Diffuse Brain Injury-Review of Literature and Representative Case Reports

Review of Literature: Diffuse brain injury includes diffuse axonal injury (DAI), diffuse vascular injury, hypoxic-ischemic injury and brain swelling. Adams described three grades of DAI. Diffuse vascular injury is usually incompatible with life. Ischemic hypoxia results in hemispheric hypodensity. Cerebral hemispheric swelling has the highest mortality.

 Administration of mannitol, hyperventilation for short duration and infusion of barbiturate are useful to control ICP. Decompressive craniectomy is recommended in patients with severe brain edema. Transgastric jejunal feeding and early tracheostomy are recommended in ventilated patients. Cognitive rehabilitation therapy (CRT) is the fundamental component of comprehensive rehabilitation.

Case Reports: The 28 year male with DAI grade 1 improved in 2 weeks. The 19 year male with DAI grade 3 needed prolonged ventilation, tracheostomy and jejunal feeding. He improved by 2 months. A 3 year old child with DAI grade 1 improved in 2 weeks. A 15 year old boy had progressive multiple intracerebral haemorrhages, suggestive of vascular injury. Decompressive craniectomy was done. He improved by three months. A 20 year male with polytrauma had hemispheric hypodensity due to hypoxic ischaemia. He died after 18 hours. A 27 year male had severe diffuse brain swelling, for which decompressive craniectomy was done. He died after 23 hours.

Conclusions: The classification of diffuse brain injury into four types and the various grading systems based on imaging are useful for prognostication. Brainstem lesions delay recovery of consciousness. Absence of basal cisterns and positive midline shift are predictors of death. Hypoxic ischaemia and brain swelling have poor prognosis.