Management of Diffuse Axonal Injury

Diagnostic Approach

Non-contrast CT is the mandatory first-line imaging in acute moderate to severe traumatic brain injury and should be performed without delay, as recommended by the American College of Radiology 1, 2
MRI is indicated when CT results are normal but persistent unexplained neurologic findings are present, with a class I recommendation from the American Academy of Neurology 1, 2
The optimal MRI sequences for detecting diffuse axonal injury include T2*-weighted gradient-echo (GRE) imaging, susceptibility-weighted imaging (SWI), and diffusion-weighted imaging (DWI), according to the American Society of Neuroradiology 1

Maintain systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion, as recommended by the American Heart Association 2, 3
Control ventilation through tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring, and prevent hypocapnia, which causes cerebral vasoconstriction and increases the risk of brain ischemia, according to the American Thoracic Society 2, 3
ICP monitoring is recommended for patients with severe traumatic brain injury to detect intracranial hypertension, with a threshold for intervention of typically ICP >20 mmHg, as recommended by the Neurocritical Care Society 4, 2

Early physical therapy and rehabilitation are essential to prevent joint contractures and muscle atrophy, with specific interventions including proper positioning and frequent repositioning, range of motion exercises, and splinting, according to the American Physical Therapy Association 2
Regular neurological assessments are necessary to detect clinical deterioration, and follow-up imaging is indicated with neurological deterioration rather than on a routine basis, as recommended by the American Academy of Neurology 2

Regular multidisciplinary case reviews are recommended for patients with severe diffuse axonal injury, and early communication with regional neuroscience centers is essential for patients with perceived devastating brain injury, according to the National Institute of Neurological Disorders and Stroke 1, 2, 5, 6
Establish patient values and preferences early to guide end-of-life care planning if needed, and honest and realistic discussions of the most likely outcome should occur at admission, as recommended by the American Medical Association 5