- Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan.
Farrukh Javeed, Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan.
DOI:10.25259/SNI_573_2020Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Farrukh Javeed, Lal Rehman, Ali Afzal, Asad Abbas. Outcome of diffuse axonal injury in moderate and severe traumatic brain injury. 03-Aug-2021;12:384
How to cite this URL: Farrukh Javeed, Lal Rehman, Ali Afzal, Asad Abbas. Outcome of diffuse axonal injury in moderate and severe traumatic brain injury. 03-Aug-2021;12:384. Available from: https://surgicalneurologyint.com/surgicalint-articles/11020/
Background: Diffuse axonal injury (DAI) is a common presentation in neurotrauma. Prognosis is variable but can be dependent on the initial presentation of the patient. In our study, we evaluated the outcome of diffuse axonal injury.
Methods: This study was conducted at a tertiary care center from September 2018 to December 2019 and included 133 adult patients with moderate or severe head injury (GCS ≤ 12) diagnosed to have the DAI on the basis of MRI. At 3 months, the result was assessed using the Extended Glasgow Outcome Scale (GOS-E).
Results: There were a total of 97 (72.9%) males and 36 (27.1%) females with an average age of 32.4 ± 10 years with a mean GCS of 9 at admission. The most common mode of head trauma was road traffic accidents (RTAs) in 51.9% of patients followed by fall from height in 27.1%. Most patients were admitted with moderate traumatic brain injury (64.7%) and suffered Grade I diffuse axonal injury (41.4%). The average hospital stay was 9 days but majority of patients stayed in hospital for ≤ 11 days. At 3 months, mortality rate was 25.6% and satisfactory outcome observed in 48.1% of patients. The highest mortality was observed in the Grade III DAI.
Conclusion: We conclude that the severity of the traumatic head injury and the grade of the DAI impact the outcome. Survivors require long-term hospitalization and rehabilitation to improve their chances of recovery.
Keywords: Diffuse axonal injury, Glasgow outcome scale extended, Magnetic resonance imaging, Traumatic brain injury
Diffuse axonal damage (DAI) is one of the most prevalent complications of traumatic brain injury (TBI), which occurs in 40–50% of all TBI patients and a major cause of these patients going into a coma.[
In DAI, computed tomography (CT) scan characteristics are typically limited to white matter microhemorrhages and traumatic brain edema.[
Thus, DAI causes significant changes in cognition and physical and social conduct in patients, jeopardizing social reintegration, productivity, and quality of life.[
A total of 133 adult patients admitted in the department of neurosurgery between September 2018 and December 2019 with moderate and severe traumatic brain injury (GCS ≤ 12) diagnosed to have DAI on MRI, were included in this prospective study after obtaining Institutional Review Board (IRB) approval. Patients with a significant intracranial hematoma on CT scan (requiring surgical intervention), a history of brain surgery, or an extracranial injury were all ruled out of the study. All patients were admitted in our department’s neurotrauma unit, where they were closely monitored for vital signs, neurochecks, intake/output monitoring, serum electrolytes, and any complications. All of the patients received oxygen (titrated based on arterial blood gases), intravascular fluids based on weight, and antiepileptic medications (only for patients with seizure episode). A nasogastric tube was inserted and feeding began within 24 hours of the injury. All the patients were managed conservatively and no patient was monitored for ICP in our studied population due to resource constraints.
The severity of DAI was determined using Adams e t al. proposed grading system (Grades I–III), which is based on the detection of axonal injury in the cerebral hemispheres, with a preference for the gray-white junction (Grade I), the corpus callosum (Grade II), and the dorsolateral, rostral brainstem (Grade III).[
Patients were tracked for up to 3 months following discharge and their outcomes were graded as satisfactory or unsatisfactory using the Glasgow Outcome Scale Extended (GOS-E). The GOS-E score of 1 was taken as death, scores 7 and 8 as satisfactory outcome while scores from 2 to 6 were taken as unsatisfactory outcome. P ≤ 0.05 was labeled significant.
Our study included 133 patients who were diagnosed as DAI on MRI. According to gender distribution, males were 97 (72.9%) while female patients were 36 (27.1%) and the average age of patients was 32.41 ± 10.02 years. The more prevalent causes of injury were road accident in 69 (51.9%) patients and fall in 36 (27.1%). A moderate injury was seen in 86 (64.7%) patients in our study while 47 (35.3%) patients had severe TBI. Out of 133 patients, most were found to have a Grade I injury, seen in 55 (41.4%) as shown in [
The aim of our study was to bring focus on the diffuse axonal injury, to evaluate the outcome of DAI based on its grade, and to identify significant predictors of prognosis. The bulk of our patients (72.9%) was men, similar to Vieira et al. who found that 89.7% of their patients were men and Ahuja et al. (94.4% male).[
Our patients were classified according to severity of TBI, 64.7% had moderate while 35.3% had severe injury. When outcome of DAI was assessed according to severity of TBI, we found a significant relationship between the two (P < 0.05) as given in [
Management of pure DAI is nonsurgical with an aim to keep the intracranial pressure within or near to the normal limits and to prevent secondary complications. The patient’s age, the severity of the TBI, and the DAI grading are all crucial criteria to consider when predicting the outcome. We found that duration of hospital stay did not change the outcome of DAI in our study but longer stays were associated with lesser number of patients falling into category of satisfactory outcome. The majority of the patients (58.6%) were only in the hospital for 11 days or less. Although the length of a hospital stay has no bearing on prognosis, it does represent the requirement for long-term nursing care and rehabilitation.
The existence and quantity of DAI hemorrhagic lesions revealed by MRI have been linked to outcome, although the predictive relevance of cerebral location is not thoroughly investigated.[
The GOS-E was used to assess patients’ clinical outcomes 3 months after sustaining a head injury in our research group. In literature, mortality after DAI is found to be variable from 30.8%[
There were few limitations in our study. It was a single-institution study and we had to exclude the associated intracranial hematomas patients which can significantly change the management and outcome of these DAI patients. Our study was limited to 3 months follow-up so the role of prolonged rehabilitation and long-term outcome beyond 3 months was not studied. The severity of the TBI with which the patient was first hospitalized, as well as the severity of DAI, had a substantial impact on the result in our research group, with poor outcomes in low initial GCS and higher DAI grades.
The findings of our study show that the outcome of DAI is determined by the severity of the traumatic brain injury and grade of DAI and is unaffected by age, gender, or TBI modality. In general, individuals with diffuse axonal injury who have a very low GCS at admission and grade III DAI have the worst outcome and the greatest mortality. A longer hospital care and rehabilitation will aid in the improvement of clinical and functional outcomes in survivors.
Dr. Farrukh Javeed conceived and designed the study, did data collection and manuscript writing. Dr. Ali Afzal did statistical analysis and editing of manuscript. Dr. Asad Abbas did data collection and manuscript writing. Dr. Lal Rehman did review and final approval of manuscript.
All authors read and approved the final version of the manuscript.
Institutional Review Board (IRB) permission obtained for the study.
There are no conflicts of interest.
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