Contribution of vasogenic and cellular edema to traumatic brain swelling measured by diffusion-weighted imaging

MLC901, a Traditional Chinese Medicine induces neuroprotective and neuroregenerative benefits after traumatic brain injury in rats

Traumatic brain injury (TBI) is a frequent and clinically highly heterogeneous neurological disorder with large socioeconomic consequences. NeuroAid (MLC601 and MLC901), a Traditional Medicine used in China for patients after stroke has been previously reported to induce neuroprotection and neuroplasticity. This study was designed to evaluate the neuroprotective and neuroregenerative effects of MLC901 in a rat model of TBI. TBI was induced by a moderate lateral fluid percussion applied to the right parietal cortex. MLC901 was injected intraperitoneally at 2h post-TBI, and then administered in drinking water at a concentration of 10mg/ml until sacrifice of the animals. The cognitive deficits induced by TBI were followed by using the "what-where-when" task, which allows the measurement of episodic-like memory. MLC901 treatment decreased brain lesions induced by TBI. It prevented the serum increase of S-100 beta (S100B) and neuron-specific enolase (NSE), which may be markers to predict the neurologic outcome in human patients with TBI. MLC901 reduced the infarct volume when injected up to 2h post-TBI, prevented edema formation and assisted its resolution, probably via the regulation of aquaporin 4. These positive MLC901 effects were associated with an upregulation of vascular endothelial growth factor (VEGF) as well as an increase of endogenous hippocampal neurogenesis and gliogenesis around the lesion. Furthermore, MLC901 reduced cognitive deficits induced by TBI. Rats subjected to TBI displayed a suppression of temporal order memory, which was restored by MLC901. This work provides evidence that MLC901 has neuroprotective and neurorestorative actions, which lead to an improvement in the recovery of cognitive functions in a model of traumatic brain injury.

[Cerebral oedema: new therapeutic ways]

Cerebral oedema (CO) after brain injury can occur from different ways. The vasogenic and cytotoxic oedema are usually described but osmotic and hydrostatic CO, respectively secondary to plasmatic hypotonia or increase in blood pressure, can also be encountered. Addition of these several mechanisms can worsen injuries. Consequences are major, leading quickly to death secondary to intracerebral hypertension and later to neuropsychic sequelae. So therapeutic care to control this phenomenon is essential and osmotherapy is actually the only way. A better understanding of physiopathological disorders, particularly energetic ways (lactate), aquaporine function, inflammation lead to new therapeutic hopes. The promising experimental results need now to be confirmed by clinical data.

Far-red tracer analysis of traumatic cerebrovascular permeability

BACKGROUND

Blood brain barrier (BBB) compromise is a key pathophysiological component of secondary traumatic brain injury characterized by edema and neuroinflammation in a previously immune-privileged environment. Current assays for BBB permeability are limited by working size, harsh extraction processes, suboptimal detection via absorbance, and wide excitation fluorescence spectra. In this study, we evaluate the feasibility of Alexa Fluor 680, a far-red dye bioconjugated to dextran, as an alternative assay to improve resolution and sensitivity.

METHODS

Alexa Fluor was introduced intravenously on the day of sacrifice to three groups: sham, controlled cortical impact (CCI), and CCI treated with a cell based therapy known to reduce BBB permeability. The brains were sectioned coronally and imaged using an infrared laser scanner to generate intensity plot profiles as well as signal threshold images to distinguish regions with varying degrees of permeability.

RESULTS

Linear plot profile analysis demonstrated greater signal intensity from CCI than treated rats at corresponding injury depths. Threshold analysis identified rims of signal at low + narrow threshold ranges. The integrated signals from a treatment group known to preserve the BBB were significantly less than the groups with CCI injury alone. There was no significant difference at high + wide signal intensity threshold ranges.

CONCLUSIONS

Alexa Fluor 680 infrared photodetection and image analysis can aid in detecting differential degrees of BBB permeability after traumatic brain injury and maybe particularly useful in demonstrating BBB preservation of at-risk regions in response to therapeutic agents.

Effect of needle insertion speed on tissue injury, stress, and backflow distribution for convection-enhanced delivery in the rat brain

Flow back along a needle track (backflow) can be a problem during direct infusion, e.g. convection-enhanced delivery (CED), of drugs into soft tissues such as brain. In this study, the effect of needle insertion speed on local tissue injury and backflow was evaluated in vivo in the rat brain. Needles were introduced at three insertion speeds (0.2, 2, and 10 mm/s) followed by CED of Evans blue albumin (EBA) tracer. Holes left in tissue slices were used to reconstruct penetration damage. These measurements were also input into a hyperelastic model to estimate radial stress at the needle-tissue interface (pre-stress) before infusion. Fast insertion speeds were found to produce more tissue bleeding and disruption; average hole area at 10 mm/s was 1.87-fold the area at 0.2 mm/s. Hole measurements also differed at two fixation time points after needle retraction, 10 and 25 min, indicating that pre-stresses are influenced by time-dependent tissue swelling. Calculated pre-stresses were compressive (0 to 485 Pa) and varied along the length of the needle with smaller average values within white matter (116 Pa) than gray matter (301 Pa) regions. Average pre-stress at 0.2 mm/s (351.7 Pa) was calculated to be 1.46-fold the value at 10 mm/s. For CED backflow experiments (0.5, 1, and 2 µL/min), measured EBA backflow increased as much as 2.46-fold between 10 and 0.2 mm/s insertion speeds. Thus, insertion rate-dependent damage and changes in pre-stress were found to directly contribute to the extent of backflow, with slower insertion resulting in less damage and improved targeting.

Monocyte chemoattractant protein-1 and the blood-brain barrier

The blood-brain barrier (BBB) is a dynamic structure that maintains the homeostasis of the brain and thus proper neurological functions. BBB compromise has been found in many pathological conditions, including neuroinflammation. Monocyte chemoattractant protein-1 (MCP1), a chemokine that is transiently and significantly up-regulated during inflammation, is able to disrupt the integrity of BBB and modulate the progression of various diseases, including excitotoxic injury and hemorrhage. In this review, we first introduce the biochemistry and biology of MCP1, and then summarize the effects of MCP1 on BBB integrity as well as individual BBB components.

Toward objective markers of concussion in sport: a review of white matter and neurometabolic changes in the brain after sports-related concussion

Abstract Sports-related concussion is an issue that has piqued the public's attention of late as concerns surrounding potential long-term sequelae as well as new methods of characterizing the effects of this form of injury continue to develop. For the most part, diagnosis of concussion is based on subjective clinical measures and thus is prone to under-reporting. In the current environment, where conventional imaging modalities, such as computed tomography and magnetic resonance imaging, are unable to elucidate the degree of white matter damage and neurometabolic change, a discussion of two advanced imaging techniques-diffusion tensor imaging (DTI) and magnetic resonance spectroscopy (MRS)-is undertaken with a view to highlighting their potential utility. Our aim is to outline a variety of the approaches to concussion research that have been employed, with special attention given to the clinical considerations and acute complications attributed to concussive injury. DTI and MRS have been at the forefront of research as a result of their noninvasiveness and ease of acquisition, and hence it is thought that the use of these neuroimaging modalities has the potential to aid clinical decision making and management, including guiding return-to-play protocols.

Overexpression of aquaporin‑1 aggravates hippocampal damage in mouse traumatic brain injury models

'Secondary insult' following primary traumatic brain injury (TBI), including ischemia and edema, may aggravate brain impairments and affect the outcomes. The hippocampus is particularly sensitive to ischemia or edema due to its selective vulnerability, as neural cells of the hippocampus may be more prone to abnormal function or cell death in response to ischemia and edema. Aquaporin‑1 (AQP‑1) was reported to be associated with cerebral edema; however, the expression and role of AQP‑1 in hippocampal edema following TBI have seldom been investigated. In the current study, BALB/c mouse closed craniocerebral injury models were established and the changes of AQP‑1 expression in hippocampi of mouse models following TBI were investigated. Neurological function and edema formation of the models were evaluated and the apoptotic hippocampal cells were then stained in situ and detected, followed by determination of AQP‑1 expression in the hippocampus using immunohistochemistry and western blot analysis. As a result, the majority of mice in the TBI group were severely injured and hippocampal edema was confirmed. The apoptotic cells increased significantly in the hippocampi of mice in the TBI group compared with those in the sham group (P<0.01) and the apoptotic rate increased gradually in a time‑dependent manner. The expression levels of AQP‑1 in the hippocampi of mice were markedly higher in the TBI group than in the sham group (P<0.05) at various time points and AQP‑1 expression levels peaked one day following TBI. These results indicate that upregulation of AQP‑1 may participate in edema formation and delayed cell death of the hippocampus following TBI and may also be a novel therapeutic target to protect the hippocampus from secondary injury following TBI.

Timing of intracranial hypertension following severe traumatic brain injury

BACKGROUND

We asked whether continuous intracranial pressure (ICP) monitoring data could provide objective measures of the degree and timing of intracranial hypertension (ICH) in the first week of neurotrauma critical care and whether such data could be linked to outcome.

METHODS

We enrolled adult (>17 years old) patients admitted to our Level I trauma center within 6 h of severe TBI. ICP data were automatically captured and ICP 5-minute means were grouped into 12-hour time periods from admission (hour 0) to >7 days (hour 180). Means, maximum, percent time (% time), and pressure-times-time dose (PTD, mmHg h) of ICP >20 mmHg and >30 mmHg were calculated for each time period.

RESULTS

From 2008 to 2010, we enrolled 191 patients. Only 2.1% had no episodes of ICH. The timing of maximum PTD20 was relatively equally distributed across the 15 time periods. Median ICP, PTD20, %time20, and %time30 were all significantly higher in the 84-180 h time period than the 0-84 h time period. Stratified by functional outcome, those with poor functional outcome had significantly more ICH in hours 84-180. Multivariate analysis revealed that, after 84 h of monitoring, every 5% increase in PTD20 was independently associated with 21% higher odds of having a poor functional outcome (adjusted odds ratio = 1.21, 95% CI 1.02-1.42, p = 0.03).

CONCLUSIONS

Although early elevations in ICP occur, ICPs are the highest later in the hospital course than previously understood, and temporal patterns of ICP elevation are associated with functional outcome. Understanding this temporal nature of secondary insults has significant implications for management.

Multishot diffusion-weighted MR imaging features in acute trauma of spinal cord

OBJECTIVES

To analyse diffusion-weighted MRI of acute spinal cord trauma and evaluate its diagnostic value.

METHODS

Conventional MRI and multishot, navigator-corrected DWI were performed in 20 patients with acute spinal cord trauma using 1.5-T MR within 72 h after the onset of trauma.

RESULTS

Twenty cases were classified into four categories according to the characteristics of DWI: (1) Oedema type: ten cases presented with variable hyperintense areas within the spinal cord. There were significant differences in the apparent diffusion coefficients (ADCs) between lesions and unaffected regions (t = -7.621, P < 0.01). ADC values of lesions were markedly lower than those of normal areas. (2) Mixed type: six cases showed heterogeneously hyperintense areas due to a mixture of haemorrhage and oedema. (3) Haemorrhage type: two cases showed lesions as marked hypointensity due to intramedullary haemorrhage. (4) Compressed type (by epidural haemorrhage): one of the two cases showed an area of mild hyperintensity in the markedly compressed cord due to epidural haematoma.

CONCLUSIONS

Muti-shot DWI of the spinal cord can help visualise and evaluate the injured spinal cord in the early stage, especially in distinguishing the cytotoxic oedema from vasogenic oedema. It can assist in detecting intramedullary haemorrhage and may have a potential role in the evaluation of compressed spinal cord.

KEY POINTS

• Multishot, navigator-corrected diffusion-weighted MRI is helpful when evaluating spinal cord injury (SCI). • Four types of SCI may be classified according to the DWI characteristics. • DWI differentiates cytotoxic from vasogenic oedema, thereby determining the centre of SCI. • DWI can assist in detecting intramedullary haemorrhage. • DWI can help evaluate the degree of compressed spinal cord.

T Allele of nonsense polymorphism (rs2039381, Gln71Stop) of interferon-ε is a risk factor for the development of intracerebral hemorrhage

Interferons (IFNs) play key roles in various biologic responses including antiviral and immune reactions. We evaluated one possible risk factor in nonsense polymorphism (rs2039381, Gln71Stop) of interferon-ε (IFNE). We recruited stroke [119 ischemic stroke (IS) and 145 intracerebral hemorrhage (ICH)] and control (401), respectively. The nonsense SNP (rs2039381, Gln71Stop) of IFNE was selected. We identified individual genotype using sequencing. SNPStats and SPSS 18.0 programs were used to analyze genetic data. Genotype frequencies (C/C:C/T:T/T) in the ICH group and control group were 59.3:37.9:2.8 and 73.6:23.4:3.0, respectively. We found that rs2039381 was associated with ICH (OR = 2.01, 95% CI = 1.33-3.03, p = 0.001 in codominant1 model; OR = 1.91, 95% CI = 1.28-2.84, p = 0.0016 in dominant model; OR = 1.60, 95% CI = 1.14-2.26, p = 0.0074 in log-additive model). T allele frequency of rs2039381 was significantly higher in ICH than in controls. The nonsense SNP (rs2039381, Gln71Stop) of IFNE was associated with ICH (OR = 1.61, 95% CI = 1.14-2.26, p = 0.006). A nonsense SNP (rs2039381, Gln71Stop) of IFNE was associated with ICH in Korean population. Our findings raise the possibility that the T allele of rs2039381 is a risk factor which is susceptible to ICH.

Intraventricular albumin: an optional agent in experimental post-traumatic brain edema

HYPOTHESIS

Human albumin may be effective in the treatment of posttraumatic brain edema due to its hyperoncotic features. Therefore, the aim of the experimental study presented in this paper has two points: the first is to evaluate the efficacy of intraventricular hyperoncotic human albumin on post-traumatic brain edema and the second is to try to show the appropriate posttraumatic time window for albumin administration.

METHOD

Traumatic brain injury and subsequent edema was formed by a model of impact acceleration injury in rats. Human albumin was administered via intraventricular route by using a stereotactic head holder. All animals in each group were decapitated 24 hours after the procedure and the effect of albumin was evaluated by measurement of tissue specific gravity.

RESULTS

Tissue specific gravity decreased in edematous tissue (trauma indicator), increased after albumin administration at the 12th (p < 0.001), and both at the 1st and 12th hour of the trauma (edema treatment; p < 0.001). On the other hand, albumin administered at the 12th, and at both the 1st and 12th hours in the rats without trauma has caused the formation of the brain edema.

CONCLUSION

We conclude that human albumin is effective in cytotoxic, but not in vasogenic edema and exerts its best anti-edematous effect at the 12th hour of severe head trauma and this study may help future studies that will try to show the effects of albumin with different time modalities after severe head injury.

Purinergic 2Y1 receptor stimulation decreases cerebral edema and reactive gliosis in a traumatic brain injury model

Traumatic brain injury (TBI) is the leading cause of death and disability in children and young adults. Neuroprotective agents that may promote repair or counteract damage after injury do not currently exist. We recently reported that stimulation of the purinergic receptor subtype P2Y(1)R using 2-methylthioladenosine 5' diphosphate (2MeSADP) significantly reduced cytotoxic edema induced by photothrombosis. Here, we tested whether P2Y(1)R stimulation was neuroprotective after TBI. A controlled closed head injury model was established for mice using a pneumatic impact device. Brains were harvested at 1, 3, or 7 days post-injury and assayed for morphological changes by immunocytochemistry, Western blot analysis, and wet/dry weight. Cerebral edema and expression of both aquaporin type 4 and glial fibrillary acidic protein were increased at all time points examined. Immunocytochemical measurements in both cortical and hippocampal slices also revealed significant neuronal swelling and reactive gliosis. Treatment of mice with 2MeSADP (100 μM) or MRS2365 (100 μM) 30 min after trauma significantly reduced all post-injury symptoms of TBI including edema, neuronal swelling, reactive gliosis, and AQ4 expression. The neuroprotective effect was lost in IP(3)R2-/- mice treated with 2MeSADP. Immunocytochemical labeling of brain slices confirmed that P2Y(1)R expression was defined to cortical and hippocampal astrocytes, but not neurons. Taken together, the data show that stimulation of astrocytic P2Y(1)Rs significantly reduces brain injury after acute trauma and is mediated by the IP(3)-signaling pathway. We suggest that enhancing astrocyte mitochondrial metabolism offers a promising neuroprotective strategy for a broad range of brain injuries.

Hypoxia-inducible factor 1 is essential for spontaneous recovery from traumatic brain injury and is a key mediator of heat acclimation induced neuroprotection

Heat acclimation (HA), a well-established preconditioning model, confers neuroprotection in rodent models of traumatic brain injury (TBI). It increases neuroprotective factors, among them is hypoxia-inducible factor 1α (HIF-1α), which is important in the response to postinjury ischemia. However, little is known about the role of HIF-1α in TBI and its contribution to the establishment of the HA protecting phenotype. Therefore, we aimed to explore HIF-1α role in TBI defense mechanisms as well as in HA-induced neuroprotection. Acriflavine was used to inhibit HIF-1 in injured normothermic (NT) or HA mice. After TBI, we evaluated motor function recovery, lesion volume, edema formation, and body temperature as well as HIF-1 downstream transcription targets, such as glucose transporter 1 (GLUT1), vascular endothelial growth factor, and aquaporin 4. We found that HIF-1 inhibition resulted in deterioration of motor function, increased lesion volume, hypothermia, and reduced edema formation. All these parameters were significantly different in the HA mice. Western blot analysis and enzyme-linked immunosorbent assay showed reduced levels of all HIF-1 downstream targets in HA mice, however, only GLUT1 was downregulated in NT mice. We conclude that HIF-1 is a key mediator in both spontaneous recovery and HA-induced neuroprotection after TBI.

Detection of white matter lesions in the acute stage of diffuse axonal injury predicts long-term cognitive impairments: a clinical diffusion tensor imaging study

BACKGROUND

White matter disruption is known to contribute to neurocognitive deficits after diffuse axonal injury (DAI). This study evaluated the relationship between white matter integrity using diffusion tensor imaging in the early stage and cognitions in the chronic stage.

METHODS

Diffusion tensor imaging was performed in 15 patients with DAI within 7 days of injury and in 15 patients in the control group. Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were calculated within regions of interest, including the posterior limb of the internal capsule, uncinate fasciculus (UF), anterior corona radiate (ACR), superior longitudinal fasciculus (SLF), inferior longitudinal fasciculus (ILF), genu of the corpus callosum, body of the corpus callosum, and splenium of the corpus callosum and cingulum bundle (CB). The patients with DAI and the patients in the control group also underwent neuropsychological testing during the chronic stage after DAI.

RESULTS

The region-of-interest analysis showed significantly reduced FA and AD values in all nine regions within 7 days of injury as well as increased MD values in the corpus callosum among patients in the DAI group. The patients demonstrated significantly poorer performance on the working memory tests and attention test. In patients, working memory function was positively correlated with the AD value in the UF and with the FA value in the CB, UF, SLF, and ILF. Working memory function was inversely correlated with the RD value in the CB, SLF, and ILF and with the MD value in the SLF and ILF. In addition, the attention function demonstrated a positive correlation with the RD value in the ACR, SLF, and ILF and with the MD value in the ACR, SLF, and ILF. In addition, attention was inversely correlated with the FA values for the posterior limb of the internal capsule, ACR, SLF, and ILF.

CONCLUSION

The results indicated that the presence of white matter changes during the early stage of DAI may be helpful for predicting cognitive dysfunction over the long term.

LEVEL OF EVIDENCE

Prognostic study, level III.

Treating seizures and epilepsy with anticoagulants?

Thrombin is a serine protease playing an essential role in the blood coagulation cascade. Recent work, however, has identified a novel role for thrombin-mediated signaling pathways in the central nervous system. Binding of thrombin to protease-activated receptors (PARs) in the brain appears to have multiple actions affecting both health and disease. Specifically, thrombin has been shown to lead to the onset of seizures via PAR-1 activation. In this perspective article, we review the putative mechanisms by which thrombin causes seizures and epilepsy. We propose a potential role of PAR-1 antagonists and novel thrombin inhibitors as new, possible antiepileptic drugs.

Speed of development of cerebral swelling following blunt cranial trauma

A 22-year-old male suffered severe injuries to the head, chest and abdominal cavities in a vehicle crash, with death occurring at the scene. At autopsy, the cranial cavity was opened and markedly disrupted with compound and comminuted fracturing of all bones of the skull and facial skeleton. The brain showed extensive lacerations with almost complete parenchymal disruption. However, a preserved fragment of right frontal lobe exhibited marked swelling with gyral flattening. This case could provide further evidence for prompt cerebral swelling after blunt head trauma, and is supportive of animal studies that have demonstrated rapid swelling that is most likely is related to reactive vasodilation rather than to vasogenic oedema.

Ultrasmall implantable composite microelectrodes with bioactive surfaces for chronic neural interfaces

Implantable neural microelectrodes that can record extracellular biopotentials from small, targeted groups of neurons are critical for neuroscience research and emerging clinical applications including brain-controlled prosthetic devices. The crucial material-dependent problem is developing microelectrodes that record neural activity from the same neurons for years with high fidelity and reliability. Here, we report the development of an integrated composite electrode consisting of a carbon-fibre core, a poly(p-xylylene)-based thin-film coating that acts as a dielectric barrier and that is functionalized to control intrinsic biological processes, and a poly(thiophene)-based recording pad. The resulting implants are an order of magnitude smaller than traditional recording electrodes, and more mechanically compliant with brain tissue. They were found to elicit much reduced chronic reactive tissue responses and enabled single-neuron recording in acute and early chronic experiments in rats. This technology, taking advantage of new composites, makes possible highly selective and stealthy neural interface devices towards realizing long-lasting implants.

In vivo two-photon microscopy reveals immediate microglial reaction to implantation of microelectrode through extension of processes

OBJECTIVE

Penetrating cortical neural probe technologies allow investigators to record electrical signals in the brain. Implantation of probes results in acute tissue damage, and microglia density increases around implanted devices over weeks. However, the mechanisms underlying this encapsulation are not well understood in the acute temporal domain. The objective here was to evaluate dynamic microglial response to implanted probes using two-photon microscopy.

APPROACH

Using two-photon in vivo microscopy, cortical microglia ∼200 µm below the surface of the visual cortex were imaged every minute in mice with green fluorescent protein-expressing microglia.

MAIN RESULTS

Following probe insertion, nearby microglia immediately extended processes toward the probe at (1.6 ± 1.3) µm min(-1) during the first 30-45 min, but showed negligible cell body movement for the first 6 h. Six hours following probe insertion, microglia at distances <130.0 µm (p = 0.5) from the probe surface exhibit morphological characteristics of transitional stage (T-stage) activation, similar to the microglial response observed with laser-induced blood-brain barrier damage. T-stage morphology and microglia directionality indexes were developed to characterize microglial response to implanted probes. Evidence suggesting vascular reorganization after probe insertion and distant vessel damage was also observed hours after probe insertion.

SIGNIFICANCE

A precise temporal understanding of the cellular response to microelectrode implantation will facilitate the search for molecular cues initiating and attenuating the reactive tissue response.

A new method for modulating traumatic brain injury with mechanical tissue resuscitation

BACKGROUND

Traumatic brain injuries remain a treatment enigma with devastating late results. As terminally differentiated tissue, the brain retains little capacity to regenerate, making early attempts to preserve brain cells after brain injury essential.

OBJECTIVE

To resuscitate damaged tissue by modulating edema, soluble cytokines, and metabolic products in the "halo" of damaged tissue around the area of central injury that progressively becomes compromised. By re-equilibrating the zone of injury milieu, it is postulated neurons in this area will survive and function.

METHODS

Mechanical tissue resuscitation used localized, controlled, subatmospheric pressure directly to the area of controlled cortical impact injury and was compared with untreated injured controls and with sham surgery in a rat model. Functional outcome, T2 magnetic resonance imaging hyperintense volume, magnetic resonance imaging spectroscopy metabolite measurement, tissue water content, injury cavity area, and cortical volume were compared.

RESULTS

There were significant differences between mechanical tissue resuscitation treated and untreated groups in levels of myoinositol, N-acetylaspartate, and creatine. Treated animals had significantly less tissue swelling and density than the untreated animals. Nonviable brain tissue areas were smaller in treated animals than in untreated animals. Treated animals performed better than untreated animals in functional tests. Histological analysis showed the remaining viable ipsilateral cerebral area was 58% greater for treated animals than for untreated animals, and the cavity for treated animals was 95% smaller than for untreated animals 1 month after injury.

CONCLUSION

Mechanical tissue resuscitation with controlled subatmospheric pressure can significantly modulate levels of excitatory amino acids and lactate in traumatic brain injury, decrease the water content and volume of injured brain, improve neuronal survival, and speed functional recovery.

Mild traumatic brain injury: is diffusion imaging ready for primetime in forensic medicine?

Mild traumatic brain injury (MTBI) is difficult to accurately assess with conventional imaging because such approaches usually fail to detect any evidence of brain damage. Recent studies of MTBI patients using diffusion-weighted imaging and diffusion tensor imaging suggest that these techniques have the potential to help grade tissue damage severity, track its development, and provide prognostic markers for clinical outcome. Although these results are promising and indicate that the forensic diagnosis of MTBI might eventually benefit from the use of diffusion-weighted imaging and diffusion tensor imaging, healthy skepticism and caution should be exercised with regard to interpreting their meaning because there is no consensus about which methods of data analysis to use and very few investigations have been conducted, of which most have been small in sample size and examined patients at only one time point after injury.

Blast-induced moderate neurotrauma (BINT) elicits early complement activation and tumor necrosis factor α (TNFα) release in a rat brain

Blast-induced neurotrauma (BINT) is a major medical concern yet its etiology is largely undefined. Complement activation may play a role in the development of secondary injury following traumatic brain injury; however, its role in BINT is still undefined. The present study was designed to characterize the complement system and adaptive immune-inflammatory responses in a rat model of moderate BINT. Anesthetized rats were exposed to a moderate blast (120 kPa) using an air-driven shock tube. Brain tissue injury, systemic and local complement, cerebral edema, inflammatory cell infiltration, and pro-inflammatory cytokine production were measured at 0.5, 3, 48, 72, 120, and 168 h. Injury to brain tissue was evaluated by histological evaluation. Systemic complement was measured via ELSIA. The remaining measurements were determined by immunohistoflourescent staining. Moderate blast triggers moderate brain injuries, elevated levels of local brain C3/C5b-9 and systemic C5b-9, increased leukocyte infiltration, unregulated tumor necrosis factor alpha (TNFα), and aquaporin-4 in rat brain cortex at 3- and 48-hour post blast. Early immune-inflammatory response to BINT involves complement and TNFα, which correlates with hippocampus and cerebral cortex damage. Complement and TNFα activation may be a novel therapeutic target for reducing the damaging effects of BINT inflammation.

Further investigations into the speed of cerebral swelling following blunt cranial trauma

An anesthetized sheep model of traumatic brain injury (TBI) has been developed to assess early changes in intracranial pressure (ICP) following closed head injury. Immediately after TBI, a transient (<10 min) hypertensive response occurred, followed by significant and prolonged systemic hypotension. ICP demonstrated a biphasic response, being seven times baseline values of 8 ± 2 mm Hg 10 min after injury, decreasing to 25 ± 2 mm Hg by 30 min, and then increasing to values exceeding 30 mm Hg by 4 h postinjury. ICP was always significantly higher than baseline values, which combined with hypotension, reduced cerebral perfusion pressure to less than 60% of normal. This early and sustained increase in ICP after craniocerebral trauma acutely alters cerebral perfusion pressure and brain oxygenation and provides a potential pathophysiological explanation for immediate clinical manifestations in humans following significant TBI.

Efficacy of reductive ventricular osmotherapy in a swine model of traumatic brain injury

BACKGROUND

The presence of osmotic gradients in the development of cerebral edema and the effectiveness of osmotherapy are well recognized. A modification of ventriculostomy catheters described in this article provides a method of osmotherapy that is not currently available. The reductive ventricular osmotherapy (RVOT) catheter removes free water from ventricular cerebrospinal fluid (CSF) by incorporating hollow fibers that remove water vapor, thereby providing osmotherapy without increasing osmotic load.

OBJECTIVE

To increase osmolarity in the ventricular CSF through use of RVOT in vivo.

METHODS

Twelve Yorkshire swine with contusional injury were randomized to external ventricular drainage (EVD) or RVOT for 12 hours. MR imaging was obtained. Serum, CSF, and brain ultrafiltrate were analyzed. Histology was compared using Fluor-Jade B and hematoxylin and eosin (H & E) stains.

RESULTS

With RVOT, CSF osmolality increased from 292 ± 2.7 to 345 ± 8.0 mOsmol/kg (mean ± SE, P = 0.0006), and the apparent diffusion coefficient (ADC) in the injury region increased from 0.735 ± 0.047 to 1.135 ± .063 (P = 0.004) over 24 hours. With EVD controls, CSF osmolarity and ADC were not significantly changed. Histologically, all RVOT pigs showed no evidence of neuronal degeneration (Grade 1/4) compared to moderate degeneration (Grade 2.6 ± .4/4) seen in EVD treated animals (P = 0.02). The difference in intracranial pressure (ICP) by area under the curve approached significance at P = .065 by Mann Whitney test.

CONCLUSION

RVOT can increase CSF osmolarity in vivo after experimental traumatic brain injury (TBI). In anticipated clinical use, only a slight increase in CSF osmolarity may be required to reduce cerebral edema.

Diffusion tensor imaging of diffuse axonal injury in a rat brain trauma model

Diffusion tensor imaging (DTI) was used to study traumatic brain injury. The impact-acceleration trauma model was used in rats. Here, in addition to diffusivities (mean, axial and radial), fractional anisotropy (FA) was used, in particular, as a parameter to characterize the cerebral tissue early after trauma. DTI was implemented at 7 T using fast spiral k-space sampling and the twice-refocused spin echo radiofrequency sequence for eddy current minimization. The method was carefully validated on different phantom measurements. DTI of a trauma group (n = 5), as well as a sham group (n = 5), was performed at different time points during 6 h following traumatic brain injury. Two cerebral regions, the cortex and corpus callosum, were analyzed carefully. A significant decrease in diffusivity in the trauma group versus the sham group was observed, suggesting the predominance of cellular edema in both cerebral regions. No significant FA change was detected in the cortex. In the corpus callosum of the trauma group, the FA indices were significantly lower. A net discontinuity in fiber reconstructions in the corpus callosum was observed by fiber tracking using DTI. Histological analysis using Hoechst, myelin basic protein and Bielschowsky staining showed fiber disorganization in the corpus callosum in the brains of the trauma group. On the basis of our histology results and the characteristics of the impact-acceleration model responsible for the presence of diffuse axonal injury, the detection of low FA caused by a drastic reduction in axial diffusivity and the presence of fiber disconnections of the DTI track in the corpus callosum were considered to be related to the presence of diffuse axonal injury.

Diffusion tensor tractography indices in patients with frontal lobe injury and its correlation with neuropsychological tests

OBJECTIVES

Diffusion tensor tractography (DTT) was performed to quantify diffuse axonal injury (DAI) in major white matter (WM) fiber bundles (FBs) of patients with frontal lobe injury and to correlate these changes with neuropsychological tests (NPT) at 6 month follow-up.

PATIENTS AND METHODS

DTT was performed in 21 patients with moderate traumatic brain injury (TBI) within week and after 6 month follow-up, and in controls. DTI indices were calculated from the entire FBs in patients as well as controls. Bonferroni multiple comparisons Post hoc test was performed for determining the changes in DTI indices. Paired t-test was performed between DTI indices at baseline and follow-up. Pearson's correlation was performed between NPT scores and DTI indices.

RESULTS

Significant changes in DTI indices were observed in some of the FBs as compared to controls which incompletely recovered at 6 month follow-up. DTI indices of different WM FBs correlated significantly with some of the NPT.

CONCLUSION

We conclude that DTT based quantification helps in assessment of DAI in patients with moderate frontal lobe injury. Some of the FBs recover partially at 6 month follow-up and correlate with NPT scores.

Effects of hemodilution after traumatic brain injury in juvenile rats

BACKGROUND

Normovolemic hemodilution (HD) in adult animal studies has shown exacerbation of traumatic brain injury (TBI) lesion volumes. Similar studies in juvenile rats have not been reported and outcomes are likely to be different. This study investigated the effects of normovolemic hemodilution (21% hematocrit) in a juvenile TBI (jTBI) model.

METHODS

Twenty 17-day-old rats underwent moderate cortical contusion impact injury (CCI) and were divided into four groups: CCI/hemodilution (HD) (group HD), CCI/no HD (group C), Sham/HD (group SHD), and Sham/no HD (group S). Regional laser Doppler flowmetry (LDF), edema formation (MRI-T2WI), water mobility assessed using diffusion weighted imaging (MRI-DWI), open field activity tests, and histological analyses were evaluated for lesion characteristics.

RESULTS

Hemodilution significantly increased blood flow in the HD compared to the C group after TBI. T2WI revealed a significantly increased extravascular blood volume in HD at 1, 7, and 14 days post-CCI. Edematous tissue and total contusional lesion volume were higher in HD-treated animals at 1 and 14 days. DWI revealed that HD, SHD, and C groups had elevated water mobility compared to S groups in the ipsilateral cortex and striatum. Histology showed a larger cortical lesion in the C than HD group. Open field activity was increased in HD, C, and SHD groups compared to the S group.

CONCLUSIONS

Hemodilution results in significant brain hyperemia with increased edema formation, extravascular blood volume, and water mobility after jTBI. Hemodilution results in less cortical damage but did not alter behavior. Hemodilution is likely not to be clinically beneficial following jTBI.

Diffusion MRI at 25: exploring brain tissue structure and function

Diffusion MRI (or dMRI) came into existence in the mid-1980s. During the last 25 years, diffusion MRI has been extraordinarily successful (with more than 300,000 entries on Google Scholar for diffusion MRI). Its main clinical domain of application has been neurological disorders, especially for the management of patients with acute stroke. It is also rapidly becoming a standard for white matter disorders, as diffusion tensor imaging (DTI) can reveal abnormalities in white matter fiber structure and provide outstanding maps of brain connectivity. The ability to visualize anatomical connections between different parts of the brain, non-invasively and on an individual basis, has emerged as a major breakthrough for neurosciences. The driving force of dMRI is to monitor microscopic, natural displacements of water molecules that occur in brain tissues as part of the physical diffusion process. Water molecules are thus used as a probe that can reveal microscopic details about tissue architecture, either normal or in a diseased state.

Post-traumatic hypoxia exacerbates neurological deficit, neuroinflammation and cerebral metabolism in rats with diffuse traumatic brain injury

Background

The combination of diffuse brain injury with a hypoxic insult is associated with poor outcomes in patients with traumatic brain injury. In this study, we investigated the impact of post-traumatic hypoxia in amplifying secondary brain damage using a rat model of diffuse traumatic axonal injury (TAI). Rats were examined for behavioral and sensorimotor deficits, increased brain production of inflammatory cytokines, formation of cerebral edema, changes in brain metabolism and enlargement of the lateral ventricles.

Methods

Adult male Sprague-Dawley rats were subjected to diffuse TAI using the Marmarou impact-acceleration model. Subsequently, rats underwent a 30-minute period of hypoxic (12% O₂/88% N₂) or normoxic (22% O₂/78% N₂) ventilation. Hypoxia-only and sham surgery groups (without TAI) received 30 minutes of hypoxic or normoxic ventilation, respectively. The parameters examined included: 1) behavioural and sensorimotor deficit using the Rotarod, beam walk and adhesive tape removal tests, and voluntary open field exploration behavior; 2) formation of cerebral edema by the wet-dry tissue weight ratio method; 3) enlargement of the lateral ventricles; 4) production of inflammatory cytokines; and 5) real-time brain metabolite changes as assessed by microdialysis technique.

Results

TAI rats showed significant deficits in sensorimotor function, and developed substantial edema and ventricular enlargement when compared to shams. The additional hypoxic insult significantly exacerbated behavioural deficits and the cortical production of the pro-inflammatory cytokines IL-6, IL-1β and TNF but did not further enhance edema. TAI and particularly TAI+Hx rats experienced a substantial metabolic depression with respect to glucose, lactate, and glutamate levels.

Conclusion

Altogether, aggravated behavioural deficits observed in rats with diffuse TAI combined with hypoxia may be induced by enhanced neuroinflammation, and a prolonged period of metabolic dysfunction.

Dynamics of rabbit brain edema in focal lesion and perilesion area after traumatic brain injury: a MRI study

To understand the dynamics of brain edema in different areas after traumatic brain injury (TBI) in rabbit, we used dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusion-weighted imaging (DWI) to monitor blood-brain barrier (BBB) permeability and cytotoxic brain edema after weight drop-induced TBI in rabbit. The dynamics of BBB permeability and brain edema were quantified using K(trans) and apparent diffusion coefficient (ADC) in the focal and perifocal lesion areas, as well as the area contralateral to the lesion. In the focal lesion area, K(trans) began to increase at 3 h post-TBI, peaked at 3 days, and decreased gradually while remaining higher than sham injury animals at 7 and 30 days. ADC was more variable, increased slightly at 3 h, decreased to its lowest value at 7 days, then increased to a peak at 30 days. In the perifocal lesion area, K(trans) began to increase at 1 day, peaked at 3-7 days, and returned to control level by 30 days. ADC showed a trend to increase at 1 day, followed by a continuous increase thereafter. In the contralateral area, no changes in K(trans) and ADC were observed at any time-point. These data demonstrate that different types of brain edema predominate in the focal and perifocal lesion areas. Specifically cytotoxic edema was predominant in the focal lesion area while vasogenic edema predominated in the perifocal area in acute phase. Furthermore, secondary opening of the BBB after TBI may appear if secondary injury is not controlled. BBB damage may be a driving force for cytotoxic brain edema and could be a new target for TBI intervention.

Aquaporin-4 expression in cultured astrocytes after fluid percussion injury

The development of cytotoxic brain edema resulting in increased intracranial pressure is a major cause of death occurring in the early phase of traumatic brain injury (TBI). Such edema predominantly develops as a consequence of astrocyte swelling. We recently documented that fluid percussion injury (FPI) to cultured astrocytes causes cell swelling. Since aquaporin-4 (AQP4) has been strongly implicated in the development of brain edema/astrocyte swelling in various neurological conditions, this study examined the effect of in vitro trauma on AQP4 protein expression in cultured astrocytes. Exposure of astrocytes to FPI resulted in a significant upregulation of AQP4 protein in the plasma membrane due to neosynthesis, as cycloheximide blocked the trauma-induced AQP4 upregulation. Silencing the aqp4 gene by siRNA resulted in a significant reduction in trauma-induced astrocyte swelling, indicating a critical role of AQP4 in this process. We recently documented that oxidative/nitrative stress (ONS), the mitochondrial permeability transition (mPT), and activation of mitogen-activated protein kinases (MAPKs), contribute to trauma-induced astrocyte swelling in culture. We now show that inhibition of these factors reduces the upregulation of AQP4 following trauma. Since TBI has been shown to activate nuclear factor-kappa B (NF-κB), as well as the Na(+),K(+),Cl(-) co-transporter (NKCC), both of which are implicated in brain edema/astrocyte swelling in other conditions, we also examined the effect of BAY 11-7082 and bumetanide, inhibitors of NF-κB and NKCC, respectively, and found that these agents also significantly inhibited the trauma-induced AQP4 upregulation. Our findings show that in vitro trauma upregulates AQP4, and that ONS, MAPKs, mPT, NF-κB, and NKCC are involved in its upregulation.

Na-K-Cl cotransporter-1 in the mechanism of cell swelling in cultured astrocytes after fluid percussion injury

Brain edema and associated increased intracranial pressure are major consequences of traumatic brain injury (TBI). An important early component of the edema associated with TBI is astrocyte swelling (cytotoxic edema). Mechanisms for such swelling, however, are poorly understood. Ion channels/transporters/exchangers play a major role in cell volume regulation, and a disturbance in one or more of these systems may result in cell swelling. To examine potential mechanisms in TBI-mediated brain edema, we employed a fluid percussion model of in vitro barotrauma and examined the role of the ion transporter Na(+)-K(+)-2Cl(-)-cotransporter 1 (NKCC1) in trauma-induced astrocyte swelling as this transporter has been strongly implicated in the mechanism of cell swelling in various neurological conditions. Cultures exposed to trauma (3, 4, 5 atm pressure) caused a significant increase in NKCC1 activity (21%, 42%, 110%, respectively) at 3 h. At 5 atm pressure, trauma significantly increased NKCC1 activity at 1 h and it remained increased for up to 3 h. Trauma also increased the phosphorylation (activation) of NKCC1 at 1 and 3 h. Inhibition of MAPKs and oxidative/nitrosative stress diminished the trauma-induced NKCC1 phosphorylation as well as its activity. Bumetanide, an inhibitor of NKCC1, significantly reduced the trauma-induced astrocyte swelling (61%). Silencing NKCC1 with siRNA led to a reduction in trauma-induced NKCC1 activity as well as in cell swelling. These findings demonstrate the critical involvement of NKCC1 in the astrocyte swelling following in vitro trauma, and suggest that blocking NKCC1 activity may represent a useful therapeutic strategy for the cytotoxic brain edema associated with the early phase of TBI.

Engaging neuroscience to advance translational research in brain barrier biology

The delivery of many potentially therapeutic and diagnostic compounds to specific areas of the brain is restricted by brain barriers, of which the most well known are the blood-brain barrier (BBB) and the blood-cerebrospinal fluid (CSF) barrier. Recent studies have shown numerous additional roles of these barriers, including an involvement in neurodevelopment, in the control of cerebral blood flow, and--when barrier integrity is impaired--in the pathology of many common CNS disorders such as Alzheimer's disease, Parkinson's disease and stroke.

Mechanisms of cerebral edema in traumatic brain injury: therapeutic developments

PURPOSE OF REVIEW

Although a number of factors contribute to the high mortality and morbidity associated with traumatic brain injury (TBI), the development of cerebral edema with brain swelling remains the most significant predictor of outcome. The present review summarizes the most recent advances in the understanding of mechanisms associated with development of posttraumatic cerebral edema, and highlights areas of therapeutic promise.

RECENT FINDINGS

Despite the predominance of cytotoxic (or cellular) edema in the first week after traumatic brain injury, brain swelling can only occur with addition of water to the cranial vault from the vasculature. As such, regulation of blood-brain barrier permeability has become a focus of recent research seeking to manage brain edema. Aquaporins, matrix metalloproteinases and vasoactive inflammatory agents have emerged as potential mediators of cerebral edema following traumatic brain injury. In particular, kinins (bradykinins) and tachykinins (substance P) seem to play an active physiological role in modulating blood-brain barrier permeability after trauma. Substance P neurokinin-1 receptor antagonists show particular promise as novel therapeutic agents.

SUMMARY

Attenuating blood-brain barrier permeability has become a promising approach to managing brain edema and associated swelling given that increases in cranial water content can only be derived from the vasculature. Inflammation, both classical and neurogenic, offers a number of attractive targets.

Reduction of neurovascular damage resulting from microelectrode insertion into the cerebral cortex using in vivo two-photon mapping

Penetrating neural probe technologies allow investigators to record electrical signals in the brain. The implantation of probes causes acute tissue damage, partially due to vasculature disruption during probe implantation. This trauma can cause abnormal electrophysiological responses and temporary increases in neurotransmitter levels, and perpetuate chronic immune responses. A significant challenge for investigators is to examine neurovascular features below the surface of the brain in vivo. The objective of this study was to investigate localized bleeding resulting from inserting microscale neural probes into the cortex using two-photon microscopy (TPM) and to explore an approach to minimize blood vessel disruption through insertion methods and probe design. 3D TPM images of cortical neurovasculature were obtained from mice and used to select preferred insertion positions for probe insertion to reduce neurovasculature damage. There was an 82.8 +/- 14.3% reduction in neurovascular damage for probes inserted in regions devoid of major (>5 microm) sub-surface vessels. Also, the deviation of surface vessels from the vector normal to the surface as a function of depth and vessel diameter was measured and characterized. 68% of the major vessels were found to deviate less than 49 microm from their surface origin up to a depth of 500 microm. Inserting probes more than 49 microm from major surface vessels can reduce the chances of severing major sub-surface neurovasculature without using TPM.

Effect of secondary insults upon aquaporin-4 water channels following experimental cortical contusion in rats

Although secondary insults of hypoxia and hypotension (HH) are generally considered to cause fulminant brain edema in traumatic brain injury (TBI), the combined effect of TBI with HH on brain edema and specifically the expression of aquaporin-4 (AQP4) have not been fully elucidated. The goal of this study was to document the effect of secondary insults on brain water, AQP4 expression, electrolytes, and blood-brain barrier (BBB) permeability during the acute stage of edema development. We measured brain water content and electrolytes (series 1); BBB permeability based on Evans blue (EB) dye extravasation (series 2); and AQP4 expression using immunoblotting (series 3) at 1 h and 5 h following cortical contusion injury (CCI). Secondary insults significantly worsened BBB function at 5 h post injury. Moreover, a significant reduction of upregulation on AQP4 expression was observed in trauma, coupled with a mild secondary insult of hypoxia hypotension. These findings indicate that a secondary insult following CCI at 5 h post injury worsens brain edema, disrupts ionic homeostasis, and blunts the normal upregulation of AQP4 that occurs after trauma, suggesting that the blunting of AQP4 may contribute to the detrimental effects of secondary insults.

Temporal and regional changes after focal traumatic brain injury

Magnetic resonance imaging (MRI) is widely used to evaluate the consequences of traumatic brain injury (TBI) in both experimental and clinical studies. Improved assessment of experimental TBI using the same methods as those used in clinical investigations would help to translate laboratory research into clinical advances. Here our goal was to characterize lateral fluid percussion-induced TBI, with special emphasis on differentiating the contused cortex from the pericontusional subcortical tissue. We used both in vivo MRI and proton magnetic resonance spectroscopy ((1)H-MRS) to evaluate adult male Sprague-Dawley rats 24 h and 48 h and 7 days after TBI. T2 and apparent diffusion coefficient (ADC) maps were derived from T2-weighted and diffusion-weighted images, respectively. Ratios of N-acetylaspartate (NAA), choline compounds (Cho), and lactate (Lac) over creatine (Cr) were estimated by (1)H-MRS. T2 values were high in the contused cortex 24 h after TBI, suggesting edema development; ADC was low, consistent with cytotoxic edema. At the same site, NAA/Cr was decreased and Lac/Cr elevated during the first week after TBI. In the ipsilateral subcortical area, NAA/Cr was markedly decreased and Lac/Cr was elevated during the first week, although MRI showed no evidence of edema, suggesting that (1)H-MRS detected "invisible" damage. (1)H-MRS combined with MRI may improve the detection of brain injury. Extensive assessments of animal models may increase the chances of developing successful neuroprotective strategies.

Traumatic brain injury, major depression, and diffusion tensor imaging: making connections

It is common for depression to develop after traumatic brain injury (TBI), yet despite poorer recovery, there is a lack in our understanding of whether post-TBI brain changes involved in depression are akin to those in people with depression without TBI. Modern neuroimaging has helped recognize degrees of diffuse axonal injury (DAI) as being related to extent of TBI, but its ability to predict long-term functioning is limited and has not been considered in the context of post-TBI depression. A more recent brain imaging technique (diffusion tensor imaging; DTI) can measure the integrity of white matter by measuring the directionality or anisotropy of water molecule diffusion along the axons of nerve fibers.

AIM

To review DTI results in the TBI and depression literatures to determine whether this can elucidate the etiology of the development of depression after TBI.

METHOD

We reviewed the TBI/DTI (40 articles) and depression/DTI literatures (17 articles). No articles were found that used DTI to investigate depression post-TBI, although there were some common brain regions identified between the TBI/DTI and depression/DTI studies, including frontotemporal, corpus callosum, and structures contained within the basal ganglia. Specifically, the internal capsule was commonly reported to have significantly reduced fractional anisotropy, which agrees with deep brain stimulation studies.

CONCLUSION

It is suggested that measuring the degree of DAI by utilizing DTI in those with or without depression post-TBI, will greatly enhance prediction of functional outcome.

Reversible post-traumatic bilateral extensive restricted diffusion of the brain. A case study and review of the literature

PRIMARY OBJECTIVE

To increase the knowledge about diffuse traumatic brain injury (TBI) by reporting the magnetic resonance imaging (MRI) findings observed in a patient with reversible extensive restricted diffusion of the brain at diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps.

CASE STUDY

An 18-year-old patient was admitted after high-energy closed TBI. Glasgow Coma Scale score was 4. Head computed tomography showed small left frontal and temporal haemorrhagic contusions and a small haemorrhage in the left thalamus. Ten days later, brain MRI showed diffuse high-signal intensity on T2-weighted images and DWI and restricted diffusion in the subcortical white matter of both centri semiovali, genu and splenium of corpus callosum and parietal cortex bilaterally (mean ADC value = 0.434-0.811 x 10(-3) mm(2) s(-1)). Eleven days later, follow-up brain MRI showed gliotic changes in the left splenium of corpus callosum, a clearcut decrease of T2-weighted high-signal intensity and resolution of abnormalities at DWI and ADC maps in all other involved sites. This was confirmed 36 days later. Three months later, the patient did not show neurological, cognitive or neuropsychiatric deficits.

CONCLUSIONS

In the patient reported herein, closed TBI most likely induced diffuse excitotoxic injury of the brain which resulted in mainly reversible cytotoxic or intramyelinic oedema.