Jebmh.com Original Research Article Clinical Profile and Prognostication of Traumatic Diffuse Axonal Injury Vaidyanathan R.1, Noor Rubina Ahamadi2, Aravind R.M.3, Shivanand V.4, Chandrashekar G.R.5 1, 2, Department of Anaesthesiology and Critical Care, Cauvery Heart and Multi-Speciality Hospital, Mysore, Karnataka, India. 3, 5 Department of General Surgery, Cauvery Heart and Multi-Speciality Hospital, Mysore, Karnataka, India. 4Department of Neurosurgery, Cauvery Heart and Multi-Speciality Hospital, Mysore, Karnataka, India. ABSTRACT BACKGROUND Diffuse Axonal Injury (DAI) is one of the most common causes of post-traumatic Corresponding Author: coma, disability and a persistent neuro-vegetative state. We wanted to study the Dr. Vaidyanathan R, Consultant Anaesthesiologist and clinical profile, prognostic factors and long-term outcome of patients admitted with Intensivist, Department of traumatic diffuse axonal injury in our ICU. Anaesthesiology and Critical Care, Cauvery Heart and Multi-Speciality METHODS Hospital, Bannur Road, Near Teresian 74 patients who were admitted to the ICU with diffuse axonal injury following brain Circle, Mysore - 28, Karnataka, India. trauma between Jan 2010 to Dec 2019 were included in the study. Baseline clinical E-mail: [email protected] assessment, GCS scoring, basic investigations including serology, complete blood count, and biochemistry, CT Brain along with x - ray of cervical spine, chest x - DOI: 10.18410/jebmh/2020/456 ray, x - ray pelvis and ultrasound abdomen was done for all patients. MRI brain How to Cite This Article: was done for all patients with clinical suspicion of diffuse axonal injury within 36 Vaidyanathan R, Ahamadi NR, Aravind hours of injury. All those patients with MRI proven diffuse axonal injury were RM, et al. Clinical profile and included in the study. Patients who had significant parenchymal lesions in the brain prognostication of traumatic diffuse in the form of contusions or haemorrhage in brain or those patients who axonal injury. J Evid Based Med Healthc underwent craniotomy were excluded from the study. All the patients were 2020; 7(39), 2199-2203. DOI: managed in ICU as per standard protocol of brain trauma foundation (BTF) 10.18410/jebmh/2020/456 guidelines. Submission 07-06-2020, Peer Review 20-06-2020, RESULTS Acceptance 12-07-2020, Out of 74 patients, 65 required ventilatory support. There was no in-hospital Published 28-09-2020. mortality. The average length of ICU stay is 14.7 days which is directly related to the initial GCS score on admission and MRI grading of diffuse axonal injury. The Copyright © 2020 JEBMH. This is an lower GCS score and severe diffuse axonal injuries as shown by higher MRI grades open access article distributed under Creative Commons Attribution License were associated with longer duration of ICU stays. Presence of ventilator [Attribution 4.0 International (CC BY associated pneumonia (VAP) is a significant factor in determining the ICU stay and 4.0)] was seen in 35 % of the patients in our study. Major deficits as assessed by Glasgow outcome evaluation scale (GOC - E) at the end of one month post discharge was seen in 6 patients (8.1 %). However, at the end of 6 months, no significant motor deficits were seen in any of the patients. 2 patients died during the intervening 5 month follow up period due to unrelated causes. One patient was lost for follow up after one month. CONCLUSIONS The overall outcome in traumatic diffuse axonal injury is favourable with 0 % mortality as against a higher rate reported in available literature ranging from 30 – 70 %.1 Disability rate at the end of 6 months was also nil in our study compared to varied distribution of 20 – 40 % reported in the literature. Infections remain one of the biggest challenges in managing these cases. A ventilator associated pneumonia (VAP) incidence of 35 % was seen in our series. KEYWORDS Diffuse Axonal Injury, Traumatic Brain Injury, GCS, MRI J Evid Based Med Healthc, pISSN - 2349-2562, eISSN - 2349-2570 / Vol. 7 / Issue 39 / Sept. 28, 2020 Page 2199 Jebmh.com Original Research Article BACKGROUND In this study an attempt is made to analyze the clinical profile of diffuse axonal injury and also to assess the Diffuse Axonal Injury (DAI) is one of the most common and prognostic factors on the long term outcome of diffuse devastating forms of traumatic brain injury and is a major axonal injury based on the clinical features, Glasgow coma cause of unconsciousness and persistent vegetative state scale (GCS) scoring and severity based on MRI grading. after head trauma. DAI is considered the most important factor in determining morbidity and mortality in victims of TBI and is the most common cause of posttraumatic coma, METHODS 1,2 disability and a persistent neuro vegetative state. Diffuse axonal injury is caused from widespread tearing In this prospective observational study, 74 patients who of axons and small vessels by shearing forces and is defined were admitted to the ICU with diffuse axonal injury following as prolonged post - traumatic coma over 6 hours following brain trauma between Jan 2010 to Dec 2019 were included injury without any demonstrable mass lesion and after in the study. Baseline clinical assessment, Glasgow coma excluding all other causes of brain swelling or ischemic brain scale (GCS) scoring, basic investigations including serology, lesions. Diffuse axonal injury is caused by acceleration- complete blood count, biochemistry, CT brain along with x - deceleration effects of the mechanical input to the head rays of cervical spine, chest x - ray, x - ray pelvis and 1 upon shaking of the brain within the skull. ultrasound abdomen were done for all the patients. MRI Diffuse axonal injury causes cognitive, physical and brain was done for all patients with clinical suspicion of behavioural changes that compromise social reintegration diffuse axonal injury within 36 hours of injury. All those return to productivity and quality of life of the patients and patients with MRI proven diffuse axonal injury were included their families. These changes persist beyond the acute phase in the study. Patients who had significant parenchymal of treatment and continue for a long period after the lesions in the brain in the form of contusions or haemorrhage traumatic event. Because the brain tissue is functionally or those patients who underwent craniotomy were excluded impaired but not destroyed, the brain may gradually regain from the study. Patients with significant blunt injuries of normal function as the clinical condition stabilizes and neural chest, abdomen and fracture of pelvis were also excluded 1 connections are remodelled. from the study. However patients who had isolated bone Traumatic brain injury in general including DAI is fractures like fractures of humerus, tibia, femur or ankle and classified as mild, moderate and severe based on the isolated limb soft tissue injuries were included in the study. Glasgow coma scale (GCS).Traumatic brain injury patients All the patients were managed in ICU with standard protocol with GCS of 13 to 15 are classified as mild injuries which for treatment of traumatic brain injury as per the brain comprises majority of the patients. Patients with GCS of 9 to trauma foundation (BTF) guidelines. Factors affecting length 12 are considered to have moderate traumatic brain injury, of hospital stay and ICU stay were assessed based on clinical while patients with GCS below eight are classified as having features, age, GCS score and MRI grading of the injury All a severe traumatic brain injury. Further GCS of less than 5 the patients were followed up after discharge, up to one are usually grouped under patients with very severe forms month and after 6 months of discharge for any possible 3 of injury. persisting neurological deficits and were assessed Conventionally magnetic resonance imaging (MRI) brain objectively using Glasgow outcome scale extended (GOS - has been used to grade the severity of diffuse axonal injury. E) scale. Based on the findings of MRI brain it can be graded into 3 All the statistical methods were done using SPSS 21.0 grades. This is also known as the Adam’s classification of version for windows. p <0.05 was considered statistically 4 diffuse axonal injury. Grade I constitute a mild form of injury significant. Summary statistics was done by means of while grade III is severe form of injury involving brain stem. proportions for categorical/binary variables and mean along with standard deviation for continuous variables. Inferential Grade I: Involves grey - white matter interfaces. This statistics was done by using, Pearson correlation, one way commonly involves parasagittal regions of frontal lobes, ANOVA, and independent t test. periventricular and temporal lobes. Less commonly, parietal and occipital lobes, internal and external capsules may be involved. RESULTS Grade II: Involves corpus callosum in addition to stage I locations most commonly involving the posterior body and splenium but does advance anteriorly with Age (in Yrs.) No. of Patients Percentage % < 18 1 1.35 increasing severity of injury. 18 - 25 14 18.9 Grade III : Involves brainstem in addition to stage I and 25 - 35 28 37.8 35 - 45 20 27.02 II locations most commonly involving rostral midbrain, 45 - 55 7 9.45 superior cerebellar peduncles, medial lemnisci and > 55 4 5.4 Total 74 100 corticospinal tracts.4 Table 1. Age Wise Distribution of Patients Similarly, the outcome of patients following diffuse Majority of the patients admitted with diffuse axonal axonal injury is usually assessed with the help of Glasgow injury belonged to the younger age group of 25 - 35 years Outcome Scale Extended (GOS - E) scale.5, 6 followed by 35 - 45 years age group. One child of 13 years J Evid Based Med Healthc, pISSN - 2349-2562, eISSN - 2349-2570 / Vol. 7 / Issue 39 / Sept. 28, 2020 Page 2200 Jebmh.com Original Research Article was the youngest and the oldest in the series was a 75 year duration of ICU stay as determined by GCS, with lower GCS old male patient.