Intracranial pressure elevations in diffuse axonal injury: association with nonhemorrhagic MR lesions in central mesencephalic structures

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OBJECTIVE

Increased intracranial pressure (ICP) in patients with severe traumatic brain injury (TBI) with diffuse axonal injury (DAI) is not well defined. This study investigated the occurrence of increased ICP and whether clinical factors and lesion localization on MRI were associated with increased ICP in patients with DAI.

METHODS

Fifty-two patients with severe TBI (median age 24 years, range 9–61 years), who had undergone ICP monitoring and had DAI on MRI, as determined using T2*-weighted gradient echo, susceptibility-weighted imaging, and diffusion-weighted imaging (DWI) sequences, were enrolled. The proportion of good monitoring time (GMT) with ICP > 20 mm Hg during the first 120 hours postinjury was calculated and associations with clinical and MRI-related factors were evaluated using linear regression.

RESULTS

All patients had episodes of ICP > 20 mm Hg. The mean proportion of GMT with ICP > 20 mm Hg was 5%, and 27% of the patients (14/52) spent more than 5% of GMT with ICP > 20 mm Hg. The Glasgow Coma Scale motor score at admission (p = 0.04) and lesions on DWI sequences in the substantia nigra and mesencephalic tegmentum (SN-T, p = 0.001) were associated with the proportion of GMT with ICP > 20 mm Hg. In multivariable linear regression, lesions on DWI sequences in SN-T (8% of GMT with ICP > 20 mm Hg, 95% CI 3%–13%, p = 0.004) and young age (−0.2% of GMT with ICP > 20 mm Hg, 95% CI −0.07% to −0.3%, p = 0.002) were associated with increased ICP.

CONCLUSIONS

Increased ICP occurs in approximately one-third of patients with severe TBI who have DAI. Age and lesions on DWI sequences in the central mesencephalon (i.e., SN-T) are associated with elevated ICP. These findings suggest that MR lesion localization may aid prediction of increased ICP in patients with DAI.

ABBREVIATIONS ADC = apparent diffusion coefficient; CPP = cerebral perfusion pressure; DAI = diffuse axonal injury; DWI = diffusion-weighted imaging; EVD = external ventricular drain; GCS = Glasgow Coma Scale; GMT = good monitoring time; GOSE = Glasgow Outcome Scale–Extended; ICC = intraclass correlation coefficient; ICP = intracranial pressure; MAP = mean arterial blood pressure; NICU = neurointensive care unit; SN-T = substantia nigra and mesencephalic tegmentum; SWI = susceptibility-weighted imaging; TBI = traumatic brain injury; T2*GRE = T2*-weighted gradient echo.

Article Information

Correspondence Sami Abu Hamdeh: Uppsala University Hospital, Uppsala, Sweden. sami.abu.hamdeh@neuro.uu.se.

INCLUDE WHEN CITING Published online September 14, 2018; DOI: 10.3171/2018.4.JNS18185.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A: Bar graph displaying the distribution of ICP > 20 mm Hg in the patient cohort. The number of patients by the proportion of GMT with ICP > 20 mm Hg is depicted. B: Dot plot displaying individual and mean proportion of GMT > 20 mm Hg in patients with (lesions) and without (no lesions) DWI-confirmed lesions in the SN-T. DWI lesions in the SN-T were significantly associated with the proportion of GMT with ICP > 20 mm Hg (p = 0.001 in univariate linear regression, p = 0.004 in multivariable linear regression). Obs = observations.

  • View in gallery

    A: DWI (b = 1000 sec/mm2) of a 54-year-old man who was involved in a motor vehicle accident (MVA). The image displays a centrally located lesion in the mesencephalic tegmentum (arrow). The patient was managed with propofol coma to control ICP. B: DWI (b = 1000 sec/mm2) of an 18-year-old man involved in an MVA. The image displays lesions in the right mesencephalic tegmentum (arrow). The patient was managed with CSF drainage to control ICP. C: Anatomical illustration of brainstem and mesencephalic structures. Cross-section of the mesencephalon through the superior colliculi is shown. Central brainstem lesions associated with increased ICP are located in the region of the SN-T (boldface type). As depicted in the figure, this region includes numerous vital structures.

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