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Infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion

Nanako Takase¹, Noboru Igarashi², Hiromichi Taneichi³

¹Department of Pediatrics, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo, Japan.

Journal of the Neurological Sciences

|May 27, 2018

Insights

Infants with traumatic brain injury (TBI) may show delayed white matter diffusion changes, mimicking acute encephalopathy with biphasic seizures and late reduced diffusion (AESD). This suggests excitotoxicity as a potential cause for TBI-related brain injury.

Area of Science:

Pediatric Neurology
Neuroradiology
Neurocritical Care

Background:

Traumatic brain injury (TBI) in infants, including abusive head trauma, can present with subcortical white matter lesions.
The underlying mechanisms and clinical presentation of these lesions remain unclear.

Observation:

Two infants with TBI exhibited biphasic clinical courses and delayed reduced diffusion in the subcortical white matter.
Seven similar TBI cases were reviewed, showing consistent clinical and radiological patterns.

Findings:

TBI patients displayed secondary neurological symptoms on days 3-6 and delayed reduced diffusion (days 3-6) after initial normal diffusion (days 1-2).
These findings closely resemble acute encephalopathy with biphasic seizures and late reduced diffusion (AESD).
MR spectroscopy indicated a transient glutamine increase, a marker also seen in AESD, pointing to excitotoxicity.

Implications:

The findings suggest excitotoxicity as a potential pathomechanism in TBI-related subcortical white matter injury in infants.
This highlights the importance of recognizing biphasic clinical courses and delayed diffusion changes in pediatric TBI.
Further research is warranted to elucidate the precise mechanisms and optimize management strategies for these critical cases.

Read full analysis

Abstract:

Reduced diffusion in the subcortical white matter has been reported in some infants with traumatic brain injury (TBI), including abusive head trauma. However, the pathomechanisms of the lesions and clinical features are uncertain. We herein report two infants with TBI who presented with biphasic clinical courses and late reduced diffusion in the subcortical white matter, and reviewed seven clinically and radiologically similar patients with TBI. Their clinical features (secondary neurological symptoms on days 3 to 6) and radiological findings (normal diffusion on days 1 to 2, followed by reduced diffusion on days 3 to 6) are very similar to those observed in patients with acute encephalopathy with biphasic seizures and late reduced diffusion (AESD). MR spectroscopy in one patient revealed a transient increase of glutamine, which is also observed in AESD, suggesting excitotoxicity as a possible pathomechanism.

Keywords:

Abusive head trauma Acute encephalopathy with biphasic seizures and late reduced diffusion Excitotoxicity Infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion MR spectroscopy Traumatic brain injury

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