Diffuse axonal injury outcome [Neurosurgery Wiki]

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====== Diffuse axonal injury outcome ======

[[Diffuse axonal injury]], and more generally [[traumatic brain injury]], often results in physical, cognitive, and behavioral impairments that can be temporary or permanent
((Gennarelli TA. Cerebral concussion and diffuse brain injuries. 2nd ed In: Cooper PR, editor. , editor. Head Injury. Baltimore: Williams & Wilkins; (1987). p. 108–24.))
((Gennarelli TA. Cerebral concussion and diffuse brain injuries. 3rd ed In: Cooper PR, editor. , editor. Head Injury. Baltimore: Williams & Wilkins; (1993). p. 137–58.))
((Lagares A, Ramos A, Alday R, Ballenilla F, Pérez-Nuñez A, Arrese I, et al. Magnetic resonance in moderate and severe head injury: comparative study of CT and MR findings. Characteristics related to the presence and location of diffuse axonal injury in MR. Neurocirugia (Astur) (2006) 17(2):105–18.10.1016/S1130-1473(06)70351-7))
((Esbjörnsson E, Skoglund T, Sunnerhagen KS. Fatigue, psychosocial adaptation and quality of life one year after traumatic brain injury and suspected traumatic axonal injury; evaluations of patients and relatives: a pilot study. J Rehabil Med (2013) 45:771–7.10.2340/16501977-1170))
((Chelly H, Chaari A, Daoud E, Dammak H, Medhioub F, Mnif J, et al. Diffuse axonal injury in patients with head injuries: an epidemiologic and prognosis study of 124 cases. J Trauma (2011) 71(4):838–46.10.1097/TA.0b013e3182127baa))
((Jeong JH, Kim YZ, Cho YW, Kim JS. Negative effect of hypopituitarism following brain trauma in patients with diffuse axonal injury. J Neurosurg (2010) 113(3):532–8.10.3171/2009.10.JNS091152))
((Ham TE, Sharp DJ. How can investigation of network function inform rehabilitation after traumatic brain injury? Curr Opin Neurol (2012) 25(6):662–9.10.1097/WCO.0b013e328359488f))
((Sousa RMC. Comparisons among measurement tools in traumatic brain injury outcomes. Rev Esc Enferm USP (2006) 40(2):203–13.10.1590/S0080-62342006000200008))
((Scholten AC, Haagsma JA, Andriessen TM, Vos PE, Steyerberg EW, van Beeck EF, et al. Health-related quality of life after mild, moderate and severe traumatic brain injury: patterns and predictors of suboptimal functioning during the first year after injury. Injury (2015) 46(4):616–24.10.1016/j.injury.2014.10.064))
((Liew BS, Johari SA, Nasser AW, Abdullah J. Severe traumatic brain injury: outcome in patients with diffuse axonal injury managed conservatively in hospital Sultanah Aminah, Johor Bahru – an observational study. Med J Malaysia (2009) 64(4):280–8.)).
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Cicuendez et al. attempted to determine whether any [[Magnetic resonance imaging]] findings of [[traumatic axonal injury]] (TAI) could be related to [[prognosis]] in 264 [[patient]]s with [[severe traumatic brain injury]]. They performed an [[ordinal logistic regression]], adjusted for the prognostic factors according to the [[International Mission for Prognosis and Analysis of Clinical Trial in TBI]] studies, adding each MR feature related to prognosis one at a time. A new prognostic model was described by adding these MR features to the classic prognostic factors. The model was externally validated in a prospective series. Harrel's c-statistic and ordinal c-index (ORC) was calculated to measure its predictive accuracy.

They found 178 patients with TAI lesions. Lesions in the [[basal ganglia]]/[[thalamus]], [[corpus callosum]] (CC) and [[brain stem]] were associated with poor outcome (P < 0.01). The highest OR was for TAI lesions in the [[splenium]] (OR: 2.6) and brain stem dorsal lesions (OR: 3.1). They only found significant differences in outcome between hemorrhagic and non-hemorrhagic TAI lesions in the subgroup of patients with white matter and basal ganglia/thalamus lesions (P = 0.01). They obtained a superior discriminatory capacity by adding these MR findings to the previous prognostic model (Harrel's c-statistic 0.72 and ORC 0.7) in a prospective series of 93 patients.

The prognostic model including MR findings maintained a superior discriminatory capacity than that obtained for the model with the classic prognostic factors alone
((Cicuendez M, Castaño-León A, Ramos A, Hilario A, Gómez PA, Lagares A. The
added prognostic value of magnetic resonance imaging in traumatic brain injury:
The importance of traumatic axonal injury when performing ordinal logistic
regression. J Neuroradiol. 2019 Sep;46(5):299-306. doi:
10.1016/j.neurad.2018.08.001. Epub 2018 Sep 1. PubMed PMID: 30179689.
)).
----

The [[outcome]] of patients after DAI has been linked to the number of lesions identified through imaging. A longitudinal study that analyzed the evolution of traumatic axonal injury using magnetic resonance imaging (MRI) of 58 patients with moderate or severe TBI showed that the greater the number of lesions observed early after trauma, the greater the impairment of functionality after 12 months
((Moen KG, Skandsen T, Folvik M, Brezova V, Kvistad KA, Rydland J, et al. A longitudinal MRI study of traumatic axonal injury in patients with moderate and severe traumatic brain injury. J Neurol Neurosurg Psychiatry (2012) 83(12):1193–200.10.1136/jnnp-2012-302644)).

A study of 26 DAI patients indicated that the volume and number of lesions identified by MRI performed within 48 h of hospital admission strongly correlated with the level of disability observed at the time of hospital discharge
((Schaefer PW, Huisman TA, Sorensen AG, Gonzalez RG, Schwamm LH. Diffusion-weighted MR imaging in closed head injury: high correlation with initial Glasgow Coma Scale score and score on modified Rankin scale at discharge. Radiology (2004) 233(1):58–66.10.1148/radiol.2323031173)).
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DAI with hypoxia, as measured by peripheral oxygen saturation, and hypotension with New [[Injury Severity Score]] (NISS)  value - had a statistically significant association with patient [[mortality]]; on the other hand, severity of DAI and length of hospital stay were the only significant predictors for dependence. Therefore, severity of DAI emerged as a risk factor for both mortality and dependence
((Vieira RC, Paiva WS, de Oliveira DV, Teixeira MJ, de Andrade AF, de Sousa RM. 
Diffuse Axonal Injury: Epidemiology, Outcome and Associated Risk Factors. Front
Neurol. 2016 Oct 20;7:178. eCollection 2016. PubMed PMID: 27812349; PubMed
Central PMCID: PMC5071911.
)).
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Clinical evidence of DAI on MRI may only be useful for predicting short-term in-hospital functional outcome. Given no association of DAI and long-term TBI outcomes, providers should be cautious in attributing DAI to future neurologic function, quality of life, and/or survival
((Humble SS, Wilson LD, Wang L, Long DA, Smith MA, Siktberg JC, Mirhoseini MF,
Bhatia A, Pruthi S, Day MA, Muehlschlegel S, Patel MB. Prognosis of diffuse
axonal injury with traumatic brain injury. J Trauma Acute Care Surg. 2018
Jul;85(1):155-159. doi: 10.1097/TA.0000000000001852. PubMed PMID: 29462087;
PubMed Central PMCID: PMC6026031.
)).
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[[Brain atrophy]] progresses over time, but patients showed better [[executive function]] (EF) and verbal [[episodic memory]] (EVM) in some of the tests, which could be due to [[neuroplasticity]]
((Stewan Feltrin F, Zaninotto AL, Guirado VMP, Macruz F, Sakuno D, Dalaqua M,
Magalhães LGA, Paiva WS, Andrade AF, Otaduy MCG, Leite CC. Longitudinal changes
in brain volumetry and cognitive functions after moderate and severe diffuse
axonal injury. Brain Inj. 2018 Jul 19:1-10. doi: 10.1080/02699052.2018.1494852.
[Epub ahead of print] PubMed PMID: 30024781.
)).

===== References =====