Subscribe to RSS
DOI: 10.1055/s-0029-1214384
© Georg Thieme Verlag KG Stuttgart · New York
The Hour-glass Model of Corpus Callosum Injury
Das Uhrglasmodell der Corpus Callosum VerletzungPublication History
Publication Date:
21 August 2009 (online)
Abstract
In this retrospective study, the authors analyze the frequency, anatomical distribution and the clinical outcome of 44 patients after severe head injury, with and without lesions of the corpus callosum (CC). 44 patients with severe head injury (GCS<9 on admission), who were admitted to the intensive care unit of the Department of Neurosurgery after trauma, underwent early MR-tomography (T1, T2 and FLAIR sequences) in addition to CCT performed on admission. CC lesions were found in about 1/3 of patients with severe head injury. Posterior (splenium) lesions of the CC were three times more common than anterior lesions. Patients with CC injury were much younger compared to patients without CC injury (25 versus 34 years). The Glasgow Outcome Scale (GOS) score after six months was poor (death, persistent vegetative state, severe disability, GOS>3) in all patients with CC injury when compared to patients without CC injury (GOS<4). CC lesions are an important parameter in the assessment of severe brain trauma, hinting at the mechanism of injury as well as the outcome of patients. If a patient does not awake after blunt head injury, MRT scans (including FLAIR sequences) are indicated. A CC lesion alone is not the cause of prolonged coma but indicates a severe diffuse injury resulting in functional deorganization of the brain. The mechanisms of CC injury are discussed and a new pathophysiological model, based on the hour-glass analogy, is presented.
Zusammenfassung
Im Rahmen dieser retrospektiven Studie analysieren die Autoren die Frequenz, anatomische Verteilung und die klinischen Langzeitergebnisse bei 44 Patienten nach schwerem Schädel-Hirn-Trauma mit und ohne Verletzung des Corpus callosum. Bei 44 Patienten mit schwerem Schädel-Hirn-Trauma (GCS<9 bei Aufnahme) die unmittelbar posttraumatisch auf die neurochirurgische Intensivstation übernommen wurden, wurden früh-posttraumatische MRT-Untersuchungen (T1, T2 and FLAIR-Sequenzen) als Ergänzung zu einem initialen CCT durchgeführt. Callosale Verletzungszeichen wurden in ca. 1/3 aller Patienten mit schwerem Schädel-Hirn-Trauma gefunden. Hintere Läsionen (Splenium) waren dreimal häufiger als vordere CC-Läsionen. Patienten mit CC-Läsionen waren durchschnittlich jünger als Patienten ohne CC-Läsion (25 bzw. 34 Jahre). Glasgow Outcome Scale (GOS)-Werte nach 6 Monaten waren schlechter (Tod, persistierender vegetativer Status, schwere Behinderung, GOS >3) bei allen Patienten mit CC-Verletzung als bei Patienten ohne CC-Verletzung (GOS<4). CC-Verletzungen sind ein wichtiger Parameter bei der Einschätzung eines schweren Schädel-Hirn-Traumas, da sie sowohl Hinweise auf Mechanismen der Entstehung als auch auf das Outcome der Patienten geben. Bei Patienten, die aus durch das CCT nicht hinreichend geklärter Ursache nach stumpfem SHT nicht aufwachen, sollte ein frühes MRT durchgeführt werden. Eine CC-Verletzung ist dabei nicht die Ursache des Komas, weist aber auf eine funktionelle Deorganisation des Gehirns durch diffuse Schädigung hin. Mechanismen der CC-Verletzung werden diskutiert und ein neues pathophysiologisches Modell, basierend auf der „Stundenglass”-Analogie wird vorgestellt.
Key words
trauma - brain injury - corpus callosum - blunt head injury - intensive care
Schlüsselwörter
Trauma - Hirnverletzung - Corpus callosum - stumpfes Schädel-Hirn- Trauma - Intensivmedizin
Literatur
- 1 Adams JH, Doyle D, Ford I. et al . Diffuse axonal injury in head injury: definition, diagnosis and grading. Histopathology. 1989; 15 49-59
- 2 Adams JH, Graham DI, Gennarelli TA. et al . Diffuse axonal injury in non-missile head injury. J Neurol Neurosurg Psychiatry. 1991; 54 481-483
- 3 Bratzke H, Franz A. Assessment of traumatic lesions of the corpus callosum. Beitr Gerichtl Med. 1988; 46 289-299
- 4 Edelman RR, Johnson K, Buxton R. et al . MR of hemorrhage: a new approach. AJNR Am J Neuroradiol. 1986; 7 751-756
- 5 Firsching R, Woischneck D, Diederich M. et al . Early magnetic resonance imaging of brainstem lesions after severe head injury. J Neurosurg. 1998; 89 707
- 6 Firsching R, Woischneck D, Klein S. et al . Classification of severe head injury based on magnetic resonance imaging. Acta Neurochir. 2001; 143 ((3)) 263-271
-
7 Graham DI, Gennarelli TA. Pathology of brain damage after head injury. In: Cooper PR, Golfinos JG, eds.
Head Injury . 4th ed. New York: MacGraw-Hill 2000: 133-153 - 8 Gennarelli TA, Thibault LE, Adams JH. et al . Diffuse axonal injury and traumatic coma in the primate. Ann Neurol. 1982; 12 564-574
- 9 Gentry LR. Imaging of closed head injury. Radiology. 1994; 191 1-17
- 10 Gentry LR, Thompson B, Godersky JC. Trauma to the corpus callosum: MR features. AJNR Am J Neuroradiol. 1988; 9 1129-1138
- 11 Gentry LR, Godersky GC, Thompson B. et al . Prospective comparative study of intermediate-field MR and CT in the evaluation of closed head trauma. AJNR Am J Neuroradiol. 1988; 150 673-682
-
12 Graham DI, Gennarelli TA. Trauma. In: Graham DI, Lantos PI, eds.
Greenfield's Neuropathology . 6th ed. London: Arnold 1997: 197-262 - 13 Kampfl A, Schmutzhard E, Franz G. et al . Prediction of recovery from post-traumatic vegetative state with cerebral magnetic resonance imaging. Lancet. 1998; 351 1763-1767
- 14 Katz DI, Alexander MP. Traumatic brain injury: predicting course of recovery and outcome for patients admitted to rehabilitation. Arch Neurol. 1994; 51 661-670
- 15 Komatsu S, Tomohiko S, Kagawa S. et al . Traumatic lesions of the corpus callosum. Neurosurgery. 1979; 5 ((1)) 32-35
- 16 Leclercq PD, MacKenzie JE, Graham DI. et al . Axonal injury is accentuated in the caudal corpus callosum of head-injured patients. J Neurotrauma. 2001; 18 1-19
- 17 Maxwell WL, Povlishock JT, Graham DL. A mechanistic analysis of nondisruptive axonal injury: a review. J Neurotrauma. 1997; 14 419-440
- 18 Meythaler JM, Peduzzi JD, Eleftheriou E. et al . Current concepts: diffuse axonal injury-associated traumatic brain injury. Arch Phys Med Rehabil. 2001; 82 1461-1471
- 19 Mittl RL, Grossman RI, Hiehle JF. et al . Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT findings. AJNR Am J Neuroradiol. 1994; 15 1583-1589
- 20 Ommaya AK, Gennarelli TA. Cerebral concussion and traumatic unconsciousness. Brain. 1974; 97 633-654
- 21 Oppenheimer DR. Microscopic lesions in the brain following head injury. J Neurol Neurosurg Psychiatry. 1968; 31 ((4)) 299-306
- 22 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
- 23 Povlishock JT. Traumatically induced axonal injury: pathogenesis and pathobiological implications. Brain Pathol. 1992; 2 1-12
- 24 Roob G, Kleinert R, Seifert T. et al . MRI evidence of cerebral microbleeds: comparative histopathologic data and possible clinical implications. Nervenarzt. 1999; 70 1082-1087
- 25 Shigemori M, Kojyo N, Yuge T. et al . Massive traumatic haematoma of the corpus callosum. Acta Neurochirurgica. 1985; 81 ((1–2)) 36-39
- 26 Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974; 2 81-84
- 27 Vuilleumier. et al . Clinical importance of lesions in the corpus callosum. Clin Neurol Neurosurg. 1995; 97 39-46
- 28 Wallesch CW, Curio N, Galazky I. et al . The neuropsychology of blunt head injury in the early postacute stage: effects of focal lesions and diffuse axonal injury. J Neurotrauma. 2001; 18 11-20
- 29 Wallesch CW, Curio N, Kutz S. et al . Outcome after mild-to-moderate blunt head injury: effects of focal lesions and diffuse axonal injury. Brain Inj. 2001; 15 401-412
- 30 Wedekind C, Hesselmann V, Lippert-Grüner M. et al . Trauma to the pontomesencephalic brainstem – a major clue to the prognosis of severe traumatic brain injury. Br J Neurosurg. 2002; 16 ((3)) 256-260
- 31 Wedekind C, Fischbach R, Pakos P. Comparative use of magnetic resonance imaging and electrophysiologic investigation for the prognosis of head injury. J Trauma. 1999; 47 ((1)) 44-49
- 32 Wilson JT, Hadley DM. et al . Neuropsychological consequences of two patterns of brain damage shown by MRI in survivors of severe head injury. J Neurol Neurosurg Psychiatry. 1995; 59 328-331
Correspondence
Dr. med. Johannes Kuchta
Department of Neurosurgery
Spine Surgery
MediaPark Klinik Köln
Im Mediapark 3
50670 Köln
Germany
Phone: +49/221/979 73 00
Fax: +49/221/979 73 33
Email: phonosphere@web.de