|Year : 2019 | Volume
| Issue : 4 | Page : 244-246
Pericontusional penumbra in patients with traumatic brain injury
Amit Agrawal1, V Anil Kumar2, Luis Rafael Moscote-Salazar3, VA Kiran Kumar1
1 Department of Neurosurgery, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
2 Department of Anesthesia, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
3 Neurosurgery-Critical Care, RED LATINO, Organizacion Latinoamericana de Trauma y Cuidado Neurointensivo, Bogota, Colombia
|Date of Submission||10-May-2019|
|Date of Acceptance||30-Oct-2019|
|Date of Web Publication||12-Dec-2019|
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Recently, a number of studies have recognized the importance of traumatic pericontusional penumbra as a potential target for therapeutic interventions to prevent the secondary brain damage. We report an illustrative case of a 40-year-old female patient who was brought to the emergency room with the alleged history of fall from the bike. Computed tomography scan brain showed left sylvian and left temporoparietal subarachnoid hemorrhage, patchy contusion of the left frontal and temporal lobes, linear fracture of the right temporal bone with edema, mass effect, and mild midline shift. After 6 h of intensive care unit stay, the patient developed pupillary asymmetry and a repeat scan showed significant increase in the size of cerebral contusions with gross pericontusional edema, mass effect, and midline shift. The patient underwent urgent left frontotemporoparietal craniotomy and evacuation of the contused brain and hematoma. Pericontusional penumbra is increasingly recognized and strategies are being suggested to salvage the apparently hypoxic (not yet ischemic) brain to preserve the neurological functions and to improve functional outcome. In future, we need more studies to support the concept of pericontusional penumbra and further characterize the imaging findings for early clinical diagnosis and to plan early appropriate intervention.
Keywords: Cerebral contusion, penumbra, secondary brain injury, traumatic brain injury
|How to cite this article:|
Agrawal A, Kumar V A, Moscote-Salazar LR, Kiran Kumar V A. Pericontusional penumbra in patients with traumatic brain injury. Apollo Med 2019;16:244-6
| Introduction|| |
In patients with severe traumatic brain injury, raised intracranial pressure and cerebral ischemia is a major concern as it can lead to cerebral hypoperfusion and secondary brain injury followed by poorer irreversible neuronal damage and poorer outcome.,,, Recently, a number of studies have recognized the importance of traumatic pericontusional penumbra as a potential target for therapeutic interventions to prevent the secondary brain damage., The concept of traumatic pericontusional penumbra explores the fact that the regions surrounding the contused brain can be hypoxic, but not ischemic at least in the initial phases.
| Case Report|| |
A 40-year-old female patient was brought to the emergency room with the alleged history of fall from the bike (the patient was pillion rider) about 6 h of the incident. She was unconscious since the time of accident, had multiple episodes of vomiting, and right ear and nasal bleed. There was no history of seizures. On examination, her pulse rate was 116 beats/min and blood pressure was 130/80 mmHg. Her Glasgow Coma Score (GCS) was E2V2M5. Her pupils were bilateral 2 mm and reacting to light. In view of low GCS, the patient was intubated and kept on elective ventilation. After stabilizing her general condition, she was shifted for an urgent computed tomography (CT) scan of the brain. CT scan brain showed left sylvian and left temporoparietal subarachnoid hemorrhage, patchy contusion of the left frontal and temporal lobes, linear fracture of the right temporal bone with edema, mass effect, and mild midline shift [Figure 1]a, [Figure 1]b, [Figure 1]c. Blood investigation showed hemoglobin 8.8 g/dl and random blood glucose 189 mg/dl. Other blood investigations including coagulation profile were within normal range. The patient was planned for conservative treatment and kept in neurocritical unit for close monitoring. She was started on antiedema measures and antiepileptics. After 6 h of intensive care unit stay, the patient developed pupillary asymmetry (right pupil 2 mm reacting to light and left 4 mm sluggishly reacting to light). The patient was shifted for an urgent repeat CT scan of the brain. Repeat scan showed significant increase in the size of cerebral contusions with gross pericontusional edema, mass effect, and midline shift [Figure 1]d, [Figure 1]e, [Figure 1]f. The patient underwent urgent left frontotemporoparietal craniotomy and evacuation of the contused brain and hematoma. Following surgery, the brain was lax and pulsatile. The dura could be closed primarily and bone flap could be replaced. The patient was electively ventilated and continued with antiedema measures and antiepileptics. Pupillary asymmetry resolved in immediate postoperative period. Postoperative CT scan of the brain showed good evacuation of the contusion and resolution of mass effect and midline shift [Figure 1]g, [Figure 1]h, [Figure 1]i. As it was anticipated that the patient will need prolonged ventilation, she underwent tracheostomy. The patient was making a gradual recovery; however, on 5th postoperative day, she was dull and drowsy. A follow-up CT scan showed increase in cerebral edema with mass effect. To relieve the mass effect, the bone flap was removed and a lax duraplasty was performed. The patient made gradual recovery in her sensorium and could be weaned off from the ventilator and from tracheostomy.
|Figure 1: (a-c) Initial computed tomography scan showing subarachnoid hemorrhage in left sylvian fissure with patchy contusion involving left frontal and temporal lobe with mild mass effect and obliteration of the basal cisterns, (d-f) follow-up computed tomography scan showing significant enlargement of frontal and temporal contusion with pericontusional edema, significant mass effect, and midline shift and (g-i) postoperative computed tomography scan showing reduction in the size of the cerebral contusions and pericontusional edema, basal cisterns opened up, ventricles are symmetrically visible, please note the increased area of normally appearing brain between frontal and temporal contusions|
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| Discussion|| |
It has been found that following primary brain injury, the brain lesions may progressively expand centrifugally, leading to progressive necrosis which can increase by 130-400% of the primary lesions. This led to the concept of traumatic pericontusional penumbra in literature and it has been suggested that this penumbra contain potentially salvageable neural tissue.,, Ischemia in the pericontusional region can lead to neuronal damage by various mechanisms including oxidative stress, neuronal, mitochondrial dysfunction, excitotoxicity, and neuronal inflammation.,,, The formation and expansion of pericontusional penumbra can be followed by impairment of blood flow to the area, edema, compromised metabolism, and neurological deterioration, and if left untreated, permanent neurological dysfunction persists.,,, CT scan is widely available modality of investigation to follow the progression or resolution of traumatic intracranial mass lesions. The role of advanced MR imaging, i.e., diffusion tensor imaging and positron emission tomography, has been explored to further characterize and understand the pathophysiology pericontusional penumbra. On diffusion tensor imaging, these lesions are characterized by a core area with raised ADC values (suggests vasogenic edema) and surrounding thin hypointense rim with decreased ADC values (suggests cytotoxic edema).
| Conclusion|| |
Pericontusional penumbra is increasingly recognized and strategies are being suggested to salvage the apparently hypoxic (not yes ischemic) brain to preserve the neurological functions and to improve functional outcome. In future, we need more studies to support the concept of pericontusional penumbra and further characterize the imaging findings for early clinical diagnosis and to plan early appropriate intervention.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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