Cerebral concussion and mild traumatic brain injury (TBI) have been used interchangeably, although the two terms have different definitions. Traumatic axonal injury (TAI) is a more severe subtype of TBI than concussion or mild TBI. Regarding the evidence of TAI lesions in patients with concussion or mild TBI, since the 1960’s, several studies have reported on TAI in patients with concussion who showed no radiological evidence of brain injury by autopsy. However, conventional CT and MRI are not sensitive to detection of axonal injury in concussion or mild TBI, therefore, previously, diagnosis of TAI in live patients with concussion or mild TBI could not be demonstrated. With the development of diffusion tensor imaging (DTI) in the 1990’s, in 2002, Arfanakis et al. reported on TAI lesions in live patients with mild TBI using DTI for the first time. Subsequently, hundreds of studies have demonstrated the usefulness of DTI in detection of TAI and TAI lesions in patients with concussion or mild TBI. In Korea, the term “TAI” has rarely been used in the clinical field while diffuse axonal injury and concussion have been widely used. Rare use of TAI in Korea appeared to be related to slow development of DTI analysis techniques in Korea. Therefore, we think that use of DTI analysis techniques for diagnosis of TAI should be facilitated in Korea.
Autopsy ; Axons* ; Brain Concussion* ; Brain Injuries* ; Diagnosis ; Diffuse Axonal Injury ; Diffusion Tensor Imaging ; Humans ; Korea ; Magnetic Resonance Imaging

OBJECTIVE: Vascular endothelial growth factor(VEGF), which is also known as vascular permeability factor, induces angiogenesis and may play a key role in tumor-related neovascularization and peritumoral edema. There are many pathological conditions associated with VEGF expression, such as brain tumor, infection and trauma. Malignant brain tumor is characterized by its prominent neovascularization and severe peritumoral edema and it is known to express high VEGF activity. The aim of this study is to investigate any differences in cerebrospinal fluid(CSF) VEGF level among gliomas, and between tumors and non-tumorous conditions. METHODS: Cerebrospinal fluid samples were collected from 28 patients whose diagnosis had been surgically proven and they were centrifuged and stored at -73 degrees C. The concentration of VEGF was analyzed using commercially available ELISA kit. RESULTS: Glioblastoma patients showed much higher level of CSF VEGF than those of other gliomas and non-tumorous conditions. And higher CSF VEGF level was found in invasive pituitary adenoma, recurrent oligoden-droglioma, central neurocytoma and diffuse axonal injury. CONCLUSION: Absolute CSF VEGF level can be useful biological marker for primary malignant glioma, especially glioblastoma, and serial check-ups may contribute to early diagnosis of malignant transformation of low grade astrocytoma.
Astrocytoma ; Biomarkers ; Brain Neoplasms* ; Brain* ; Cerebrospinal Fluid* ; Diagnosis ; Diffuse Axonal Injury ; Early Diagnosis ; Edema ; Enzyme-Linked Immunosorbent Assay ; Glioblastoma ; Glioma ; Humans ; Neurocytoma ; Pituitary Neoplasms ; Vascular Endothelial Growth Factor A*

Patients with overwhelming demage to the cerebral hemispheres commonly pass into a chronic state of unconsciounsness(ie, loss of self awareness) called the vegetative state. When such cognitive loss lasts for more then a few weeks, the condition has been termed a persistent vegetative state. The auther reviewed "Position of the American Academy of Neurology on certain aspects of the care and management of the persistent vegetative state patient" adopted by the Executive Board, American Academy of Neurology, April 21, 1988 and "Current Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association" - 1989. In the U.S.A. they insist :If the patient is competent to act in his own befalf and did not previously indicate his preferences, the family or other surrogate decision maker, in concert with the physician, must act in the best interest of the patient" and "Even if death is not imminent but a patient is beyond doubt permanently unconscious, and there are adequate safeguards to confirm the accuracy of the diagnosis, it is not unethical to discontinue all means of life-prolonging medical treatment." In Korea :brain death" has not been referred to the death of the individual yet socially and legally. The neurosurgeons in our country must consider about how seriously to treat vegetative patients and brain death patients who are unlikly to improve, in the concerns of bio-medical ethice. On the other hand, they recognize that their capacity to achieve a diagnosis and highly probable prognosis represents the indispensable basis for any decision. This article provides criteria for the diagnosis of persistent vegetative state and reviews the available data of my 19 patients. Lastly in our country any considerations or discussions have not yet been made with regard to withdrawal of life support to patients in persistent vegetative states according to the national emotion and morality.
Brain ; Brain Death ; Cerebrum ; Cognition ; Diagnosis ; Diffuse Axonal Injury ; Hand ; Humans ; Korea ; Morals ; Neurology ; Persistent Vegetative State* ; Positron-Emission Tomography ; Prognosis

Magnetic resonance imaging(MRI) and computed tomography(CT) in 30 patients with severe head trauma were compared. MRI was superior to CT in detection of intracerebral and extracerebral traumatic lesions. The results obtained were as follows : 1) 27 intracerebral(18 cerebral contusions, 5 diffuse axonal injuries & 4 intracerebral hematomas) and 13 extracerebral traumatic lesions(4 acute epidural hematomas, 4 subdural hygromas, 2 subarachnoid hemorrhages, 1 acute subdural hematoma, 1 chronic subdural hematoma & 1 pneumocephalus) in 30 patients were seen on CT and/or MRI. 2) Group I lesions which seen on MRI and not seen on CT were 5 diffuse axonal injuries(100%), & 8 cerebral contusions(44%), and group II lesions which seen on CT and MRI with better visualization on MRI were 6 cerebral contusions(33%), 2 intracerebral hematomas(50%), & 3 subdural hygromas(75%). 3) Group III lesions which seen on CT and MRI equally well were 4 cerebral contusions(22%), 2 intracerebral hematomas(50%), 2 acute epidural hematomas(50%), 2 subarachnoid hemorrhages(100%), 1 chronic subdural hematoma(100%), 1 subdural hygroma(25%) & 1 pneumocephalus(100%). 4) Group IV lesions which seen on CT and MRI with better visualization on CT were 2 acute epidural hematomas(50%), & 1 acute subdural hematoma(100%), and lesion which seen on CT and not seen on MRI was not. 5) 21 intracerebral lesions of group I and II were located on temporal(11), parietal(3), frontal(2) and occipital lobes(2), basal ganglia(1), brain stem(1) and cerebellum(1). 6) We recommended MRI in the acute stage of severe head trauma for accurate diagnosis and evaluation of intracerebral traumatic lesions, especially diffuse axonal injuries and cerebral contusions, which were not visualized clearly on CT.
Axons ; Brain ; Contusions ; Craniocerebral Trauma* ; Diagnosis ; Diffuse Axonal Injury ; Head* ; Hematoma ; Hematoma, Subdural, Acute ; Hematoma, Subdural, Chronic ; Humans ; Magnetic Resonance Imaging* ; Subarachnoid Hemorrhage ; Subdural Effusion

OBJECTIVE: To study the disability identification for cases with clinical diagnosis of diffuse axonal injury (DAI) due to traffic accidents, and to explore the possible effects of DAI on identification results. METHODS: Five hundred and fifty-six cases of cerebral injury due to traffic accidents were collected, including 467 cases diagnosed with cerebral contusion or laceration and 89 cases diagnosed with DAI. The identification results of different groups with diagnosis of DAI diagnosis, diagnosis of DAI with cerebral contusion (laceration), and diagnosis of cerebral contusion or laceration without DAI were compared and statistically analyzed, based on the results of CT and MRI re-review. RESULTS: The disability identification levels in DAI group (20 cases), DAI group (69 cases) with cerebral contusion (laceration) and DAI group (467 cases) not complicated by cerebral contusion (laceration) were 7.72 +/- 1.09, 7.78 +/- 1.11, and 8.86 +/- 0.66, respectively. The disability levels of the two groups diagnosed with DAI were higher than those of the group without DAI diagnosis (P < 0.05). CONCLUSION Patients with DAI diagnosis might have more severe cerebral injury. In the identification process, one should pay attention to the possible missed diagnosis and misdiagnosis, and meanwhile avoid relying on those evidences provided only by CT and MRI.
Accidents, Traffic ; Brain Injuries/diagnosis* ; Diagnostic Errors ; Diffuse Axonal Injury/etiology* ; Disability Evaluation ; Forensic Pathology ; Humans ; Magnetic Resonance Imaging ; Resin Cements ; Tomography, X-Ray Computed

OBJECTIVE: To investigate the relationship between the diffuse axonal injury (DAI) and cerebral contusion, primary brain stem injury and brain concussion. METHODS: One hundred and twelve cases with DAI were analyzed according to the characteristics of clinical signs and imaging features. RESULTS: Of 112 cases of DAI, 70.5% injured in traffic accident, 60.7% injured with blunt trauma more than one time and 71.4% injured with cerebral contusion. And 90 cases with brain with hemorrhage were found in CT or MRI imaging. CONCLUSION DAI may be associated with cortical contusion and primary brain stem injury. The CT or MRI is useful to investigate the cause of death and to evaluate the personal disability.
Accidents, Traffic ; Adolescent ; Adult ; Aged ; Brain Concussion/pathology* ; Brain Injuries/diagnosis* ; Brain Stem/pathology* ; Child ; Child, Preschool ; Diagnosis, Differential ; Diffuse Axonal Injury/pathology* ; Female ; Forensic Pathology ; Humans ; Intracranial Hemorrhages/etiology* ; Male ; Middle Aged ; Tomography, X-Ray Computed ; Young Adult

To delineate the clinicopathological features of diffuse axonal injury in patients with diffuse cerebral injury, we reviewed 19 cases from a series of 726 brain autopsies performed during a recent ten-year period. The criteria for inclusion were loss of consciousness for more than 6 hours in closed head injury patients, and no development of a space-occupying lesion within 7 days of injury. The injury was more prevalent in males(70.6%), and in patients aged between 10 and 50 years(82.4%). The main cause was traffic accident(82.4%), and the patients, Glasgow coma scale score on admission after injury was between 3 and 7. CT or MRI performed within the first 7 days of injury disclosed either one or combined focal lesions in the cerebral white matter, corpus callosum and brain stem in 66.7% of cases, and no identifiable lesion in 33.3%. Axonal swellings are the histologic hallmark of diffuse axonal injury in closed head trauma. In this study, careful brain dissection and neuropathologic studies demonstrated these swellings in all autopsy brains. The immunohistochemical stain for neurofilament proteins(68kD, 160/200kD) is the most sensitive marker of axonal swelling, especially when a patient survives more than 12 hours after injury. However, a neurofilament protein(160/200kD) is also expressed in a few normal pyramidal neurons and axial dendrites. Bielschowsky stain also clearly delineates axonal swellings in patients who have survived more than 2 days after injury. Cerebral edema and the appearance of amyloid body are easily identifiable by Luxol fast blue-PAS stain. In patients who survive for 6 months after injury, axonal swellings are hardly identifiable; about 25% of cases are diagnosed by neuropathologic examination only. The above data indicate that for the diagnosis of diffuse axonal injury, careful gross examination and neuropathologic studies are important.
Amyloid ; Autopsy ; Axons ; Brain ; Brain Edema ; Brain Stem ; Corpus Callosum ; Craniocerebral Trauma* ; Dendrites ; Diagnosis ; Diffuse Axonal Injury* ; Glasgow Coma Scale ; Head Injuries, Closed ; Head* ; Humans ; Magnetic Resonance Imaging ; Neurons ; Unconsciousness

Mild traumatic brain injury (mTBI) is a common type of brain disorders among young adults. The dysfunction of the brain is often exacerbated due to diffuse axonal injury (DAI) which based on the injury of white matter fibers and axons. Since mild and moderate brain injury or DAI are diffuse and subtle, conventional CT and MRI are difficult to make a positive diagnosis. Recent clinical study indicated that functional magnetic resonance imaging has a high detection rate in the diagnosis of acute mild and moderate brain injury, especially the diffusion tensor imaging (DTI) and 1H-magnetic resonance spectroscopy (1H-MRS). This paper has reviewed the principles and characteristics of DTI and 1H-MRS, and recent research in the clinical and animal experiments on brain injury.
Animals ; Axons/pathology* ; Brain/pathology* ; Brain Concussion/pathology* ; Brain Injuries/pathology* ; Diagnosis, Differential ; Diffuse Axonal Injury/pathology* ; Diffusion Tensor Imaging ; Humans ; Magnetic Resonance Spectroscopy/methods* ; Nerve Fibers, Myelinated/pathology* ; Severity of Illness Index

OBJECTIVE: To establish a diagnostic model for diffuse axonal injury (DAI) by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS). To screen the proteins or peptides associated with DAI for providing the biomarkers with theoretic foundation. METHODS: Fifteen male Sprague-Dawley rats were randomly divided into DAI group (n = 10) and control group (n = 5). The protein or peptide expression profiles of rat brain stem were detected by MALDI-TOF-MS. ClinProTools 2.2 software was used to find specific peaks, and a diagnostic model was established by the genetic algorithm. RESULTS: There were significant differences in 61 peaks of DAI group (P < 0.05), 9 peaks were down-regulated and 52 up-regulated. The diagnostic model was established based on 5 different peaks. The specificity and sensitivity of cross validation was 96.14% and 95.98%; while the specificity and sensitivity of blind validation showed was 73.33% and 70.00%, respectively. CONCLUSION A specific and sensitive diagnostic model of DAI can be established by MALDI-TOF-MS to provide a potential value for determining DAI in forensic practice.
Animals ; Biomarkers ; Brain Stem/metabolism* ; Diffuse Axonal Injury/diagnosis* ; Down-Regulation ; Male ; Peptides/blood* ; Proteomics ; Rats ; Rats, Sprague-Dawley ; Sensitivity and Specificity ; Software ; Spectrometry, Mass, Matrix-Assisted Laser Desorption-Ionization/methods* ; Up-Regulation

The brain and intracranial compartment undergo a multiplicity of physiologic and anatomical changes which influence the type of head injury and response to such injury, especially for those children in first two years of age in whom development of skull and brain is still undertaking. Thus, special attention to recognize and manage these children from such injury seems mandatory. Purpose of this study is to analyze the related causes for the head injury in this age group with various clinical parameters influencing the outcome. A total of 68 children less than two years of age who were admitted to our institution after head trauma were included in this retrospective study. The causes of head injury along with other clinical settings, such as type of pathologies, Pediatric Glassgow Coma Scale(PGCS), age, operation, hypoxia, shock, seizure, anemia, abnormal pupillary response, were reviewed and clinical outcome related with these parameters were analysed. The mean duration of admission period was 15 days and mean follow-up period was 29.4 months. Most common mode of injury was stairway injury(32.3%), followed by in-car accident(19.1%), with suspected child abuse being only 2.9%. Cerebral contusion was the most frequent diagnosis being 43 cases(63.2%), followed by skull fracture in 31(45.6%). For the outcome related to various categories, 5 cases of death were due to diffuse axonal injury or intracranial hemorrhage, but most simple linear fractures were not associated with underlying brain injury. Among those required the operation(18 cases), subdural and/or epidural hematoma were the most common pathology(50%), followed by subdural hygroma and depressed skull fracture. The outcome, however, was not related to type of pathology. Instead, it was rather closely related to the initial PGCS. The PGCS at admission was found out to be the major predicting factor to outcome. In overall, 34/36(94.4%) cases with normal PGCS in these age groups showed good recovery with deaths being 5/7(71.4%) cases of PGCSdiagnosis and aggressive management to treat and prevent clinical situations related to bad outcome is warranted.
Anemia ; Anisocoria ; Anoxia ; Brain ; Brain Injuries ; Child Abuse ; Child* ; Coma ; Contusions ; Craniocerebral Trauma* ; Diagnosis ; Diffuse Axonal Injury ; Fever ; Follow-Up Studies ; Head* ; Hematoma ; Humans ; Hypotension ; Intracranial Hemorrhages ; Mortality ; Mortuary Practice ; Pathology ; Prognosis ; Reflex ; Retrospective Studies ; Seizures ; Shock ; Skull ; Skull Fracture, Depressed ; Skull Fractures ; Subdural Effusion