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cerebral_contusion

Cerebral contusion

Cerebral cortical contusions are one of the most common computed tomography (CT) findings in head injury 1) 2).

images.radiopaedia.org_images_156914_0818f03a6db1101a278797c6803661.jpg It is a bruise of the brain tissue.

Like bruises in other tissues, cerebral contusion can be associated with multiple microhemorrhages, small blood vessel leaks into brain tissue.

The expression of caspase 3 and HAX-1 after cerebral contusion has time sequential regularity, which may provide new evidence for forensic diagnosis of cerebral contusion interval 3).

Results revealed that at 2 hours after cerebral contusion and laceration injury, aquaporin 4 expression significantly increased, brain water content and blood-brain barrier permeability increased, and the number of pinocytotic vesicles in cerebral microvascular endothelial cells increased. In addition, the mitochondrial accumulation was observed. As contusion and laceration injury became aggravated, aquaporin 4 expression continued to increase, brain water content and blood-brain barrier permeability gradually increased, brain capillary endothelial cells and astrocytes swelled, and capillary basement membrane injury gradually increased. The above changes were most apparent at 12 hours after injury, after which they gradually attenuated. Aquaporin 4 expression positively correlated with brain water content and the blood-brain barrier index. This experimental findings indicate that increasing aquaporin 4 expression and blood-brain barrier permeability after cerebral contusion and laceration injury in humans is involved in the formation of brain edema 4).

see Frontal cerebral contusion.

Epidemiology

Contusion occurs in 20–30% of severe head injuries.

A cerebral laceration is a similar injury except that, according to their respective definitions, the pia-arachnoid membranes are torn over the site of injury in laceration and are not torn in contusion.

The injury can cause a decline in mental function in the long term and in the emergency setting may result in brain herniation, a life-threatening condition in which parts of the brain are squeezed past parts of the skull.

Diagnosis

Computed tomography perfusion imaging (CTP) is a useful, fast, and appropriate method in evaluating perfusion of pericontusional hypodensity area that may help the treating physician to provide an appropriate treatment to the patient 5).

Treatment

Since brain edema presents a danger to the patient, treatment of cerebral contusion aims to prevent swelling. Measures to avoid swelling include prevention of hypotension, hyponatremia, and hypercapnia.

The early massive edema caused by severe cerebral contusion results in progressive intracranial pressure (ICP) elevation and clinical deterioration within 24-72 h post-trauma. Surgical excision of the necrotic brain tissue represents the only therapy, which can provide satisfactory control of the elevated ICP and clinical deterioration.

Contusions are likely to heal on their own without medical intervention.

Outcome

Cerebral contusions, are frequently associated with surrounding edematous-appearing tissue that exacerbates elevation of intracranial pressure (ICP). Half of all cerebral contusions enlarge in the first hours after injury, with perilesional hypodensity being a significant factor in prediction of expansion 6).

A survey of 729 patients with TBI by the TBI European Brain Injury Consortium found that cerebral contusions alone (44%) or in association with subdural haematoma (29%) were the most frequent causes for delayed surgical intervention 7)

Outpatient follow-up

Repeat outpatient CT of asymptomatic patients after nonoperative cerebral contusion and tSAH is very unlikely to demonstrate significant new pathology. Given the cost and radiation exposure associated with CT, imaging should be reserved for patients with significant symptoms or focal findings on neurological examination 8).

Case series

Twenty-two patients with traumatic cerebral contusion (diagnosed on initial noncontrast head computed tomography [CT]) who initially did not require surgical intervention were enrolled in this study. Contrast-enhanced and perfusion CT scans were performed within 6 hours of injury, and follow-up noncontrast CT scans were performed at 24 hours and 72 hours.

In each noncontrast CT scan, the volumes of the contusion hemorrhage and edema were calculated using computerized planimetric techniques. The initial Glasgow Coma Scale, hemorrhage progression, clinical deterioration, and the need for subsequent surgery were recorded. The early radiologic findings were compared with these parameters and functional outcome at 6 months to identify predictive radiologic signs. CE was present in 9 of 22 patients (41%) and was highly associated with hemorrhage progression (p < 0.05), clinical deterioration (p < 0.01), and need for subsequent surgery (p < 0.01). In addition, patients with CE had a greater volume of edema at 24 hours (p < 0.01) and 72 hours (p < 0.01) than those who did not have CE. However, CE was not found to be associated with poor outcome.

Early parenchymal CE is associated with hemorrhage progression, cerebral edema, clinical deterioration, and need for subsequent surgery. These patients should be monitored closely, and early surgery may be needed if deterioration occurs. Further elucidation of the pathophysiology is needed to formulate effective treatment for these high-risk patients 9).


In severe traumatic brain injury (TBI), contusions often are worsened by contusion expansion, or “hemorrhagic progression of contusion” (HPC), which may double the original contusion volume and worsen outcome. In humans and rodents with contusion-TBI, sulfonylurea receptor 1 (SUR1) is upregulated in microvessels and astrocytes, and in rodent models, blockade of SUR1 with glibenclamide reduces HPC. SUR1 does not function by itself, but must co-assemble with either KIR6.2 or TRPM4 to form KATP (SUR1-KIR6.2) or SUR1-TRPM4 channels, with the two having opposite effects on membrane potential. Both KIR6.2 and TRPM4 are reportedly upregulated in TBI, especially in astrocytes, but the identity and function of SUR1-regulated channels post-TBI is unknown. Here, we analyzed human and rat brain tissues after contusion-TBI to characterize SUR1, TRPM4 and KIR6.2 expression and, in the rat model, to examine the effects on HPC of inhibiting expression of the three subunits using intravenous antisense oligodeoxynucleotides (AS-ODN). GFAP immunoreactivity was used to operationally define core versus penumbral tissues. In humans and rats, GFAP-negative core tissues contained microvessels that expressed SUR1 and TRPM4, whereas GFAP-positive penumbral tissues contained astrocytes that expressed all three subunits. Förster resonance energy transfer imaging demonstrated SUR1-TRPM4 heteromers in endothelium, and SUR1-TRPM4 and SUR1-KIR6.2 heteromers in astrocytes. In rats, glibenclamide as well as AS-ODN targeting SUR1 and TRPM4, but not KIR6.2, reduced HPC at 24 hours post-TBI. Our findings demonstrate upregulation of SUR1-TRPM4 and KATP after contusion-TBI, identify SUR1-TRPM4 as the primary molecular mechanism that accounts for HPC, and indicate that SUR1-TRPM4 is a crucial target of glibenclamide 10).

1)
Becker DP, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R. The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg. 1977 Oct;47(4):491-502. PubMed PMID: 903803.
2)
Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger J; Surgical Management of Traumatic Brain Injury Author Group.. Surgical management of traumatic parenchymal lesions. Neurosurgery. 2006 Mar;58(3 Suppl):S25-46; discussion Si-iv. Review. PubMed PMID: 16540746.
3)
Li ZR, Teng DH, Dong GK, Yin WJ, Cai HX. [Expression of caspase-3 and HAX-1 after cerebral contusion in rat]. Fa Yi Xue Za Zhi. 2015 Feb;31(1):7-10, 14. Chinese. PubMed PMID: 26058125.
4)
Li X, Han Y, Xu H, Sun Z, Zhou Z, Long X, Yang Y, Zou L. Aquaporin 4 expression and ultrastructure of the blood-brain barrier following cerebral contusion injury. Neural Regen Res. 2013 Feb 5;8(4):338-45. doi: 10.3969/j.issn.1673-5374.2013.04.006. PubMed PMID: 25206674; PubMed Central PMCID: PMC4107528.
5)
Ahmad Helmy AK, Salmah Jalaluddin WM, Ab Rahman IG. Computed tomography perfusion imaging on traumatic cerebral contusion: a preliminary report. Malays J Med Sci. 2010 Oct;17(4):51-6. PubMed PMID: 22135561; PubMed Central PMCID: PMC3216185.
6)
Beaumont A. Gennarelli T. CT prediction of contusion evolution after closed head injury: the role of pericontusional edema. Acta Neurochir. 2006;96(Suppl):30–32.
7)
Compagnone C, Murray GD, Teasdale GM, Maas AI, Esposito D, Princi P, et al. The management of patients with intradural post-traumatic mass lesions: A multicenter survey of current approaches to surgical management in 729 patients coordinated by the European Brain Injury Consortium. Neurosurgery. 2005;57(6):1183–1192.
8)
Rubino S, Zaman RA, Sturge CR, Fried JG, Desai A, Simmons NE, Lollis SS. Outpatient follow-up of nonoperative cerebral contusion and traumatic subarachnoid hemorrhage: does repeat head CT alter clinical decision-making? J Neurosurg. 2014 Oct;121(4):944-9. doi: 10.3171/2014.6.JNS132204. Epub 2014 Jul 25. PubMed PMID: 25061865.
9)
Huang AP, Lee CW, Hsieh HJ, Yang CC, Tsai YH, Tsuang FY, Kuo LT, Chen YS, Tu YK, Huang SJ, Liu HM, Tsai JC. Early parenchymal contrast extravasation predicts subsequent hemorrhage progression, clinical deterioration, and need for surgery in patients with traumatic cerebral contusion. J Trauma. 2011 Dec;71(6):1593-9. doi: 10.1097/TA.0b013e31822c8865. PubMed PMID: 22182869.
10)
Gerzanich V, Stokum J, Ivanova S, Woo SK, Tsymbalyuk O, Sharma A, Akkentli F, Imran Z, Aarabi B, Sahuquillo J, Simard JM M.D., Ph.D. SUR1, TRPM4 and KIR6.2 - role in hemorrhagic progression of contusion. J Neurotrauma. 2018 Aug 30. doi: 10.1089/neu.2018.5986. [Epub ahead of print] PubMed PMID: 30160201.
cerebral_contusion.txt · Last modified: 2018/09/18 00:47 by administrador