DIFFUSE AXONAL BRAIN DAMAGE.
ASPECTS OF CT AND MRI APPLICATION IN FORENSIC MEDICINE
Medvedeva N.А.1,2, Serova N.S1
1 - I.M. Sechenov First Moscow State Medical University (Sechenov University).
2 - Bureau of Forensic Medicine of the Department of Health of the City of Moscow. Russia, Moscow.
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o determine the possibilities of computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis of diffuse axonal brain injury (DAI). To correlate the severity of the clinical condition with the data of radiological methods.
Materials and methods. The data of radiological methods in DICOM format of 37 patients was evaluated. According to emergency indications, CT was performed in all 37 cases (100%) in the first 24 hours after the trauma. At the hospital stage, MRI was performed in 32 patients (86%) within first 14 days from admission. The age of the victims ranged from 6 years to 54 years, the average age was 27 years. A standard file viewer was used to reanalyze CT and MRI data in electronic form as part of the forensic medical examination.
Results. Our results indicate the possibility of CT and MRI to detect morphological substrates of DAI in the form of micro-lesions, lesions at the boundaries of gray and white matter, cerebral edema and concomitant traumatic changes even in conditions of non-compliance with the clinical picture of DAI, namely in the absence of a comatose state in the patient. According to CT data, in all 37 cases (100%) it was possible to identify signs of cerebral edema, however, in 32 cases (86%), radiological signs of cerebral edema according to CT data were the only indirect finding, with a severe neurological condition of the patient after trauma, and it was not possible to detect the morphological substrate of DAI without MRI. Areas of acute restriction of diffusion and microhemorrhagia in the corpus callosum roller were detected according to MRI in 31 cases (83%), and only in 5 cases (13%) according to CT data. In 7 cases (18%), no radiological pathological signs were found in the corpus callosum area according to CT and MRI data. In 3 cases (8%), DAI was complicated by intraventricular hemorrhage, which, according to CT data, could be detailed only in 1 case (2%).
Discussion. Clinically, DAI does not always fit into the reference clinical picture given above, and the main stumbling block to substantiate the diagnosis of DAI is the necessary state of coma in the patient. At the same time, our study identified 13 patients (35%) who did not have a comatose state, moreover, 3 patients (8%) did not even have loss of consciousness after a traumatic episode. In these cases, the clinical justification for the diagnosis of DAI was the neurological, severe status and radiological pattern, which fully corresponded to DAI in all patients.
Conclusion. The data of CT and MRI methods display the pathognomonic picture of DAI, in accordance with the biomechanics of pulsed traumatic brain injury, even in the comatose state of the patient. Minimally pronounced microhemorrhagias can only be detailed according to MRI data in T2* and/or SWI/SWAN modes, whereas the CT pattern and routine MRI pulse sequences can remain intact. MRI is the preferred method for assessing suspected diffuse axonal damage, even in patients with completely normal brain CT results.
In order to objectify expert conclusions in order to establish the severity of harm to health in case of suspected DAI, it is necessary to consider an interdisciplinary consensus with a unified
classification of clinical degrees of DAI and with a specification of the degree of DAI in paragraph 6.1.3. medical criteria for the severity of harm to human health.
Keywords: forensic medical examination, pulse injury, diffuse axonal injury, traumatic brain injury, radiological diagnosis of DAI, forensic medical examination of living persons.
Corresponding author: Medvedeva N.A., e-mail: Этот e-mail адрес защищен от спам-ботов, для его просмотра у Вас должен быть включен Javascript
For citation: Medvedeva N.А., Serova N.S. Diffuse axonal brain damage. Aspects of CT and MRI application in forensic medicine. REJR 2024; 14(4):18-30. DOI: 10.21569/2222-7415-2024-14-4-18-30.
Received: 15.09.24 Accepted: 22.10.24