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Characterization of diffuse axonal pathology and selective hippocampal damage following inertial brain trauma in the pig.

Dynamic deformation applied to white matter tracts is a common feature of human brain trauma, and may result in diffuse axonal injury (DAI). To produce DAI in an experimental model, we have utilized nonimpact inertial loading to induce brain trauma in miniature swine. This species was chosen due to its large gyrencephalic brain with substantial white matter domains. Twenty anesthetized (2% isoflurane) miniature swine were subjected to pure impulsive centroidal rotation 110 degrees in the coronal plane in 4 to 6 ms; peak accelerations ranged from 0.6 to 1.7 x 10(5) rad/s2. Seven days following injury, the brains were fixed (4% paraformaldehyde). Histopathologic examination was performed on 40 microns sections stained with cresyl violet (Nissl), antibodies targeting neurofilament (axonal damage), GFAP (astrocytes), and pig IgG (protein extravasation). Widespread multifocal axonal injury was observed in combination with gliosis throughout the brain, most commonly in the root of gyri and at the interface of the gray and white matter. Very little vascular disruption was noted in regions of axonal injury. Neuronal damage was primarily found in the CA1 and CA3 subfields of the hippocampus. These results suggest that this model is clinically relevant and useful for evaluating mechanisms of inertial brain trauma.

Animals↗

Fast detection of diffuse axonal damage in severe traumatic brain injury: comparison of gradient-recalled echo and turbo proton echo-planar spectroscopic imaging MRI sequences.

BACKGROUND AND PURPOSE: Diffuse axonal injury (DAI) is a common type of primary neuronal injury in patients with severe traumatic brain injury (TBI), and is frequently accompanied by tissue tear hemorrhage. T2-weighted gradient-recalled echo (GRE) sequences are more sensitive than T2-weighted spin-echo images for detection of hemorrhage. The purpose of this study is to compare turbo Proton Echo Planar Spectroscopic Imaging (t-PEPSI), an extremely fast sequence, with GRE sequence in the detection of DAI. METHODS: Twenty-one patients (mean age 26.8 years) with severe TBI occurred at least 3 months earlier, underwent a brain MR Imaging study on a 1.5-T scanner. A qualitative evaluation of the t-PEPSI sequences was performed by identifying the optimal echo time and in-plane resolution. The number and size of DAI lesions, as well as the signal intensity contrast ratio (SI CR), were computed for each set of GRE and t-PEPSI images, and divided according to their anatomic location as lobar and/or deep brain. RESULTS: There was no significant difference between GRE and t-PEPSI sequences in the detection of the total number of DAI lesions (291 vs. 230, respectively). GRE sequence delineated a higher number of DAI in the temporal lobe compared to the t-PEPSI sequence (74 vs. 37, P < .004), while no differences were found for the other regions. The SI CR was significantly lower with the t-PEPSI than the GRE sequence (P < .00001). CONCLUSION: Owing to its very short scan time and high sensitivity to the hemorrhage foci, the t-PEPSI sequence may be used as an alternative to the GRE to assess brain DAI in severe TBI patients, especially if uncooperative and medically unstable.

Adolescent↗

Evolution of neurofilament subtype accumulation in axons following diffuse brain injury in the pig.

Although accumulation of neurofilament (NF) proteins in axons has been recognized as a prominent feature of brain trauma, the temporal course of the accumulation of specific NF subtypes has not been well established. In the present study, 17 miniature swine were subjected to nonimpact inertial brain injury. At 3 hours (h), 6 h, 24 h, 3 days, 7 days, and 10 days post-trauma, immunohistochemical analysis was performed to determine axonal accumulation of NF-light (NF-L), the rod and sidearm domains and sidearm phosphorylation states of NF-medium (NF-M), and heavy (NF-H). We found that NF-L accumulation was easily identified in damaged axons by 6 h post-trauma, but NF-M and H accumulation was not clearly visualized until 3 days following injury. In addition, the axonal accumulation of NF-M and H appeared to be primarily comprised of the sidearm domains. While the accumulating NF was found to be predominantly dephosphorylated, we also detected accumulation of phosphorylated NF. Finally, we found that developing axonal pathology may proceed either towards axotomy with discrete terminal bulb formation or towards the development of varicose swellings encompassing long portions of axons. These findings suggest that there is a differential temporal course in NF subtype disassembly, dephosphorylation, and accumulation in axons following initial brain trauma and that these processes occur in morphologically distinct phenotypes of maturing axonal pathology.

Animals↗

Neuropathology of inflicted head injury in children. I. Patterns of brain damage.

Fifty-three cases of non-accidental head injury in children were subjected to detailed neuropathological study, which included immunocytochemistry for microscopic damage. Clinical details were available for all the cases. There were 37 infants, age at head injury ranging from 20 days to 9 months, and 16 children (range 13 months to 8 years). The most common injuries were skull fractures (36% of cases), acute subdural bleeding (72%) and retinal haemorrhages (71%); the most usual cause of death was raised intracranial pressure secondary to brain swelling (82%). On microscopy, severe hypoxic brain damage was present in 77% of cases. While vascular axonal damage was found in 21 out of 53 cases, diffuse traumatic axonal injury was present in only three. Eleven additional cases, all of them infants, showed evidence of localized axonal injury to the craniocervical junction or the cervical cord. When the data were analysed by median age at head injury, statistically significant patterns of age-related damage emerged. Our study shows that infants of 2-3 months typically present with a history of apnoea or other breathing abnormalities, show axonal damage at the craniocervical junction, and tend also to have a skull fracture, a thin film of subdural haemorrhage, but lack extracranial injury. Children over 1 year are more likely to suffer severe extracranial, particularly abdominal, injuries. They tend to have larger subdural haemorrhages, and where traumatic axonal injury is present, show patterns of hemispheric white matter damage more akin to those reported in adults. Diffuse axonal injury is an uncommon sequel of inflicted head injury in children.

Age Distribution↗

Heavy neurofilament accumulation and alpha-spectrin degradation accompany cerebellar white matter functional deficits following forebrain fluid percussion injury.

Evidence for diffuse traumatic axonal injury (TAI) in clinical cases and animal models of traumatic brain injury (TBI) indicate that pathophysiological mechanisms extend to regions remote from the injury epicenter. The potential for indirect cerebellar trauma contributing to TBI pathophysiology is of significance since impairment of motor function and coordination is a common consequence of TBI but is also a domain associated with cerebellar function. The relationship between cerebellar white matter structure and function following traumatic head injury has not been examined. Using the fluid percussion injury (FPI) device applied unilaterally in the forebrain, evoked compound action potential (CAP) recordings from cerebellar white matter of Sprague-Dawley rats indicated a spatial and temporal pattern of electrophysiological deficits throughout the cerebellar vermis. The posterior and middle lobules of the cerebellum exhibited significant declines in evoked CAP amplitude compared to sham controls (p=0.004, p=0.005, respectively). Duration of the CAP decay also increased, suggesting that functional white matter deficits were a combination of axonal loss and compromised axonal integrity. Functional white matter deficits persisted at 14 days post-injury in the posterior and middle regions of the cerebellum. Evidence of heavy chain neurofilament (NF200) degradation was observed at 1 day post-injury by Western blot. Immunohistochemistry labeling for NF200 indicated the presence of highly immunoreactive NF200 axonal swellings consistent with morphological features of TAI. alpha-Spectrin degradation was also observed between 1 and 14 days post-injury. This study demonstrates the electrophysiological consequences of cerebellar white matter injury and a temporal profile of NF200 and spectrin degradation following forebrain FPI.

Action Potentials↗

Illuminating protein interactions in tissue using confocal and two-photon excitation fluorescent resonance energy transfer microscopy.

Traumatic brain injury (TBI) remains the most common cause of death in persons under age 45 in the Western world. One of the principal determinants of morbidity and mortality following TBI is traumatic axonal injury (TAI). Current hypotheses on the pathogenesis of TAI involve activation of apoptotic cascades secondary to TBI. While a number of studies have demonstrated direct evidence for the activation of apoptotic cascades in TAI, the precise pathway by which these cascades are initiated remains a subject of intense investigation. As axolemmal disruption with the subsequent intra-axonal influx of large molecular weight species has been demonstrated to occur in relation to local axonal breakdown, attention has focused on cascades that may occur as a result of loss of ionic homeostasis. One proposed pathway by which this has been hypothesized to occur is the Ca(2+)-mediated activation of calmodulin and subsequent activation of the phosphatase calcineurin with dephosphorylation of a protein known as BAD, leading to a proapoptotic interaction between BAD and the mitochondrial protein Bcl-xL. While this pathway is an intriguing route for traumatic axonal pathogenesis, neither conventional immunocytochemical/histochemical nor ultrastructural approaches have had the capacity to shed insight on whether BAD and Bcl-xL interact in TAI in vivo. We describe the implementation of confocal and two-photon excitation fluorescence resonance energy transfer (FRET) microscopy techniques through which we demonstrate interaction between the proapoptotic protein BAD and the prosurvival protein Bcl-xL within TAI following TBI. Further, we report on a method to reliably detect protein interactions within aldehyde fixed tissue sections through conventional immunohistochemical approaches.

Animals↗

Beta-amyloid precursor protein staining of nonaccidental central nervous system injury in pediatric autopsies.

Immunohistochemical staining for beta-amyloid precursor protein (betaAPP) is a well-established marker of traumatic axonal injury in adults. Recent studies have used similar techniques to evaluate nonaccidental central nervous system injury (NAI) in infants and young children. In this prospective study, we report the results of betaAPP immunohistochemistry on the brain and spinal cord in 28 pediatric cases of NAI. BetaAPP-immunoreactive axons were present in 27/28 cases. Vascular axonal injury (VAI) due to brain swelling and secondary vascular compromise was the most common pattern of betaAPP immunoreactivity and was detected in 22 of 28 cases. Traumatic axonal injury was detected in 19/28 cases, although only eight of these cases showed brainstem staining, thus fulfilling the criteria for the diagnosis of diffuse traumatic axonal injury (dTAI). TAI and VAI were both present in 16/28 cases. Isolated TAI and VAI occurred in three and five cases, respectively. All children with isolated VAI were <18 months of age. An additional finding highlighted by betaAPP immunostaining was a penumbra of axonal injury adjacent to focal lesions, such as lacerations. We conclude that betaAPP immunohistochemistry aids in documenting trauma in nonaccidental central nervous system injury in infants and young children and that VAI is a common finding.

Age Factors↗

Predicting unconsciousness from a pediatric brain injury threshold.

The objective of this study was to utilize tissue deformation thresholds associated with acute axonal injury in the immature brain to predict the duration of unconsciousness. Ten anesthetized 3- to 5-day-old piglets were subjected to nonimpact axial rotations (110-260 rad/s) producing graded injury, with periods of unconsciousness from 0 to 80 min. Coronal sections of the perfusion-fixed brain were immunostained with neurofilament antibody (NF-68) and examined microscopically to identify regions of swollen axons and terminal retraction balls. Each experiment was simulated with a finite element computational model of the piglet brain and the recorded head velocity traces to estimate the local tissue deformation (strain), the strain rate and their product. Using thresholds associated with 50, 80 and 90% probability of axonal injury, white matter regions experiencing suprathreshold responses were determined and expressed as a fraction of the total white matter volume. These volume fractions were then correlated with the duration of unconsciousness, assuming a linear relationship. The thresholds for 80 and 90% probability of predicting injury were found to correlate better with injury severity than those for 50%, and the product of strain and strain rate was the best predictor of injury severity (p=0.02). Predictive capacity of the linear relationship was confirmed with additional (n=13) animal experiments. We conclude that the suprathreshold injured volume can provide a satisfactory prediction of injury severity in the immature brain.

Aging↗

Large animal models of traumatic injury to the immature brain.

Large animal models have been used much less frequently than rodent models to study traumatic brain injury. However, large animal models offer distinct advantages in replicating specific mechanisms, morphology and maturational stages relevant to age-dependent injury responses. This paper reviews how each of these features is relevant in matching a model to a particular scientific question and discusses various scaling strategies, advantages and disadvantages of large animal models for studying traumatic brain injury in infants and children. Progress to date and future directions are outlined.

Aging↗

Polyethylene glycol treatment after traumatic brain injury reduces beta-amyloid precursor protein accumulation in degenerating axons.

Polyethylene glycol (PEG; 2,000 MW; 30% v/v) is a nontoxic molecule that can be injected intravenously and possesses well-documented neuroprotective properties in the spinal cord of the guinea pig. Recent studies have shown that intravenous PEG can also enter the rat brain parenchyma after injury and repair cellular membrane damage in the region of the corpus callosum. Disrupted anterograde axonal transport and resulting beta-amyloid precursor protein (APP) accumulation are byproducts of traumatic axonal injury (TAI) in the brain. APP accumulation indicates axonal degeneration as a result of axotomy, a detriment that can lead to cell death. In this study, we show that PEG treatment can eliminate APP accumulation in specific brain areas of rats receiving TAI. Six areas of the brain were analyzed: the medial cortex, hippocampus, lateral cortex, thalamus, medial lemniscus, and medial longitudinal fasciculus. Increased APP expression after injury was abolished in the thalamus and reduced in the medial longitudinal fasciculus by PEG treatment. In all remaining areas except for the lateral cortex, APP expression was not increased between injured and uninjured brains, indicating that damage was undetected in those brain areas in this study.

Amyloid beta-Peptides↗

Initial CSF total tau correlates with 1-year outcome in patients with traumatic brain injury.

OBJECTIVE: We investigated if tau, microtubular binding protein, in serum and ventricular CSF (vCSF) in patients with severe traumatic brain injury (TBI) during the initial posttraumatic days correlated to 1-year outcome. METHODS: Patients with severe TBI (n = 39, Glasgow Coma Scale score 2,126 pg/mL on days 2 to 3 discriminated between dead and alive (sensitivity of 100% and a specificity of 81%). A vCSF total tau level of >702 pg/mL on days 2 to 3 discriminated between bad (GOSE 1 to 4) and good (GOSE 5 to 8) outcome (sensitivity of 83% and a specificity of 69%). Patients with GOSE 1 (dead) had higher vCSF total tau levels on days 2 to 3 (p < 0.001) vs both surviving patients (GOSE 2 to 8) and those with NPH. Total tau was not detected in serum throughout the study. CONCLUSION: The increase in ventricular CSF (vCSF) total tau probably reflects axonal damage, known to be a central pathologic mechanism in traumatic brain injury (TBI). These results suggest that vCSF total tau may be an important early biochemical neuromarker for predicting long-term outcome in patients with a severe TBI.

Adolescent↗

High-field proton magnetic resonance spectroscopy of a swine model for axonal injury.

A miniature swine model for diffuse brain injury has recently been developed that replicates the inertial loading conditions associated with rotational acceleration during automotive accidents. The swine model induces diffuse axonal pathology without macroscopic injury such as contusions and hematomas, thus affording a unique opportunity to study axonal injury with noninvasive techniques such as magnetic resonance imaging (MRI) and spectroscopy (MRS). In the present study, we evaluated this diffuse injury model with proton MRS, in vivo, using a high-field (4.0-T) MR scanner, since MRS has been demonstrated as a sensitive probe for detecting neurochemical abnormalities. Our study examined a region of the swine brain at timepoints before and after brain injury. Spectroscopic results indicate that N-acetylaspartate/creatine is diminished by at least 20% in regions of confirmed axonal pathology, whereas conventional MRI did not detect any abnormalities. These findings suggest that MRS has high sensitivity in diagnosing microscopic pathology following diffuse brain injury.

Animals↗

Blunt carotid artery injury: the futility of aggressive screening and diagnosis.

BACKGROUND: Blunt carotid artery injury (BCI) remains a rare but potentially lethal condition. Recent studies recommend that aggressive screening based on broad criteria (hyperextension-hyperflexion mechanism of injury, basilar skull fracture, cervical spine injury, midface fracture, mandibular fracture, diffuse axonal brain injury, and neck seat-belt sign) increases the rate of diagnosis of BCI by 9-fold. If this recommendation becomes a standard of care, it will require a major consumption of resources and may give rise to liability claims. The benefits of aggressive screening are unclear because the natural history of asymptomatic BCI is unknown and the existing treatments are controversial. HYPOTHESIS: The lack of an aggressive angiographic screening protocol does not result in delayed BCI diagnosis or BCI-related neurologic deficits. METHODS: A 10-year medical record review of patients with BCI was undertaken in 2 level I academic trauma centers. In both centers, urgent screening for BCI was performed in patients with focal neurologic signs or neurologic symptoms unexplainable by results of computed tomography of the brain as well as in selected patients undergoing angiography for another reason. RESULTS: Of 35 212 blunt trauma admissions, 17 patients (0.05%) were diagnosed as having BCI. Six showed no evidence of BCI-related neurologic symptoms during hospitalization or prior to death as a result of associated injuries. Eleven sustained a BCI-related stroke, 9 of whom had it within 2 hours of injury. The remaining 2 had a delayed diagnosis (9 and 12 hours after injury) and received only anticoagulation because the lesions were surgically inaccessible. Just 1 of these 2 patients met the criteria for BCI screening and could have been offered earlier treatment, of uncertain benefit, if we had adopted an aggressive screening policy. CONCLUSIONS: Of the few patients with BCI, most remain asymptomatic or develop neurologic deficits shortly after injury. Although a widely applied, resource-consuming screening program may increase the rate of early diagnosis of BCI, an improvement in outcome is uncertain. A cost-effectiveness analysis should be done before trauma surgeons accept an aggressive screening protocol as the standard of care.

Adolescent↗

Hypoglycaemia is a cause of axonal injury.

Axonal injury as demonstrated immunohistochemically is increasingly being recognized at post-mortem in patients who have been unconscious, and in some cases the cause of the coma may not be immediately apparent. Considerations include microscopical diffuse traumatic axonal injury and axonal injury associated with a range of metabolic encephalopathies. In this study, extensive neurohistological examination was undertaken in 13 patients in whom coma was attributed to hypoglycaemia and in whom neurohistological examination had revealed varying degrees of widely distributed neuronal necrosis: in five of these cases there was also evidence that the intracranial pressure had been high with internal hernation. It is concluded that a significant amount of axonal injury found in these 13 cases can be attributed to hypoglycaemia per se although the amount and distribution of the axonal damage is altered in the presence of raised intracranial pressure. However, in some cases axonal damage is seen in the absence of an elevated intracranial pressure and in one case its distribution closely mimicked that seen in microscopical diffuse traumatic axonal injury. This further demonstrates that not all axonal pathology is traumatic, and that adequate sampling and care in interpretation of Abeta-PP staining is required in forensic practice.

Adolescent↗

Continued in situ DNA fragmentation of microglia/macrophages in white matter weeks and months after traumatic brain injury.

Paraffin-embedded material from the pons of head-injured patients whose disability could be attributed to diffuse traumatic axonal injury, and controls, was identified from the department's archive. The cases were divided into three groups based on survival, viz Group 1 (n = 5) who survived for between 4 and 8 weeks, Group 2 (n = 5) for between 3 and 9 months, and Group 3 (n = 5) who survived for more that 12 months. Sections were stained by the TUNEL (TdT-mediated UTP nick end labelling) technique, and by H&E, LFB/CV and immunohistochemically for astrocytes (GFAP) and microglia/macrophages (CD68). Microscopic abnormalities were mapped onto line diagrams of two levels of the pons and quantitation of the response determined by an eye-piece graticule placed over the medial lemmisci, cortico-spinal and transverse fiber tracts. Data were pooled by region of interest. In the H&E and LFB/CV stained sections, there was variable pallor of staining in ascending and descending fiber tracts due to loss of myelin: within these same tracts there was an astrocytosis and increased numbers of microglia/macrophages compared with controls. In the white matter tracts of the controls, there was on average 1-2 TUNEL+ cells per unit area. In contrast, there were on average 2-16 TUNEL+ cells in the cortico-spinal tracts and in the medial lemnisci of all groups of head-injured patients. CD68+ cells co-located with the TUNEL+, and their number mirrored the TUNEL + staining with on average 16-30 cells per unit area in Group 1, 14-27 cells per unit area in Group 2, and 12-14 cells per unit area in Group 3. There was a statistical association between the TUNEL+ and CD68+ cells. Few changes were seen in the transverse fiber tracts of the pons. These findings indicate that most of the in situ DNA fragmentation occurred in microglia/macrophages in ascending and descending fiber tracts of the brain stem in which by conventional light microscopy there is Wallerian degeneration. However, in addition, a few TUNEL+ oligodendrocyte-like cells were also seen.

Adolescent↗

[MR imaging of corpus callosal injuries].

The MR imaging and CT findings of corpus callosal injury were analyzed in 32 of 224 patients with acute head injuries. MR imaging was more sensitive than CT in the detection of callosal injuries. All 9 hemorrhagic lesions were visualized on both MR imaging and CT. Fifteen of 23 nonhemorrhagic lesions were not visualized on CT, although all nonhemorrhagic lesions were visualized on MR imaging. Twenty-four lesions of the corpus callosum were located in the splenium, but no lesion was located in the rostrum. Diffuse axonal shear injuries were visualized in 25 patients with callosal injury as associated traumatic lesions. Twenty-three patients with callosal injury had low initial Glasgow Coma Scale scores (less than 9), but 9 patients had high scores. Associated diffuse axonal shear injuries, especially in the brain stem could be a possible explanation for this difference. MR imaging is useful to detect traumatic lesions of the corpus callosum.

Accidents, Traffic↗

Altered expression patterns of metabotropic glutamate receptors in diffuse brain injury.

The metabotropic glutamate receptors (mGluRs), as one of the newly found glutamate receptors, play an important role in the physiological processes of the central nervous system. The authors examined the changes of expression patterns of mGluRs after diffuse brain injuries (DBI) in rats. DBI was produced by Marmarou's methods. The mRNA expression of mGluRs was detected by hybridization in situ at different time points after brain injuries. Compared with normal control and sham-operated control, the animals with DBI showed a significantly increased expression of group I and group III mGluRs (except mGluR6, P<0.05). The increased peak of group I appeared at 24 h after injuries and group III at 6 h after injuries. While, group II mGluRs decreased after DBI (P<0.05) and the lowest point occurred at 48 h after DBI. The difference of time sequence of the expression alterations between group I and group III mGluRs may reflect a self-protection first mechanism of the damaged neurons. It may provide new insight for the development of new pharmaceuticals in the treatment of DBI.

Animals↗