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Detecting axonal injury in individual patients after traumatic brain injury.

检测创伤性脑损伤后个别患者的轴索损伤。

  • 影响因子:7.52
  • DOI:10.1093/brain/awaa372
  • 作者列表:"Jolly AE","Bălăeţ M","Azor A","Friedland D","Sandrone S","Graham NSN","Zimmerman K","Sharp DJ
  • 发表时间:2021-02-12
Abstract

:Poor outcomes after traumatic brain injury (TBI) are common yet remain difficult to predict. Diffuse axonal injury is important for outcomes, but its assessment remains limited in the clinical setting. Currently, axonal injury is diagnosed based on clinical presentation, visible damage to the white matter or via surrogate markers of axonal injury such as microbleeds. These do not accurately quantify axonal injury leading to misdiagnosis in a proportion of patients. Diffusion tensor imaging provides a quantitative measure of axonal injury in vivo, with fractional anisotropy often used as a proxy for white matter damage. Diffusion imaging has been widely used in TBI but is not routinely applied clinically. This is in part because robust analysis methods to diagnose axonal injury at the individual level have not yet been developed. Here, we present a pipeline for diffusion imaging analysis designed to accurately assess the presence of axonal injury in large white matter tracts in individuals. Average fractional anisotropy is calculated from tracts selected on the basis of high test-retest reliability, good anatomical coverage and their association to cognitive and clinical impairments after TBI. We test our pipeline for common methodological issues such as the impact of varying control sample sizes, focal lesions and age-related changes to demonstrate high specificity, sensitivity and test-retest reliability. We assess 92 patients with moderate-severe TBI in the chronic phase (≥6 months post-injury), 25 patients in the subacute phase (10 days to 6 weeks post-injury) with 6-month follow-up and a large control cohort (n = 103). Evidence of axonal injury is identified in 52% of chronic and 28% of subacute patients. Those classified with axonal injury had significantly poorer cognitive and functional outcomes than those without, a difference not seen for focal lesions or microbleeds. Almost a third of patients with unremarkable standard MRIs had evidence of axonal injury, whilst 40% of patients with visible microbleeds had no diffusion evidence of axonal injury. More diffusion abnormality was seen with greater time since injury, across individuals at various chronic injury times and within individuals between subacute and 6-month scans. We provide evidence that this pipeline can be used to diagnose axonal injury in individual patients at subacute and chronic time points, and that diffusion MRI provides a sensitive and complementary measure when compared to susceptibility weighted imaging, which measures diffuse vascular injury. Guidelines for the implementation of this pipeline in a clinical setting are discussed.

摘要

: 创伤性脑损伤 (TBI) 后的不良结果是常见的,但仍然难以预测。弥漫性轴索损伤对预后很重要,但其评估在临床上仍然有限。目前,轴突损伤是基于临床表现、对白质的可见损伤或通过轴突损伤的替代标记 (例如微出血) 来诊断的。这些不能准确地量化导致部分患者误诊的轴突损伤。弥散张量成像提供了体内轴突损伤的定量测量,部分各向异性通常用作白质损伤的代表。弥散加权成像中得到了广泛的应用在TBI但并未普遍应用于临床.这部分是因为尚未开发在个体水平上诊断轴突损伤的稳健分析方法。在这里,我们提出了一条用于弥散成像分析的管道,旨在准确评估个体大白质束中轴突损伤的存在。均匀各向异性分数计算大片的基础上选择了高重测信度、良好解剖覆盖面及其认知和临床损伤TBI后.我们针对常见的方法学问题测试我们的管道,如不同的对照样本量、局灶性病变和年龄相关变化的影响,以证明高特异性、敏感性和重测可靠性。我们评估了92例慢性期 (损伤后 ≥ 6个月) 中重度TBI患者,25例亚急性期 (损伤后10天至6周) 患者,随访6个月,并建立了大型对照队列 (n   = 103)。在52% 的慢性和28% 的亚急性患者中发现了轴突损伤的证据。那些分类为轴索损伤的患者的认知和功能结果显著低于那些没有的患者,在局灶性病变或微出血方面没有发现差异。几乎40% 的标准mri患者有轴突损伤的证据,而的可见微出血患者没有轴突损伤的扩散证据。在不同慢性损伤时间的个体中以及在亚急性和6个月扫描之间的个体中,随着损伤时间的延长,观察到更多的扩散异常。我们提供的证据表明,该管道可用于诊断亚急性和慢性时间点个体患者的轴突损伤,并且与测量弥漫性血管损伤的磁敏感加权成像相比,弥散MRI提供了敏感和互补的测量。讨论了在临床环境中实施该管道的指南。

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