What is the treatment for a couple with contracture (contractual injury) and traumatic axonal injury?

Treatment of Contracture Injury and Traumatic Axonal Shearing

The management of traumatic axonal injury requires a multidisciplinary approach focused on preventing secondary brain injury, as there is no specific treatment for the primary axonal damage. 1

Diagnostic Approach

• Non-contrast CT (NCCT) is the first-line imaging modality for acute evaluation of traumatic brain injury and should be performed without delay 2
• 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 1
  • Susceptibility-weighted imaging (SWI), which is 3-6 times more sensitive than T2* in detecting hemorrhagic axonal injuries 1
  • Diffusion-weighted imaging (DWI) for visualization of non-hemorrhagic axonal injuries 1

Acute Management

• Maintain systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion 2
• Control ventilation through tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring 2
• Prevent hypocapnia which can cause cerebral vasoconstriction and increase risk of brain ischemia 2
• Rapid correction of arterial hypotension using vasopressors such as phenylephrine and norepinephrine when needed 2

Neurosurgical Interventions

• External ventricular drainage for persistent intracranial hypertension despite sedation and correction of secondary brain insults 2
• Decompressive craniectomy may be considered for refractory intracranial hypertension 2
• Neurosurgical interventions are indicated for:
  • Removal of significant acute subdural hematoma (thickness >5 mm with midline shift >5 mm) 2
  • Removal of symptomatic extradural hematoma 2
  • Drainage of acute hydrocephalus 2
  • Closure of open displaced skull fracture 2

Management of Contractures

• Early physical therapy and rehabilitation to prevent joint contractures and muscle atrophy 1
• Proper positioning and frequent repositioning to prevent pressure sores and contractures 1
• Range of motion exercises should be initiated as soon as the patient is stabilized 1
• Splinting may be necessary to maintain proper joint alignment and prevent contracture formation 1

Monitoring and Follow-up

• Intracranial pressure monitoring is recommended for patients with severe traumatic brain injury 2
• Regular neurological assessments to detect clinical deterioration 2
• Follow-up imaging is indicated with neurological deterioration rather than on a routine basis 2
• Multidisciplinary case reviews are recommended for patients with severe diffuse axonal injury 1

Prognostic Considerations

• The location and extent of axonal injury lesions correlate with clinical outcomes 1
• Presence of both contusion and multiple foci of hemorrhagic axonal injury on MRI is an independent prognostic predictor 1
• Diffuse axonal injury involving the brainstem (Grade III) is associated with poor outcomes 3

Common Pitfalls and Considerations

• Traumatic axonal injury is often underdiagnosed with conventional CT imaging 2
• The number of microhemorrhages, while helpful for diagnosis, may not directly correlate with injury severity or outcomes 1
• Axonal or white matter loss may progress for years post-injury, representing a mechanism for progressive neurodegeneration 4
• Almost a third of patients with unremarkable standard MRIs may have evidence of axonal injury detectable only with advanced imaging techniques 5