Austin Neurosurgery: Open Access

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Austin Neurosurgery: Open Access is an open access, peer reviewed, scholarly journal committed to publication of unique contributions concerned with the prevention, analysis, cure, and rehabilitation of disorders which affect any section of the nervous system including the peripheral nerves, brain, extra-cranial cerebrovascular system, and spinal cord. The aim of this journal is to give a platform for scientists and academicians all over the world to endorse, share, and talk about various advancements in all aspects of neurosurgery. Austin Neurosurgery: Open Access accepts original research articles, review articles, case reports, clinical images and rapid communication on all the aspects of diagnosis and treatment of Neurology. Austin Neurosurgery: Open Access is an open access, peer reviewed, scholarly journal committed to publication of unique contributions concerned with the prevention, analysis, cure, and rehabilitation of disorders which affect any section of the nervous system including the peripheral nerves, brain, extra-cranial cerebrovascular system, and spinal cord.
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  Citation:  Sivakumar J. Approach to Imaging in Mild Traumatic Brain Injury and Diffuse Axonal Injury. Austin Neurosurg Open Access . 2017; 4(2): 1059. Austin Neurosurg Open Access - Volume 4 Issue 2 - 2017 Submit your Manuscript  | www.austinpublishinggroup.com Sivakumar. © All rights are reserved Austin Neurosurgery: Open Access Open Access  Abstract Traumatic brain injury is a commonly encountered condition in the emergency department. Mild traumatic brain injury and its squeal of diffuse axonal injury are difcult to diagnose with computed tomography scans as the preferred acute imaging modality. Our current decision on whether or not to scan a patient in the acute setting is best decided upon by the Canadian CT Head Rule. The role for MRI scans in diagnosing diffuse axonal injury is unclear, but current evidence suggests that they are preferred after the initial 48 hour period following head trauma. Keywords:  Surgical imaging; Diffuse axonal injury; Traumatic brain injury Introduction While the definition has varied depending on circumstances, raumatic Brain Injury (BI) is defined as the result o the application o either external physical orce or rapid acceleration/deceleration orces that disrupts brain unction as maniested by immediately apparent impairments in cognitive or physical unction [1]. Tis is urther classified as mild, moderate, and severe, depending on the patient’s Glasgow Coma Scale Score (GCS) [2,3]. Te majority o these cases present to hospital as minor BI, and previous studies suggest that 40% o these cases are secondary to motor-vehicle-related events [4]. Discussion In terms o neuroimaging ollowing head injury, the decision on whether or not to scan tends to be guided by hospital-specific protocol, or is physician dependent. Te general consensus, however, is that patients with new clinical symptoms or a change in GCS ollowing head injury, should undergo a Computed omography (C) scan o the brain. Te specific clinical predictors or this are still very much debateable. Te Canadian C Head Rule study, as demonstrated in (able 1), has developed a highly sensitive clinical decision rule or the use o C in patients with minor head injuries [5]. Tese patients are classified into whether or not imaging is required based off five high-risk actors or neurosurgical intervention, and two medium-risk actors or clinically important lesions. Te implementation o this guideline in other centres was associated with a modest reduction in C use and an increased diagnostic yield o head Cs or trauma to the head [6,7]. Review Article  Approach to Imaging in Mild Traumatic Brain Injury and Diffuse Axonal Injury  Sivakumar J * Discipline of Surgery, University of Sydney, Australia *Corresponding author:  Jonathan Sivakumar Discipline of Surgery, University of Sydney, Camper-down, Australia Received:  September 07, 2017;  Accepted:  November 24, 2017; Published:  December 01, 2017 C scans are used in the assessment o head injury as they have widespread availability; rapid scanning times, and is compatible with medical devices. Furthermore, they are sensitive in demonstrating significant pathologies such as mass effect, abnormal ventricular size and configuration, bone injuries, as well as acute haemorrhage [8]. Despite its many advantages in the assessment o traumatic brain injury, C imaging is limited in that lesions with smaller dimensions than that o its resolution remain undetected [9]. Consequently, a common diagnosis o afer traumatic brain injury, Diffuse Axonal Injury (DAI), is likely to unnoticed on C scans, and are better  visualised with Magnetic Resonance Imaging (MRI) [10]. MRI scans, on the other hand, are provide superior sof tissue details, compared with C scans, when evaluating complicated minor traumatic brain injury, including improved ability to detect DAI [11-13]. In spite o this, the drawbacks o MRI include its limited availability in the acute trauma setting, long scanning times, high sensitivity to patient motion, poor compatibility with various medical devices, and relative insensitivity to subarachnoid haemorrhage. DAI is a complication o traumatic brain injury induced by sudden acceleration-deceleration or rotational orces and the subsequent tissue injury is characterized by axonal stretching, disruption and eventual separation o nerve fibers in the white matter [14]. Current imaging modalities in clinical use tend to under-estimate DAI, and while MRI does have better resolution than C scans in detecting this pathology, there is still a high rate o alse negative results or small lesions and milder orms o DAI [15]. Previous studies have quantitatively demonstrated that C scans miss approximately 10-20% o abnormalities seen on MRI [13,16]. Although MRI scans High risk criteria: Rules out need for neurosurgical interventionGCS <15 at 2 hours post-injurySuspected open or depressed skull fractureSigns of basilar skull fracture: Hemotympanum, raccoon eyes, Battle’s Sign, CSF oto-/rhinorrhea ≥ 2 episodes of vomiting Age ≥ 65 Medium risk criteria: Rules out “clinically important” brain injury Retrograde amnesia to the event ≥ 30 minutes “Dangerous” mechanism? The Canadian CT Head Rules have been validated in multiple settings and have consistently demonstrated that they are 100% sensitive for detecting injuries that will require neurosurgery. Table 1:  Canadian CT Head injury/Trauma rule.   Austin Neurosurg Open Access 4(2): id1059 (2017) - Page - 02 Sivakumar J  Austin Publishing Group Submit your Manuscript  | www.austinpublishinggroup.com have greater sensitivity in detecting smaller lesions such as DAI, it is unclear whether the recognition o additional lesions on MRI would impact acute management o head trauma [9].In light o the above inormation, and as C scans are more convenient in the acute setting with an alibility to evaluate or the our types o cranial haemorrhages, the current preerence is to initially C scan a patient ollowing head injury, rather than use MRI. Tere is a role, however, or MRI scan in patient ollowing the initial 48 hour observation period whose symptoms continue to persist [17]. Conclusion While current protocols guide us on when to image in the acute setting o head trauma, there is still difficulty in accurately diagnosing mild traumatic brain injury and its sequela, such as diffuse axonal injury (able 2). Te principal o C head in the acute setting and either a C or MRI afer 48-72 hours, however, seems reasonable and the most evidence-based approach. References 1. Savitsky B, Givon A, Rozenfeld M, Radomislensky I, Peleg K. Traumatic brain  injury: It is all about denition. Brain injury. 2016; 30: 1194-200. 2. Parikh S, Koch M, Narayan RK. Traumatic brain injury. International  anesthesiology clinics. 2007; 45: 119-135.3. Jennett B. Epidemiology of head injury. Journal of neurology, neurosurgery,  and psychiatry. 1996; 60: 362-369. 4. Kraus JF, Nourjah P. The epidemiology of mild, uncomplicated brain injury.  The Journal of trauma. 1988; 28: 1637-1643. 5. Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et  al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001; 357: 1391-1396.6. Sharp AL, Huang BZ, Tang T, Shen E, Melnick ER, Venkatesh AK, et al. Implementation of the Canadian CT Head Rule and Its Association With GradePathologyGrade I Widespread axonal damage in white matter of cerebral hemispheres Grade II White matter axonal damage extending to the corpus callosum with tissue tear haemorrhages Grade III Pathology of Grade II diffuse axonal injury with tissue tear haemorrhages in brain stem Table 2:  Diffuse axonal injury (Grading).Use of Computed Tomography Among Patients With Head Injury. Annals of   emergency medicine. 2017; 21: S0196-0644. 7. Valle Alonso J, Fonseca Del Pozo FJ, Vaquero Alvarez M, Lopera Lopera E, Garcia Segura M, Garcia Arevalo R. Comparison of the Canadian CT  head rule and the New Orleans criteria in patients with minor head injury in a Spanish hospital. Medicina clinica. 2016; 147: 523-530. 8. Davis PC, Expert Panel on Neurologic I. Head trauma. AJNR American  journal of neuroradiology. 2007; 28: 1619-1621. 9. Lee B, Newberg A. Neuroimaging in traumatic brain imaging. NeuroRx: the   journal of the American Society for Experimental NeuroTherapeutics. 2005;  2: 372-383. 10. Coles JP. Imaging after brain injury. British journal of anaesthesia. 2007; 99:  49-60. 11. Gentry LR. Imaging of closed head injury. Radiology. 1994; 19: 1-17.12. Gentry LR, Godersky JC, Thompson B. MR imaging of head trauma: review  of the distribution and radiopathologic features of traumatic lesions. AJR   American journal of roentgenology. 1988; 150: 663-672.13. Mittl RL, Grossman RI, Hiehle JF, Hurst RW, Kauder DR, Gennarelli TA,  et al. Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT ndings. AJNR American journal of  neuroradiology. 1994; 15: 1583-1589. 14. Chung SW, Park YS, Nam TK, Kwon JT, Min BK, Hwang SN. Locations and clinical signicance of non-hemorrhagic brain lesions in diffuse axonal injuries. Journal of Korean Neurosurgical Society. 2012; 52: 377-383. 15. Ma J, Zhang K, Wang Z, Chen G. Progress of Research on Diffuse Axonal  Injury after Traumatic Brain Injury. Neural plasticity. 2016; 2016: 7.16. Doezema D, King JN, Tandberg D, Espinosa MC, Orrison WW. Magnetic resonance imaging in minor head injury. Annals of emergency medicine. 1991; 20: 1281-1285.17. Halstead ME, Walter KD, Council on Sports M, Fitness. American Academy of Pediatrics. Clinical report--sport-related concussion in children and  adolescents. Pediatrics. 2010; 126: 597-615. Citation:  Sivakumar J. Approach to Imaging in Mild Traumatic Brain Injury and Diffuse Axonal Injury. Austin Neurosurg Open Access . 2017; 4(2): 1059. Austin Neurosurg Open Access - Volume 4 Issue 2 - 2017 Submit your Manuscript  | www.austinpublishinggroup.com Sivakumar. © All rights are reserved
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