
11. Ueno H; Maruishi M; Miyatani M, et al. Brain activations in errorless and
errorful learning in patients with diffuse axonal injury: a functional MRI study.
Brain Inj;23(4):291-8, 2009.
12. Gasparovic C; Yeo R; Mannell M; et al. Neurometabolite concentrations
in gray and white matter in mild traumatic brain injury: an 1H-magnetic
resonance spectroscopy study. J Neurotrauma;26(10):1635-43, 2009 Oct.
13. Topal NB; Hakyemez B; Erdogan C, et al. MR imaging in the detection of
diffuse axonal injury with mild traumatic brain injury. Neurol Res;30(9):974-8,
2008 .
14. Wang JY; Bakhadirov K; Devous, et al. Diffusion tensor tractography of
traumatic diffuse axonal injury. Arch Neurol;65(5):619-26, 2008.
15. Morais DF; Spotti AR; Tognola WA, et al. Clinical application of magnetic
resonance in acute traumatic brain injury. Arq neuropsiquiatr;66(1):53-8,
2008.
16. Blitstein MK; Tung GA, et al. MRI of cerebral microhemorrhages. AJR
Am Roentgenol; 189(3): 720-5, 2007. 20) Marquez de la Plata C;
Ardelean A; Koovakkattu D, et al. Magnetic resonance imaging of diffuse
axonal injury: quantitative assessment of white matter lesion volume.
JNeurotrauma:;24(4):591-8, 2007.

Personal Information

Leonardo P. G. Amaral. MD.

Fellow in the Department of Neuroradiology, Hospital Roger Salengro University of Lille II

- France. Master of Radiology, Federal University of Rio de Janeiro. Radiology Specialist
in the Course of Specialization in Radiology Institute of Postgraduate Medical Carlos
Chagas (IPGMCC).

Email: leopgamaral@gmail.com

Alair Augusto Sarmet M. D dos Santos. MD, PhD.

Corresponding Author. Associate Professor, Department of Radiology and Head of the

Radiology and Diagnostic Imaging Service of University Hospital Antnio Pedro (HUAP) /
UFF (Federal Fluminense University) - Niteri, RJ, Brazil. Coordinator of Image Center-
HCN (Hospital Clinicas de Niteri) and Coordinator of the Specialization Course in

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Radiology Institute of Postgraduate Medical Carlos Chagas (IPGMCC).Rio de Janeiro,
Brazil.

Email: alairsarmet@globo.com

e-curriculum: http://lattes.cnpq.br/1215394507629695

Vinicius Eduardo Campos Oliveira.

Student of the Specialization Course in Radiology Institute of Postgraduate Medical

Carlos Chagas (IPGMCC). Rio de Janeiro. Brazil.

Email: viduardo@gmail.com

Cristina Asvolinsque Pantaleo Fontes. MD.

Assistent Professor. Departament of Radiology, and Diagnostic Imaging Service of

University Hospital Antnio Pedro (HUAP) /UFF (Federal Fluminense University) -
Niteri, RJ, Brazil.

Medical radiologist in Image Center-HCN (Hospital Clinicas de Niteri).

Email: cristinasvolinsque@gmail.com

Teresa Cristina de Castro R.S. dos Santos

Medical radiologist in Radiology Services: University Hospital Antnio Pedro/UFF

(Federal Fluminense University), Fernandes Figueiras Institute(FIOCRUZ) and HCN
(Niteroi Clinical Hospital). Student of Master of Medical Sciences UFF

teresasarmet@globo.com

Mrcia Heizer Santos

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Medical radiologist in Image Center-HCN (Hospital Clinicas de Niteri). Niteroi, RJ,Brazil.

Email: marciahsantos@bol.com.br

Maria Lucia Oliveira Santos. MD, PhD.

Associate Professor, Department of Radiology University Hospital Antnio Pedro

(HUAP) /UFF (Federal Fluminense University) - Niteri, RJ, Brazil.

Email: mlucia.santos@gmail.com

Study site

Hospital de Clnicas de Niteri, Institute of Postgraduate Medical Carlos Chagas

(IPGMCC) and Federal Fluminense University (UFF) - Niteri, Rio de Janeiro, Brazil.

Potential Conflict of Interest

No potential conflict of interest relevant.

Funding Sources

This study did not have funding source.

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