Diffuse Axonal Injury

Diffuse axonal injury is one of the more severe types of the closed head injuries.   It is also one of the most common traumatic brain injuries.  It is called a diffuse injury because, unlike focal brain injuries, it affects the whole brain. Symptoms of these types of injuries gradually progress if left untreated so that quick treatment is very important. While most other traumatic brain injuries are caused by a blow to the head, diffuse axonal injuries are cause by the sloshing around of the brain within the skull.   A closed head injury is actually considered more dangerous than an open head injury.  This is because the brain tissue is torn and there is secondary swelling with no place for the swelling to go.   In a diffuse axonal injury, the brain movements disrupt the axons of the nerve cells which are there because the neurons need to talk to one another.  If this is diffuse within the brain, there is severe disruption of the messaging system of the brain.  This can easily result in a coma or in a persistent vegetative state.  Once the nerve cells are disrupted, the links that tie them together become broken and the signaling process cannot occur.  The different functions such as speech, movement and respiratory system fail to function.  The end result can be death relatively quickly after an injury. When a patient enters a coma, greater than 90 percent never wake up.

Diffuse Axonal Injuries can be caused by shaking of the head or by a strong rotation of the head.  Common causes of this type of injury are shaken baby syndrome or car accidents.  Diffuse Axonal Injury occurs because the brain lags behind the skull movement causing tearing of blood vessels and nerve tissue in all parts of the brain.  Brain chemicals are then released by damaged nerve cells, worsening the injury.  When the nerve cells are torn, there can be no communication between the various nerve cells. This brain disturbance can lead to temporary or permanent brain damage, coma, persistent vegetative state, or death.

Symptoms and Diagnosis of Diffuse Axonal Injury
The primary symptom of diffuse axonal injury is unconsciousness.   The patient may then enters a coma from which the vast majority does not recover.  Many people enter into a persistent vegetative state in which the patient has a sleep wake cycle but talks little and is completely bedridden.  Some patients never enter the persistent vegetative state but die because they lack the necessary brain cells to sustain life.   A few patients awaken from their coma but have severe neurological deficits and cannot function in society. When it comes to diagnosis of diffuse axonal injury, much is based on the clinical findings of unconsciousness and coma.  The test most often used in diagnosing diffuse axonal injury is the CT scan.  This test combines x-ray technology and computers to give a detailed three dimensional image of the person’s brain.  There can be false negatives with the CT scan so it can’t completely be relied on to give the diagnosis of diffuse axonal injury.  One can also do a test called evoked potentials, which is usually called a BAER test, an SSEP test or a VEP test.  These tests examine the auditory, visual and sensory pathways within the brain. In diffuse axonal injury, these pathways will be disrupted.  An EEG or electroencephalogram is also a good test for diffuse axonal injury.  This test uses electrodes attached to the scalp that measures the electrical activity within the brain.  In diffuse axonal injury, the EEG will be abnormal.

Treatment and Prognosis of Diffuse Axonal Injury
Initially, measures will be taken to decrease the swelling of the brain.  Mannitol, steroids and other medications are used to decrease swelling and reduce the inflammation of the brain.  The patient will be carefully monitored.  Surgery will not help this injury.  If the diffuse axonal injury is mild or moderate, the patient will enter rehabilitation once they are awake and stable. In the rehabilitation phase, both the family and the patient will be managed by a multidisciplinary staff that will include nurses, doctors, occupational therapists, physical therapists and other specialists who will work with the patient to return the patient to normal or at least to the maximum level of function they are capable of.  This can include physical therapy, speech therapy, recreational therapy, occupational therapy, adaptive equipment training and mental/emotional counseling.  Over a period of weeks to months, the patient will improve to a maximum level.   Concussion is believed to be the mildest form of diffuse axonal injury.  There are various forms of severity of this illness, with mild to moderate forms of the disease having the best chance of recovery.  The mildest cases of diffuse axonal injury usually have few if any long term problems.  People with severe injuries often live out their lives in a persistent vegetative state or die at an early age from complications of a coma.
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