Treatment of Traumatic Axonal Injury

Diagnostic Approach

The American College of Radiology recommends Non-contrast CT (NCCT) as the first-line imaging modality for acute evaluation of traumatic brain injury, which should be performed without delay 2, 3
The American College of Radiology suggests MRI is indicated when NCCT results are normal but persistent unexplained neurologic findings are present 2, 1
Specialized MRI sequences for optimal detection of axonal injury include T2*-weighted gradient-echo imaging for microhemorrhages, Susceptibility-weighted imaging (SWI), and Diffusion-weighted imaging (DWI) 1

The Anaesthesia society recommends maintaining systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion 3, 4
The Anaesthesia society suggests controlling ventilation through tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring 3, 4
The Anaesthesia society advises preventing hypocapnia which can cause cerebral vasoconstriction and increase risk of brain ischemia 3
The Anaesthesia society recommends rapid correction of arterial hypotension using vasopressors such as phenylephrine and norepinephrine when needed 3, 4

The Anaesthesia society recommends external ventricular drainage for persistent intracranial hypertension despite sedation and correction of secondary brain insults 4
The Anaesthesia society suggests decompressive craniectomy may be considered for refractory intracranial hypertension 4
The Anaesthesia society indicates neurosurgical interventions are necessary for removal of significant acute subdural hematoma, removal of symptomatic extradural hematoma, drainage of acute hydrocephalus, and closure of open displaced skull fracture 4

The Praxis Medical Insights society recommends early physical therapy and rehabilitation to prevent joint contractures and muscle atrophy 1
The Praxis Medical Insights society suggests proper positioning and frequent repositioning to prevent pressure sores and contractures 1
The Praxis Medical Insights society advises range of motion exercises should be initiated as soon as the patient is stabilized 1
The Praxis Medical Insights society recommends splinting may be necessary to maintain proper joint alignment and prevent contracture formation 1

The Anaesthesia society recommends intracranial pressure monitoring is recommended for patients with severe traumatic brain injury 4
The Anaesthesia society suggests regular neurological assessments to detect clinical deterioration 3
The American College of Radiology recommends follow-up imaging is indicated with neurological deterioration rather than on a routine basis 2, 5
The Praxis Medical Insights society recommends multidisciplinary case reviews are recommended for patients with severe diffuse axonal injury 1

The Praxis Medical Insights society indicates the location and extent of axonal injury lesions correlate with clinical outcomes 1
The Praxis Medical Insights society suggests presence of both contusion and multiple foci of hemorrhagic axonal injury on MRI is an independent prognostic predictor 1

The JCI Insight society warns traumatic axonal injury is often underdiagnosed with conventional CT imaging 6, 7
The Praxis Medical Insights society notes the number of microhemorrhages, while helpful for diagnosis, may not directly correlate with injury severity or outcomes 1