Diffuse Axonal Injury Management and Prognosis

Diagnostic Approach

Non-contrast CT (NCCT) is mandatory as the first-line imaging modality in all patients with suspected moderate to severe traumatic brain injury, including DAI, and should be performed immediately upon presentation, according to the American College of Radiology 1, 2.
NCCT predicts mortality and unfavorable outcomes but has significant limitations in detecting DAI, as microhemorrhages associated with axonal injury are frequently not visible on conventional CT, as stated by the American College of Radiology 1, 2, 4.
MRI is indicated when NCCT results are normal but persistent unexplained neurologic findings are present, with a class I recommendation from the American College of Radiology 1, 5, 6, 2, 3.

Optimal MRI sequences for DAI detection include T2*-weighted gradient-echo (GRE) imaging, susceptibility-weighted imaging (SWI), and diffusion-weighted imaging (DWI), as recommended by the American College of Radiology 1, 2, 3, 5, 6.

Management focuses on preventing secondary brain injury, as there is no specific treatment for the primary axonal damage itself, according to Praxis Medical Insights 2.
Maintain systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion, as recommended by Praxis Medical Insights 3.
Control ventilation through tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring; prevent hypocapnia, which causes cerebral vasoconstriction and increases the risk of brain ischemia, as stated by Praxis Medical Insights 3.

The presence of both a contusion and >4 foci of hemorrhagic axonal injury on MRI is an independent prognostic predictor, according to the American College of Radiology 1, 2.
DAI grading correlates strongly with outcomes, with Grade III DAI (dorsolateral brainstem lesions) associated with poor outcomes and highest mortality, as reported by Praxis Medical Insights 2, 4.

Early physical therapy and rehabilitation are essential to prevent joint contractures and muscle atrophy, as recommended by Praxis Medical Insights 3.
Regular multidisciplinary case reviews are recommended for patients with severe DAI, and early communication with regional neuroscience centers is essential for patients with perceived devastating brain injury, according to Praxis Medical Insights 2, 3.
For elderly patients with severe injuries unlikely to be fully recoverable, early insertion of palliative medicine consultation in the decision-making process improves outcomes, reduces in-hospital mortality and length of stay, and improves communication with family, as stated by the World Journal of Emergency Surgery 9.