J Korean Neurosurg Soc.  2012 Jan;51(1):24-30. 10.3340/jkns.2012.51.1.24.

The Prognostic Factors Related to Traumatic Brain Stem Injury

• Kim HJ

• KMID: 2190464
• DOI: http://doi.org/10.3340/jkns.2012.51.1.24

Abstract

OBJECTIVE
This study was conducted to assess the clinical significance of traumatic brain stem injury (TBSI) reflected on Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS) by various clinical variables.
METHODS
A total of 136 TBSI patients were selected out of 2695 head-injured patients. All initial computerized tomography and/or magnetic resonance imaging studies were retrospectively analyzed according to demographic- and injury variables which result in GCS and GOS.
RESULTS
In univariate analysis, mode of injury showed a significant effect on combined injury (p<0.001), as were the cases with skull fracture on radiologic finding (p<0.000). The GCS showed a various correlation with radiologic finding (p<0.000), mode of injury (p<0.002), but less favorably with impact site (p<0.052), age (p<0.054) and skull fracture (p<0.057), in order of statistical significances. However, only GOS showed a definite correlation to radiologic finding (p<0.000). In multivariate analysis, the individual variables to enhance an unfavorable effect on GCS were radiologic finding [odds ratio (OR) 7.327, 95% confidence interval (CI)], mode of injury (OR; 4.499, 95% CI) and age (OR; 3.141, 95% CI). Those which influence an unfavorable effect on GOS were radiologic finding (OR; 25.420, 95% CI) and age (OR; 2.674, 95% CI).
CONCLUSION
In evaluation of TBSI on outcome, the variables such as radiological finding, mode of injury, and age were revealed as three important ones to have an unfavorable effect on early stage outcome expressed as GCS. However, mode of injury was shown not to have an unfavorable effect on late stage outcome as GOS. Among all unfavorable variables, radiological finding was confirmed as the only powerful prognostic variable both on GCS and GOS.

Keyword

Traumatic brain stem injury (TBSI); Diffuse axonal injury (DAI); Glasgow Coma Score (GCS); Glasgow Outcome Score (GOS)

MeSH Terms

Brain
Brain Stem
Coma
Humans
Imidazoles
Magnetic Resonance Imaging
Multivariate Analysis
Retrospective Studies
Skull Fractures
Imidazoles

Figure

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  Fig. 1 This illutrates Type 1 brain stem injury which has hemorrhage around brain stem (white arrow).

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  Fig. 2 This is Type 2 brain stem injury which has intraparenchymal hemorrhage (white arrow).

Reference

1. Adams H, Mitchell DE, Graham DI, Doyle D. Diffuse brain damage of immediate impact type. Its relationship to 'primary brain-stem damage' in head injury. Brain. 1977; 100:489–502. PMID: 589428.

2. Adler DE, Milhorat TH. The tentorial notch: anatomical variation, morphometric analysis, and classification in 100 human autopsy cases. J Neurosurg. 2002; 96:1103–1112. PMID: 12066913.

3. Andrews BT, Chiles BW 3rd, Olsen WL, Pitts LH. The effect of intracerebral hematoma location on the risk of brain-stem compression and on clinical outcome. J Neurosurg. 1988; 69:518–522. PMID: 3418383.

4. Bouras T, Stranjalis G, Sakas DE. Traumatic midbrain hematoma in a patient presenting with an isolated palsy of voluntary facial movements. Case report. J Neurosurg. 2007; 107:158–160. PMID: 17639886.

5. Carpentier A, Galanaud D, Puybasset L, Muller JC, Lescot T, Boch AL, et al. Early morphologic and spectroscopic magnetic resonance in severe traumatic brain injuries can detect "invisible brain stem damage" and predict "vegetative states". J Neurotrauma. 2006; 23:674–685. PMID: 16689669.

6. Courville CB. Trauma of the Central Nervous System. 1945. Baltimor: Williams and Wilkins;Chap 4.

7. Crompton MR. Brainstem lesions due to closed head injury. Lancet. 1971; 1:669–673. PMID: 4101614.

8. Eder HG, Legat JA, Gruber W. Traumatic brain stem lesions in children. Childs Nerv Syst. 2000; 16:21–24. PMID: 10672425.

9. Firsching R, Woischneck D, Klein S, Ludwig K, Döhring W. Brain stem lesions after head injury. Neurol Res. 2002; 24:145–146. PMID: 11877897.

10. Firsching R, Woischneck D, Klein S, Reissberg S, Döhring W, Peters B. Classification of severe head injury based on magnetic resonance imaging. Acta Neurochir (Wien). 2001; 143:263–271. PMID: 11460914.

11. 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. PMID: 3257625.

12. Gentry LR, Godersky JC, Thompson BH. Traumatic brain stem injury : MR imaging. Radiology. 1989; 171:177–187. PMID: 2928523.

13. Hashimoto T, Nakamura N, Richard KE, Frowein RA. Primary brain stem lesions caused by closed head injuries. Neurosurg Rev. 1993; 16:291–298. PMID: 8127442.

14. Hirano A, Matsumura S, Maeda Y, Hashimoto Y, Hirai H. [Two cases of isolated ambient cistern hematoma after head injury]. No To Shinkei. 1995; 47:281–284. PMID: 7669431.

15. Kara A, Celik SE, Dalbayrak S, Yilmaz M, Akansel G, Tireli G. Magnetic resonance imaging finding in severe head injury patients with normal computerized tomography. Turk Neurosurg. 2008; 18:1–9. PMID: 18382970.

16. Katsuno M, Kobayashi S, Yokota H, Teramoto A. [Primary oculomotor nerve palsy due to mild head injury--report of two cases]. Brain Nerve. 2008; 60:89–91. PMID: 18232337.

17. Kim YS, Lim HY, Nah JH, Doh JO, Chang KS. Traumatic tentorial hemorrhage. J Korean Neurosurg Soc. 1986; 15:439–444.

18. Kinoshita Y, Tsuru E, Yasukouchi H, Yokota A. [A case of hematoma in cisterna magna after mild head injury]. No To Shinkei. 2000; 52:320–323. PMID: 10793419.

19. Mitchell DE, Adams JH. Primary focal impact damage to the brainstem in blunt head injuries. Does it exist? Lancet. 1973; 2:215–218. PMID: 4124416.

20. Moskała M, Polak J, Moskała A, Kleinrok K, Zawiliński J. Haematoma of the tentorium cerebelli - new pathology or new prognostic factor in neurotraumatology? A preliminary report. Neurol Neurochir Pol. 2007; 41:234–240. PMID: 17629817.

21. Okuchi K, Fujioka M, Konobu T, Fujikawa A, Nishimura A, Miyamoto S, et al. [Traumatic primary brain stem injury and ambient cistern hematoma evaluated with magnetic resonance imaging]. No Shinkei Geka. 1993; 21:799–804. PMID: 8377896.

22. Park E, Ai J, Baker AJ. Cerebellar injury : clinical relevance and potential in traumatic brain injury research. Prog brain Res. 2007; 161:327–338. PMID: 17618988.

23. Rosenblum WI, Greenberg RP, Seelig JM, Becker DP. Midbrain lesions : frequent and significant prognostic feature in closed head injury. Neurosurgery. 1981; 9:613–620. PMID: 7322325.

24. Saeki N, Otaki M, Oka N, Takase M. [A case of hematoma localized to midbrain tegmentum following closed head injury (author's transl)]. No Shinkei Geka. 1981; 9:1193–1197. PMID: 7290323.

25. Saeki N, Yamaura A, Sunami K. Brain stem contusion due to tentorial coup injury : case report and pathomechanical analysis from normal cadavers. Br J Neurosurg. 1998; 12:151–155. PMID: 11013669.

26. Sato M, Kodama N, Yamaguchi K. Post-traumatic brain stem distortion : a case report. Surg Neurol. 1999; 51:613–616. PMID: 10369228.

27. Se YB, Kim CH, Bak KH, Kim JM. Traumatic brainstem hemorrhage presenting with hemiparesis. J Korean Neurosurg Soc. 2009; 45:176–178. PMID: 19352480.

28. Shibata Y, Matsumura A, Meguro K, Narushima K. Differentiation of mechanism and prognosis of traumatic brain stem lesions detected by magnetic resonance imaging in the acute stage. Clin Neurol Neurosurg. 2000; 102:124–128. PMID: 10996708.

29. Shukla D, Mahadevan A, Sastry KV, Shankar SK. Pathology of post traumatic brainstem and hypothalamic injuries. Clin Neuropathol. 2007; 26:197–209. PMID: 17907596.

30. Soldner F, Hölper BM, Choné L, Wallenfang T. Evoked potentials in acute head injured patients with MRI-detected intracerebral lesions. Acta Neurochir (Wien). 2001; 143:873–883. PMID: 11685619.

31. Stewart WA, Litten SP, Sheehe PR. A prognostic model for brain stem injury. Surg Neurol. 1973; 1:303–310. PMID: 4724952.

32. Tandon PN. Brain stem hemorrhage in cranio-cerebral trauma. Acta Neurol Scand. 1964; 40:375–385. PMID: 14215769.

33. Tsai FY, Teal JS, Quinn MF, Itabashi HH, Huprich JE, Ahmadi J, et al. CT of brainstem injury. AJR Am J Roentgenol. 1980; 134:717–723. PMID: 6767357.

34. Wedekind C, Hesselmann V, Lippert-Grüner M, Ebel M. Trauma to the pontomesencephalic brainstem-a major clue to the prognosis of severe traumatic brain injury. Br J Neurosurg. 2002; 16:256–260. PMID: 12201395.

35. Woischneck D, Klein S, Reissberg S, Peters B, Avenarius S, Günther G, et al. Prognosis of brain stem lesion in children with head injury. Childs Nerv Syst. 2003; 19:174–178. PMID: 12644869.

36. Wong CW. The MRI and CT evidence of primary brain stem injury. Surg Neurol. 1993; 39:37–40. PMID: 8451717.

37. Wright RL. Traumatic hematomas of the posterior cranial fossa. J Neurosurg. 1966; 25:402–409. PMID: 5297035.