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

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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.

ABBREVIATIONSDAI = diffuse axonal injury; FLAIR = fluid-attenuated inversion recovery; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; GOSE = GOS-extended; GRE = gradient recalled echo; ICH = intracerebral hemorrhage; ICP = intracranial pressure; MNI = Montreal Neurological Institute; MP-RAGE = magnetization-prepared gradient echo; ROI = region of interest; SDMT = Symbol Digit Modalities Test; SDMT-O = SDMT-Oral; SDMT-W = SDMT-Written; SRT-6 = 6-trial version of the Selective Reminding Test; TBI = traumatic brain injury; TMT-B = part B of the Trail Making Test.

Article Information

INCLUDE WHEN CITING Published online May 27, 2016; DOI: 10.3171/2016.3.JNS151781.

Correspondence Paul M. Vespa, Departments of Neurology and Neurosurgery, David Geffen School of Medicine at UCLA, 757 Westwood Blvd., RR 6236A, Los Angeles, CA 90095. email: pvespa@mednet.ucla.edu.

© AANS, except where prohibited by US copyright law.

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Figures

  • View in gallery

    Montage of representative slices from the acute and follow-up GRE images from each patient in the study cohort (labeled to match the case numbers in Table 1). Hypointensities within the brain parenchyma represent blood products. The patient in Case 1 also had a left frontal subdural hematoma. The patient in Case 13 had a right frontal epidural hematoma.

  • View in gallery

    Scatter plots showing that larger total acute hemorrhage volumes (hemorrhage cm3 per total brain cm3) were associated with larger absolute hemorrhage change (upper), but not larger percent hemorrhage change (lower) over a 6-month follow-up period. rho = Spearman's rank correlation coefficient. Figure is available in color online only.

  • View in gallery

    Scatter plots showing that larger acute (A) and chronic (B) temporal hemorrhage volumes (hemorrhage cm3 per total brain cm3) are associated with larger volumes of percent temporal lobe atrophy over a 6-month follow-up period. Larger absolute change in temporal lobe hemorrhage volume (C), but not percent change in temporal lobe volume (D), was associated with larger volumes of percent temporal lobe atrophy. Figure is available in color online only.

  • View in gallery

    Scatter plots showing that larger acute temporal hemorrhage volumes are associated with worse scores on a test of attention, Symbol Digit Modalities Test (SDMT), in both written (A) and oral (B) modalities. Higher test scores on the SDMT reflect better performance. Larger absolute change in temporal lobe hemorrhage was also associated with worse SDMT scores (C and D). Figure is available in color online only.

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