Diffusion-weighted MR Imaging in Closed Head Injury: High Correlation with Initial Glasgow Coma Scale Score and Score on Modified Rankin Scale at Discharge

PURPOSE: To determine whether diffusion-weighted magnetic resonance (MR) imaging findings and conventional MR imaging findings correlate with initial Glasgow Coma Scale score and score on modified Rankin scale at discharge.

MATERIALS AND METHODS: Twenty-six patients (18 male and eight female patients; mean age, 25.2 years; age range, 4–72 years) with diffuse axonal injury were examined with diffusion-weighted MR imaging and with fluid-attenuated inversion recovery, T2-weighted fast spin-echo, and T2*-weighted gradient-echo sequences. All images were evaluated by two neuroradiologists in consensus. Tissue volume with trauma-related signal-intensity abnormality on images from each sequence, number of lesions for each sequence, number of lesions for all sequences, and number of lesions with reduced apparent diffusion coefficient were correlated with scores on Glasgow Coma Scale and modified Rankin scale. Involvement of brainstem, deep gray matter, and corpus callosum were also correlated with clinical scores. Spearman rank correlation coefficients (r) were calculated.

RESULTS: The strongest correlation was between signal-intensity abnormality volume on diffusion-weighted images and modified Rankin score (r = 0.772, P < .001). The strength of this correlation did not improve when only volume of lesions with decreased apparent diffusion coefficient was considered. For lesion number, the strongest correlation was between lesion number on images acquired with all sequences and modified Rankin score (r = 0.662, P < .001). For lesion location, the strongest correlation was between lesion location in the corpus callosum and modified Rankin score (r = 0.513, P = .007).

CONCLUSION: Volume of lesions on diffusion-weighted MR images provides the strongest correlation with a score of subacute on modified Rankin scale at discharge. Total lesion number also correlates well with modified Rankin score. In future, diffusion-weighted images may be useful in determining treatment strategies for acute head injury.

© RSNA, 2004

References

  • 1 Gean AD. White matter shearing injury and brainstem injury In: Gean AD, Imaging of head trauma. New York, NY: Raven, 1994; 207-248.
  • 2 Murray JG, Gean AD, Evans SJ. Imaging of acute head injury. Semin Ultrasound CT MR 1996; 17:185-205.
  • 3 Adams JH, Graham DI, Murray LS, Scott G. Diffuse axonal injury due to nonmissile head injury in humans: an analysis of 45 cases. Ann Neurol 1982; 12:557-563.
  • 4 Gennarelli TA, Thibault LE, Adams JH, Graham DI, Thompson CJ, Marcincin RP. Diffuse axonal injury and traumatic coma in the primate. Ann Neurol 1982; 12:564-574.
  • 5 Gentry LR, Godersky JC, Thompson B. MR imaging of head trauma: review of the distribution and radiopathologic features of traumatic lesions. AJR Am J Roentgenol 1988; 150:663-672.
  • 6 Gentry LR. Imaging of closed head injury. Radiology 1994; 191:1-17.
  • 7 Gentry LR, Thompson B, Godersky JC. Trauma to the corpus callosum: MR features. AJNR Am J Neuroradiol 1988; 9:1129-1138.
  • 8 Adams JH, Doyle D, Ford I, Gennarelli TA, Graham DI, McLellan DR. Diffuse axonal injury in head injury: definition, diagnosis and grading. Histopathology 1989; 15:49-59.
  • 9 Strich SJ. Diffuse degeneration of the cerebral white matter in severe dementia following head injury. J Neurochem 1956; 19:163-185.
  • 10 Kelly AB, Zimmerman RD, Snow RB, Gandy SE, Heier LA, Deck MD. Head trauma: comparison of MR and CT experience in 100 patients. AJNR Am J Neuroradiol 1988; 9:699-708.
  • 11 Teasdale G, Teasdale E, Hadley D. Computed tomographic and magnetic resonance imaging classification of head injury. J Neurotrauma 1992; 9(suppl 1):S249-S257.
  • 12 Gentry LR, Godersky JC, Thompson B, Dunn VD. Prospective comparative study of intermediate field MR and CT in the evaluation of closed head trauma. AJR Am J Roentgenol 1988; 150:673-682.
  • 13 Orrison WW, Gentry LR, Stimac GK, Tarrel RM, Espinosa MC, Cobb LC. Blinded comparison of cranial CT and MR in closed head injury evaluation. AJNR Am J Neuroradiol 1994; 15:351-356.
  • 14 Mittl RL, Grossman RI, Hiehle JF, et al. Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal CT findings. AJNR Am J Neuroradiol 1994; 15:1583-1589.
  • 15 Ashikaga R, Araki Y, Ishida O. MRI of head injury using FLAIR. Neuroradiology 1997; 39:239-242.
  • 16 Parizel PM, Ozsarlak O, van Goethem JW, et al. Imaging findings in diffuse axonal injury after closed head trauma. Eur Radiol 1998; 8:960-965.
  • 17 Yanagawa Y, Tsushima Y, Tokumaru A, et al. A quantitative analysis of head injury using T2*-weighted gradient-echo imaging. J Trauma 2000; 49:272-277.
  • 18 Kuzma BB, Goodman JM. Improved identification of axonal shear injuries with gradient echo MR technique. Surg Neurol 2000; 53:400-402.
  • 19 Gale SD, Johnson SC, Bigler ED, Blatter DD. Trauma-induced degenerative diseases in brain injury: a morphometric analysis of three patients with preinjury and postinjury MR scans. J Neurotrauma 1995; 12:151-158.
  • 20 Anderson CV, Wood DG, Bigler ED, Blatter DD. Lesion volume, injury severity, and thalamic integrity following head injury. J Neurotrauma 1996; 13:59-64.
  • 21 Huisman TA, Sorensen AG, Hergan K, Gonzalez RG, Schaefer PW. Diffusion weighted imaging for the evaluation of diffuse axonal injury in closed head injury. J Comput Assist Tomogr 2003; 27:5-11.
  • 22 Unterberg AW, Stroop R, Thomale UW, Kiening KL, Paeuser S, Vollmann W. Characterisation of brain edema following “controlled cortical impact injury” in rats. Acta Neurochir Suppl (Wien) 1997; 70:106-108.
  • 23 Ito J, Marmarou A, Barzo P, Fatouros P, Corwin F. Characterization of edema by diffusion-weighted imaging in experimental traumatic brain injury. J Neurosurg 1996; 84:97-103.
  • 24 Barzo P, Marmarou A, Fatouros P, Hayasaki K, Corwin F. Contribution of vasogenic and cellular edema to traumatic brain swelling measured by diffusion-weighted imaging. J Neurosurg 1997; 87:900-907.
  • 25 Lai SM, Duncan PW. Evaluation of the American Heart Association Stroke Outcome Classification. Stroke 1999; 30:1840- 1843.
  • 26 Huisman TA, Schwamm LH, Schaefer PW, et al. Diffusion tensor imaging as potential biomarker of white matter injury in diffuse axonal injury. AJNR Am J Neuroradiol 2004; 25:370-376.
  • 27 Sorensen AG, Buonanno FS, Gonzalez RG, et al. Hyperacute stroke: evaluation with combined multisection diffusion-weighted and hemodynamically weighted echo-planar MR imaging. Radiology 1996; 199:391-401.
  • 28 Sorensen AG, Wu O, Copen WA, et al. Human acute cerebral ischemia: detection of changes in water diffusion anisotropy by using MR imaging. Radiology 1999; 212:785-792.
  • 29 Povlishock JT, Christman CW. The pathobiology of traumatically induced axonal injury in animals and humans: a review of current thoughts. J Neurotrauma 1995; 12:555-564.
  • 30 Hanstock CC, Faden AI, Bendall RM, Vink R. Diffusion-weighted imaging differentiates ischemic tissue from traumatized tissue. Stroke 1994; 25:843-848.
  • 31 Yuan XQ, Prough DS, Smith TL, Dewitt DS. The effects of traumatic brain injury on regional cerebral blood flow in rats. J Neurotrauma 1988; 5:289-301.
  • 32 Gonzalez RG, Schaefer PW, Buonanno FS, et al. Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. Radiology 1999; 210:155-162.
  • 33 Pierallini A, Pantano P, Fantozzi LM, et al. Correlation between MRI findings and long-term outcome in patients with severe brain trauma. Neuroradiology 2000; 42:860-867.
  • 34 Levin HS, Williams DH, Eisenberg HM, High WM, Guinto FC. Serial MRI and neurobehavioral findings after mild to moderate closed head injury. J Neurol Neurosurg Psychiatry 1992; 55:255-262.
  • 35 Wilson JT, Wiedman KD, Hadley DM, Condon B, Teasdale GM. Early and late magnetic resonance imaging and neuropsychological outcome after head injury. J Neurol Neurosurg Psychiatry 1988; 51:391-396.
  • 36 Pellicano G, Beccani D, Cellerini M, Nistri M, Dal Pozzo G. MRI evaluation of complications and long term sequelae of cranial trauma (abstr). Neuroradiology 1997; 39:S82.
  • 37 Graham DI, Gennarelli TA, McIntosh TK. Blunt head injury. In: Graham DI, Lantos PL, eds. Greenfield’s neuropathology. 7th ed. New York, NY: Arnold, 2002; 824-879.
  • 38 Segatore M, Way C. The Glasgow Coma Scale: time for change. Heart Lung 1992; 21:548-557.
  • 39 The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Glasgow coma scale score. J Neurotrauma 2000; 17:563-571.
  • 40 Starmark JE, Holmgren E, Stalhammar D. Current reporting of responsiveness in acute cerebral disorders: a survey of the neurosurgical literature. J Neurosurg 1988; 69:692-698.
  • 41 Sulter G, Steen C, De Keyser J. Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke 1999; 30:1538-1541.

Article History

Published in print: Oct 2004