Head Injury in Man and Experimental Animals: Neuropathology
All of the principal types of brain damage that occur in man as a result of a non-missile head injury, viz. cerebral contusions, intracranial haematoma, raised intracranial pressure, diffuse axonal injury, diffuse hypoxic damage, and diffuse swelling have
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* Department of Neuropathology, Institute of Neurological Scienccs, Glasgow, Scotland, and ** Division ofNeurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.
Head Injury in Man and Experimental Animals: Neuropathology By
J. H. Adams*, D. 1. Graham*, and T. A. Gennarelli** With 9 Figures
Summary
Ali ofthe principal types ofbrain damage that occur in man as a result of a nonmissile head injury, viz. cerebral contusions, intracranial haematoma, raised intracranial pressure, diffuse axonal injury, diffuse hypoxic damagc, and diffuse swelling ha ve been produced in subhuman primates subjected to inertial, i.e. nonimpact, controlled angular acceleration of the head through 60° in the sagittal, oblique and lateral planes. Keywords: Head injury; man; experimental; diffuse axonal injury.
Introduction
The most important factor governing outcome in a non-missile head injury-and indeed in almost any type of injury-is the damage sustained by the brain 2 . Some of this may occur at the moment of injury (primary brain damage) but often much of the brain damage is caused by a complication of the original injury (secondary brain damage). Thus, the initial injury-whether mild or severe-may set in motion a progressive and dynamic sequence
J. H. Adams etal.:
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Table 1. lncidence of Fora! and Diffuse TJpes ofBrain Damage After Non-Missile Head lnjury in Man and Experimental Subhuman Primates Man without DAI (n = 132)
Penn. 1 (n = 53)
Man with DAI (n = 45)
Penn. 2 (n = 26)
17.8 88.0 (66.7%) 114.0 (86.4%)
4.2 19.0 (35.9%) 31.0 (58.5%)
8.3 5.0 (11.1%) 25.0 (55.6%)
1.3 Nil
Nil
Nil
45.0 (100%)
18.0 (69.2%)
61.0 (47.2) 24.0 (18.2%)
4.0 (7.5%) 13.0 (24.5%)
22.0 (48.9%) 7.0 (15.6%)
Nil
Foca! brain damage Total mean contusion index Subdural haematoma Rai sed intracranial pressure
Nil
Diffuse brain damage Diffuse axonal injury Hypoxic damage in cerebral cortex Brain swelling
Nil
of events, the identification and understanding of which is the essence ofthe management of a patient with a head injury. There is, however, an increasing tendency to think of brain damage in head injury as being foca! or dif/ilse 3 • In this era of computerized tomography foca! brain damage-and its type-are usually known to be present during life, and are easy to identify post mortem: foca! brain damage includes contusions, intracranial haematoma, shift and herniation of the brain, and rai sed intracranial pressure. In an unconscious patient without any evidence of intracranial haematoma-a situation that occurs in almost 50% of patients who ha ve sustained a severe non-missile head injury 1 1-it is usually concluded that the patient has sustained diffuse brain damage but its precise type is rarely identifiable during life: the three principal types of diffuse brain damage that occur in patients who survive their injury for more than a few hours are diffuse axonal injury, diffuse hypoxic brain damage and diffuse brain swelling 3 .
Head Injury in Man and Experimental Animals
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There has in the past been a tendenc
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