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Updated: Dec 18 2019

Diffuse Axonal Injury

  • Snapshot
    • A 35-year-old man is brought the emergency department following a motor vehicle accident in which his car struck a tree at high speeds. His airway, breathing, and circulation is intact and a noncontrast CT scan of the head is unremarkable. He is unconconscious but hemodynamically stabe. An MRI brain demonstrates multifocal T2-hyperintensities in the splenium of the corpus callosum.
  • Introduction
    • Definition
      • a type of traumatic brain injury (TBI) secondary to blunt injury to the brain
        • it is generally found in severe TBI, and is thus considered in patients with a Glasgow coma score < 8
  • Epidemiology
    • incidence
      • TBI is a leading cause of death and disability in children and young adults
  • Etiology
    • high-speed motor vehicle accidents (most common)
  • Pathogenesis
    • accelerating and decelerating motions that result in shearing forces to the white matter of axons, impairing neuron interconnection
      • microscopic damage to the axons at the junction of the grey and white matter
      • most commonly affected sites are the corpus callosum and the brainstem
  • Presentation
    • Symptoms
      • headache
      • dizziness
      • nausea and vomiting
      • fatigue
      • loss of concousness and coma (in severe cases)
    • Physical exam
      • dysautonomia (e.g., tachycardia, tachypnea, hyperthermia, posturing, and vasoplegia)
  • Imaging
    • Noncontrast head CT
      • indication
        • initial head imaging study in patients with head injury
      • findings
        • small punctate hemorrhages in white matter tracts
          • note that head CT is low yield in detecting diffuse axonal injury
    • MRI brain
      • indication
        • imaging modality of choice in diagnosing diffuse axonal injury
  • Studies
    • Making the diagnosis
      • this is a clinical diagnosis supported by radiographic findings
        • suspect in a patient with rotational or acceleration-deceleration closed head injury
  • Differential
    • Subdural hematoma
      • differentiating factors
        • crescent-shaped hemorrhage seen on CT head without contrast
    • Subarachnoid hemorrhage
      • differentiating factors
        • thunderclap headache
        • hyperdensity in the subarachnoid space on CT head without contrast
    • Epidural hematoma
      • differentiating factors
        • lens-shaped and biconvex hyperdensity that does not cross the suture lines
  • Treatment
    • Management is geared towards preventing secondary injuries and facilitating rehab
      • e.g., preventing hypotension, cerebral edema, hypoxia, and increased intracranial pressure
  • Complications
    • Dysautonomia
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