Traumatic hemorrhagic brain injury: impact of location and resorption on cognitive outcome

Abstract

OBJECTIVE Hemorrhagic contusions are often the most visible lesions following traumatic brain injury. However, the incidence, location, and natural history of traumatic parenchymal hemorrhage and its impact on neurological outcome have been understudied. The authors sought to examine the location and longitudinal evolution of traumatic parenchymal hemorrhage and its association with cognitive outcome. METHODS Sixteen patients with hemorrhagic contusions due to acceleration-deceleration injuries underwent MRI in the acute (mean 6.3 days postinjury) and chronic (mean 192.9 days postinjury) phases. ImageJ was used to generate GRE and FLAIR volumes. To account for the effect of head-size variability across individuals, the authors calculated each patient's total brain tissue volume using SIENAX. GRE and FLAIR volumes were normalized to the total brain tissue volume, and values for absolute and percent lesion volume and total brain volume change were generated. Spearman's rank correlations were computed to determine associations between neuroimaging and 6-month postinjury neuropsychological testing of attention (Symbol Digit Modalities Test [SDMT], oral [O] and written [W] versions), memory (Selective Reminding Test, total learning and delayed recall), and executive function (Trail Making Test Part B [TMT-B]). RESULTS The patients' mean age was 31.4 ± 14.0 years and their mean Glasgow Coma Scale score at admission was 7.9 ± 2.8. Lesions were predominantly localized to the frontal (11 lesions) and temporal (9 lesions) lobes. The average percent reductions in GRE and FLAIR volumes were 44.2% ± 46.1% and 80.5% ± 26.3%, respectively. While total brain and frontal lesion volumes did not correlate with brain atrophy, larger temporal lobe GRE and FLAIR volumes were associated with larger volumes of atrophy (GRE: acute, −0.87, p < 0.01, chronic, −0.78, p < 0.01; FLAIR: acute, −0.81, p < 0.01, chronic, −0.88, p < 0.01). Total percent volume change of GRE lesions correlated with TMT-B (0.53, p < 0.05) and SDMT-O (0.62, p < 0.05) scores. Frontal lobe lesion volume did not correlate with neuropsychological outcome. However, robust relationships were seen in the temporal lobe, with larger acute temporal lobe GRE volumes were associated with worse scores on both oral and written versions of the SDMT (SDMT-W, −0.85, p < 0.01; SDMT-O, −0.73, p < 0.05). Larger absolute change in temporal GRE volume was strongly associated with worse SDMT scores (SDMT-W, 0.88, p < 0.01; SDMT-O, 0.75, p < 0.05). The same relationships were also seen between temporal FLAIR lesion volumes and neuropsychological outcome. CONCLUSIONS Traumatic parenchymal hemorrhages are largely clustered in the frontal and temporal lobes, and significant residual blood products are present at 6 months postinjury, a potential source of ongoing secondary brain injury. Neuropsychological outcome is closely tied to lesion volume size, particularly in the temporal lobe, where larger GRE and FLAIR volumes are associated with more brain atrophy and worse SDMT scores. Interestingly, larger volumes of hemorrhage resorption were associated with worse SDMT and TMT-B scores, suggesting that the initial tissue damage had a lasting impact on attention and executive function.

Increase in brain atrophy after subdural hematoma to rates greater than associated with dementia

“…1,14,15,24,33 A constant, local presence of neurotoxic compounds in the vicinity of the brain suggests a causative relationship with subdural atrophy. This is in accordance with Martin et al, 23 who demonstrated a correlation between traumatic brain injury-associated intraparenchymal hemorrhage volume, BV, and cognitive testing over a 6-month period.…”

“…1,14,15,24,33 There is a pathophysiological basis for an intracranial hemorrhage to cause inflammation-related brain atrophy. 16,23,28,31,32 The clinical significance of this process in cSDH when compared with other atrophy-related neurodegenerative conditions, such as dementia, has not been well defined. Our laboratory has developed software that relies on segmentation of the density on CT scans to volumetrically assess brain atrophy and cSDH volume in the brain.…”

Imaging of Intracranial Hemorrhage

“…Hemorrhagic parenchymal contusions most commonly occur with significant head motion and head impact [ 20 ]. These contusions are characterized on CT as hyperdense hemorrhage within the brain parenchyma itself, and they are caused by microvascular arterial or venous injury.…”

“…MRI is more sensitive than CT for the detection of small focal hemorrhagic contusions, especially when volumetric GRE sequences are obtained ( Figure 5 ) [ 21 , 22 ]. Hemorrhagic parenchymal contusions have a predilection for the anterior and posterior temporal lobes, and the inferior frontal lobes, all of which are located adjacent to the bony structures of the skull ( Figure 5 ) [ 20 ]. In the setting of significant force, the brain impacts the adjacent skull with deformation of the underlying brain that results in hemorrhagic parenchymal contusions.…”

Estudo prospectivo dos achados de ressonância magnética de pacientes com lesão axonial difusa traumática

“…Estes testes foram selecionados conjuntamente com a neuropsicóloga envolvida no estudo por serem testes já utilizados em estudos pregressos de trauma. Optamos por utilizar o escore bruto de cada teste, e não o percentil em relação à população, seguindo a metodologia já executada em estudos pregressos da literatura onde o objetivo é comparar o indivíduo consigo mesmo em dois ou mais momentos distintos (Strangman et al, 2010;O'neil-Pirozzi et al, 2012;Strangman et al, 2012;Martin et al, 2016).…”