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Diffuse axonal injury

Slides from the stemlynspodcast.org on diffuse axonal injury.

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Diffuse axonal injury

  1. 1. Diffuse axonal injury Dr John Hell Consultant neuroanaesthetist and neurointensivist
  2. 2. Prevalence  Probably present even in concussion  Present in 72% of TBI survivors with GCS 3-13 (moderate-severe TBI)  Combined with haematomas/contusions in 50%
  3. 3. Mechanism  Severe acceleration of brain in skull  Differing density of grey & white matter causes shearing of axons  Lateral & rotational impacts especially  No absorption of force by facial or skull fractures
  4. 4. Pathophysiology  Axonal shearing  Stretching of axons – primary brain injury  Swelling & rupture of axons  Biochemical changes & release of mediators  Cerebral oedema causing raised ICP & restriction of diffusion  Secondary brain injury from hypoxia & relative hypotension (↓CPP)
  5. 5. Radiology  Poorly seen on initial CT – better later  Better seen on MRI  Graded according to increasing severity:  1: only lobar white matter – grey/white  2: lesions of corpus callosum  3: dorsolateral brainstem – negative prognostic sign
  6. 6. Management  Initial resuscitation to normal parameters  Keep everything normal  Maintain venous drainage  Adequate sedation  Avoid hyperventilation acutely  Expect cerebral oedema to develop  ICP monitor – maintain CPP
  7. 7. Prognosis  Death  Disability – unpredictable nature & severity  Brainstem involvement – worse  Young – better (but not children)  Better connectivity – better outcome  Poor initial GCS – worse outcome  Complicated by hydrocephalus/infection – worse  Can recover to very good quality of life
  8. 8. Diffuse axonal injury  Suspect from mechanism  Resuscitate to normal parameters  Expect to swell – ICP bolt  Avoid hyperventilation unless ICP raised  Diagnose on repeat CT or MRI  Aggressive TBI management of ICP  All outcomes possible

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