На основании опыта ФГАУ «НИИ нейрохирургии им. акад. Н.Н.Бурденко» Минздрава России рассмотрены клинические аспекты диффузного аксонального повреждения (ДАП) головного мозга. Подробно представлена неврологическая симптоматика ДАП с выделением характерного синдрома разобщения коры полушарий мозга и подкорково-стволовых образований. Описаны варианты клинического течения ДАП и выхода из комы. Внимание уделено нейровизуализационной диагностике ДАП с особым акцентом на различные модальности магнитно-резонансной томографии, позволяющие четко определять микроповреждения различных структур мозга, в том числе нервных проводников. Представлены принципы лечения, а также прогноз и исходы ДАП.
Based on the experience of the Burdenko Institute of Neurosurgery the clinical aspects of diffuse axonal injury (DAI) of the brain were reviewed Details presented with neurological symptoms of DAI reveal characteristic syndrome separation of cerebral cortex and subcortical-stem structures. Variants of clinical course of the DAI and the exit out of the coma. Attention is paid to the DAI neuroimaging diagnosis with particular emphasis on the various modalities of MRI, that allows to clearly define microdamages various brain structures, including nerve agents. The principles of treatment and the prognosis and outcome of the DAI.
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4. Корниенко В.Н., Васин Н.Я., Кузьменко В.А. Компьютерная томография в диагнозе черепно-мозговой травмы. М.: Медицина, 1987. / Kornienko V.N., Vasin N.Ia., Kuz'menko V.A. Komp'iuternaia tomografiia v diagnoze cherepno-mozgovoi travmy. M.: Meditsina, 1987. [in Russian]
5. Корниенко В.Н., Лихтерман Л.Б., Кузьменко В.А., Туркин A.M. Компьютерная томография. В кн.: Клиническое руководство по черепно-мозговой травме. Под ред. А.Н.Коновалова, Л.Б.Лихтермана, А.А.Потапова. Т. 1. М.: Антидор, 1998; с. 472–94. / Kornienko V.N., Likhterman L.B., Kuz'menko V.A., Turkin A.M. Komp'iuternaia tomografiia. V kn.: Klinicheskoe rukovodstvo po cherepno-mozgovoi travme. Pod red. A.N.Konovalova, L.B.Likhtermana, A.A.Potapova. T. 1. M.: Antidor, 1998; s. 472–94. [in Russian]
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7. Лихтерман Л.Б. Неврология черепно-мозговой травмы. В кн.: Клиническое руководство по черепно-мозговой травме. Под ред. А.Н.Коновалова, Л.Б.Лихтермана, А.А.Потапова. Т. 1. М.: Антидор, 1998; с. 230–68. / Likhterman L.B. Nevrologiia cherepno-mozgovoi travmy. V kn.: Klinicheskoe rukovodstvo po cherepno-mozgovoi travme. Pod red. A.N.Konovalova, L.B.Likhtermana, A.A.Potapova. T. 1. M.: Antidor, 1998; s. 230–68. [in Russian]
8. Лихтерман Л.Б., Корниенко В.Н., Потапов А.А. и др. Черепно-мозговая травма: прогноз течения и исходов. М.: Книга ЛТД, 1993. / Likhterman L.B., Kornienko V.N., Potapov A.A. i dr. Cherepno-mozgovaia travma: prognoz techeniia i iskhodov. M.: Kniga LTD, 1993. [in Russian]
9. Лихтерман Л.Б., Потапов А.А. Классификация черепно-мозговой травмы. В кн.: Клиническое руководство по черепно-мозговой травме. Под ред. А.Н.Коновалова, Л.Б.Лихтермана, А.А.Потапова. Т. 1. М.: Антидор, 1998; с. 47–123. / Likhterman L.B., Potapov A.A. Klassifikatsiia cherepno-mozgovoi travmy. V kn.: Klinicheskoe rukovodstvo po cherepno-mozgovoi travme. Pod red. A.N.Konovalova, L.B.Likhtermana, A.A.Potapova. T. 1. M.: Antidor, 1998; s. 47–123. [in Russian]
10. Потапов А.А., Лихтерман Л.Б., Касумова С.Ю. Диффузное аксональное повреждение головного мозга. В кн.: Клиническое руководство по черепно-мозговой травме. Под ред. А.Н.Коновалова, Л.Б.Лихтермана, А.А.Потапова. Т. 2. М., 2001;
с. 426–50. / Potapov A.A., Likhterman L.B., Kasumova S.Iu. Diffuznoe aksonal'noe povrezhdenie golovnogo mozga. V kn.: Klinicheskoe rukovodstvo po cherepno-mozgovoi travme. Pod red. A.N.Konovalova, L.B.Likhtermana, A.A.Potapova. T. 2. M., 2001; s. 426–50. [in Russian]
11. Потапов А.А., Коновалов А.Н., Корниенко В.Н. и др. Черепно-мозговая травма: фундаментальные проблемы и клинические решения. В кн.: Современные технологии и клинические исследования в нейрохирургии. Под ред. А.Н.Коновалова. Т. 1. М., 2012; с. 159–264. / Potapov A.A., Konovalov A.N., Kornienko V.N. i dr. Cherepno-mozgovaia travma: fundamental'nye problemy i klinicheskie resheniia. V kn.: Sovremennye tekhnologii i klinicheskie issledovaniia v neirokhirurgii. Pod red. A.N.Konovalova. T. 1. M., 2012; s. 159–264. [in Russian]
12. Потапов А.А., Лихтерман Л.Б., Касумова С.Ю. и др. Диффузные аксональные повреждения головного мозга. Вопр. нейрохирургии. 1990; 2: 3–7. / Potapov A.A., Likhterman L.B., Kasumova S.Iu. i dr. Diffuznye aksonal'nye povrezhdeniia golovnogo mozga. Vopr. neirokhirurgii. 1990; 2: 3–7. [in Russian]
13. Adams JH et al. Diffuse axonal injury in head- injuries caused by a fall. Lancet 1984; 22 (29): 1420–1.
14. Adams JH, Gracham DI, Gennarelli TA. Head injury in man and experimental animals: neuropathology. Actaneurochirurgica 1983; 32 (Suppl.): 15–30.
15. Adams JH, Gracham DI, Murray LS, Scott G. Diffuse axonal injury due to non-missile head injury in human: an analysis of 45 cases. Ann Neurol 1982; 12 (6): 557–63.
16 Adams JH, Mitchell DE, Graham DI, Doyle D. Diffuse brain, damage of immediate impact type. Its relationship to primary brainstem damage in head injury. Brain 1977; 100: 469–502.
17. Aldman B, Thorngren L, Ljung C. Patterns of deformation in brain models under rotational motion, Proceedings of a workshop on headand neck injury criteria, U.S. Department of transportation. National High way traffic safety administration. Washington, 1981; p. 163–8.
18. Bruce DA, Alavi A, Bilaniuk L et al. Diffuse cerebral swelling following head, injuries in children: the syndrome of «malignant brain edems». J Neurosurg 1981; 54: 170–8.
19. Cecil KM, Hills EC, Sandel ME et al. Proton magnetic resonance spectroscopy for detection of axonal injury in the splenium of the corpus callosum of brain-injured patients. J Neurosurg 1998; 88 (5): 795–801.
20. Clark JM. Distribution of microglial clusters in the brain after head injury. J Neurol Neurosurg Psychiatry 1974; 37: 463–74.
21. Erb DE, Povlishock JT. Axonal damage in severe traumatic brain injury: an experimental study in cat. Acta Neuropathol 1988; 76 (4): 347–58.
22. Gennarelii TA. Head injury in man and experimental animals: clinical aspects. Actaneurochirurgica 1983; 32 (Suppl.): 1–13.
23. Gennarelii TA. Cerebral Concussion and Diffuse Brain Injuries. Head Injury. Baltimor, 1982; p. 83–97.
24. Gennarelii TA, Adams JH, Graham DI. Diffuse axonal injury, A new conceptual approach to an old problem. In: Mechanisms of Secondary Brain Damage. Eds. A.Baethmann, K.O.Go, A.Unterberd. New York, London: Plenum Press, 1986; p. 17–28.
25. Gennarelii TA, Ommaya AK, Thibault LE. Comparison of linear and rotational acceleration in experimental cerebral concussion. 15-st Stapp car crash conf., Proc. SAE. New York, 1971; p. 797–803.
26. Gennarelii TA, Thibault LE, Adams JH et al. Diffuse axonal injury arid traumatic coma in the primate. Ann Neurol 1982; 12: 564–74.
27. Gennarelii ТА. Mechanisms of brain injury. J Emerg Med 1993; 11 (Suppl. 1): 5–11.
28. Holbourn AHS. Mechanics of head injuries. Lancet 1943; 2: 438–41.
29. Imajo T, Challener RC, Roesmann U. Diffuse-axonal injury by assault. Am J Forensic Med Pathol 1987: 8 (3): 217–9.
30. Jellinger K. Pathology and pathogenesis apalicsyndrom following closed head injuries. In: Theapalic syndrome. Eds. G.D.Ore et al. Berlin: Springer, 1977; p. 128–42.
31. Jennett B. The vegetative state. Cambridge: Cambridge University Press, 2002.
32. Jennett B, Plum F. Persistent vegetative state after brain damage. Lancet, 1972; i: 734–7.
33. Kuzma BB, Goodman JM. Improved identification of axonal shear injuries with gradient echo MR technique. Surg Neurol 2000; 53 (4): 400–2.
34. Lang DA, Teasdale GM, Macpherson P, Lawrence A. Diffuse brain swelling after head injury: more often malignant in adults than children? J Neurosurg 1994; 80 (4): 675–80.
35. Lee TT, Galarza M, Villanueva PA. Diffuse axonal injury (DAI) is not associated with elevated intracranial pressure (ICP). Acta Neurochir (Wien) 1998; 140 (l): 41–6.
36. Levin HS, Handel SF, Goldman AM et al. Magnetic resonance imaging after Diffuse non-missile head injury. Acta Neurol 1985; 42: 963–8.
37. Liu AY, Maldjian JA, Bagley LJ et al. Traumatic brain injury: diffusion-weighted MR imaging findings. AJNR Am J Neuroradiol 1999; 20 (9): 1636–41.
38. Lobato RD, Cordobes F, Rivas JJ et al. Outcome from severe head injury related to the type of intracranial lesion, A computerised tomography study. J Neurosurg 1983; 59: 762–74.
39. Meaney DF, Smith DH, Shreiber DI et al. Biomechanical analysis of experimental diffuse axonal injury. J Neurotrauma 1995; 12 (4): 689–94.
40. Mittl RL, Grossman RI, Hiehle JF et al. Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT findings. AJNR Am J Neuroradiol 2000; 21 (5): 808–9.
41. Nakazawa C, Kobayashi S, Yokota H et al. A clinical study of diffuse axonal injury. In: Book of Abstracts. Eds. R.Bhatia, S.Bhatia. New Delhi, 1989; p. 257.
42. Ong L, Selladurai BM, Dhillon MK et al. The prognostic value of the Glasgow Coma Scale, hypoxia and computerised tomography in outcome prediction of pediatric head injury. Pediatr Neurosurg 1996; 24 (6): 285–91.
43. Parizel PM, Ozsarlak, van Goethem JW et al. Imaging findings in diffuse axonal injury after closed head trauma. Eur Radiol 1998; 8 (6): 960–5.
44. Posner JB, Saper CB, Schiff ND, Plum F. Plum and Posner’s diagnosis of stupor and coma. 4-th edition, Oxford University Press, 2007.
45. Povlishock JT. Traumatically induced axonal damages without concomitant in focally related neuronal somata and dendrites. Acta Neuropathol 1986; 70 (1): 53–9.
46. Povlishock JT, Becker DP, Cheng CLY et al. Axonal change in minor head injury. J Neuropathol Exp Neurol 1983; 42: 225–42.
47. Sahuquillo-Barris J, Lamarcav-Ciuro J, Vilalta-Castan J et al. Acute subdural hematoma arid diffuse axonal injury after severe head trauma. J Neurosurg 1988; 68: 894–900.
48. Shimura Т, Nakazawa S, Kobayashi S et al. Clinicopathological studies of diffuse axonal injury (five autopsy cases). No Shinkei – Geca 1988; 16 (5): 647–53.
49. Slazinski T, Johnson MC. Severe diffuse axonal injury in adults and children. J Neurosci Nurs 1994; 26 (3): 151–4.
50. Smith DH, Nonaka M, Miller R et al. Immediate coma following inertial brain injury dependent on axonal damage in the brainstem. J Neurosurg 2000; 93 (2): 315–22.
51. Wang H, Duan G, Zhang J, Zhou D. Clinical studies on diffuse axonal injury in patients with severe closed head injury. Chin Med J (Engl) 1998; 111 (1): 59–62.
________________________________________________
1. Dobrokhotova T.A. Neiropsikhiatriia. M.: Binom, 2006. [in Russian]
2. Zakharova N.E., Kornienko V.N. Pronin I.N., Potapov A.A. Neirovizualizatsionnye tekhnologii v izuchenii i diagnostike posledstvii i oslozhnenii cherepno-mozgovoi travmy. V kn.: Rekonstruktivnaia i minimal'no invazivnaia khirurgiia posledstvii cherepno-mozgovoi travmy. M., 2012; s. 55–117. [in Russian]
3. Kasumova S.Iu. Patologicheskaia anatomiia cherepno-mozgovoi travmy. V kn.: Klinicheskoe rukovodstvo po cherepno-mozgovoi travme. Pod red. A.N.Konovalova, L.B.Likhtermana, A.A.Potapova. T. 1. M.: Antidor, 1998; s. 169–225. [in Russian]
4. Kornienko V.N., Vasin N.Ia., Kuz'menko V.A. Komp'iuternaia tomografiia v diagnoze cherepno-mozgovoi travmy. M.: Meditsina, 1987. [in Russian]
5. Kornienko V.N., Likhterman L.B., Kuz'menko V.A., Turkin A.M. Komp'iuternaia tomografiia. V kn.: Klinicheskoe rukovodstvo po cherepno-mozgovoi travme. Pod red. A.N.Konovalova, L.B.Likhtermana, A.A.Potapova. T. 1. M.: Antidor, 1998; s. 472–94. [in Russian]
6. Kornienko V.N., Turkin A.M., Likhterman L.B. Magnitno-rezonansnaia tomografiia v diagnostike cherepno-mozgovoi travmy. V kn.: Klinicheskoe rukovodstvo po cherepno-mozgovoi travme. Pod red. A.N.Konovalova, L.B.Likhtermana, A.A.Potapova. T. 1. M.: Antidor, 1998; s. 510–33. [in Russian]
7. Likhterman L.B. Nevrologiia cherepno-mozgovoi travmy. V kn.: Klinicheskoe rukovodstvo po cherepno-mozgovoi travme. Pod red. A.N.Konovalova, L.B.Likhtermana, A.A.Potapova. T. 1. M.: Antidor, 1998; s. 230–68. [in Russian]
8. Likhterman L.B., Kornienko V.N., Potapov A.A. i dr. Cherepno-mozgovaia travma: prognoz techeniia i iskhodov. M.: Kniga LTD, 1993. [in Russian]
9. Likhterman L.B., Potapov A.A. Klassifikatsiia cherepno-mozgovoi travmy. V kn.: Klinicheskoe rukovodstvo po cherepno-mozgovoi travme. Pod red. A.N.Konovalova, L.B.Likhtermana, A.A.Potapova. T. 1. M.: Antidor, 1998; s. 47–123. [in Russian]
10. Potapov A.A., Likhterman L.B., Kasumova S.Iu. Diffuznoe aksonal'noe povrezhdenie golovnogo mozga. V kn.: Klinicheskoe rukovodstvo po cherepno-mozgovoi travme. Pod red. A.N.Konovalova, L.B.Likhtermana, A.A.Potapova. T. 2. M., 2001; s. 426–50. [in Russian]
11. Potapov A.A., Konovalov A.N., Kornienko V.N. i dr. Cherepno-mozgovaia travma: fundamental'nye problemy i klinicheskie resheniia. V kn.: Sovremennye tekhnologii i klinicheskie issledovaniia v neirokhirurgii. Pod red. A.N.Konovalova. T. 1. M., 2012; s. 159–264. [in Russian]
12. Potapov A.A., Likhterman L.B., Kasumova S.Iu. i dr. Diffuznye aksonal'nye povrezhdeniia golovnogo mozga. Vopr. neirokhirurgii. 1990; 2: 3–7. [in Russian]
13. Adams JH et al. Diffuse axonal injury in head- injuries caused by a fall. Lancet 1984; 22 (29): 1420–1.
14. Adams JH, Gracham DI, Gennarelli TA. Head injury in man and experimental animals: neuropathology. Actaneurochirurgica 1983; 32 (Suppl.): 15–30.
15. Adams JH, Gracham DI, Murray LS, Scott G. Diffuse axonal injury due to non-missile head injury in human: an analysis of 45 cases. Ann Neurol 1982; 12 (6): 557–63.
16 Adams JH, Mitchell DE, Graham DI, Doyle D. Diffuse brain, damage of immediate impact type. Its relationship to primary brainstem damage in head injury. Brain 1977; 100: 469–502.
17. Aldman B, Thorngren L, Ljung C. Patterns of deformation in brain models under rotational motion, Proceedings of a workshop on headand neck injury criteria, U.S. Department of transportation. National High way traffic safety administration. Washington, 1981; p. 163–8.
18. Bruce DA, Alavi A, Bilaniuk L et al. Diffuse cerebral swelling following head, injuries in children: the syndrome of «malignant brain edems». J Neurosurg 1981; 54: 170–8.
19. Cecil KM, Hills EC, Sandel ME et al. Proton magnetic resonance spectroscopy for detection of axonal injury in the splenium of the corpus callosum of brain-injured patients. J Neurosurg 1998; 88 (5): 795–801.
20. Clark JM. Distribution of microglial clusters in the brain after head injury. J Neurol Neurosurg Psychiatry 1974; 37: 463–74.
21. Erb DE, Povlishock JT. Axonal damage in severe traumatic brain injury: an experimental study in cat. Acta Neuropathol 1988; 76 (4): 347–58.
22. Gennarelii TA. Head injury in man and experimental animals: clinical aspects. Actaneurochirurgica 1983; 32 (Suppl.): 1–13.
23. Gennarelii TA. Cerebral Concussion and Diffuse Brain Injuries. Head Injury. Baltimor, 1982; p. 83–97.
24. Gennarelii TA, Adams JH, Graham DI. Diffuse axonal injury, A new conceptual approach to an old problem. In: Mechanisms of Secondary Brain Damage. Eds. A.Baethmann, K.O.Go, A.Unterberd. New York, London: Plenum Press, 1986; p. 17–28.
25. Gennarelii TA, Ommaya AK, Thibault LE. Comparison of linear and rotational acceleration in experimental cerebral concussion. 15-st Stapp car crash conf., Proc. SAE. New York, 1971; p. 797–803.
26. Gennarelii TA, Thibault LE, Adams JH et al. Diffuse axonal injury arid traumatic coma in the primate. Ann Neurol 1982; 12: 564–74.
27. Gennarelii ТА. Mechanisms of brain injury. J Emerg Med 1993; 11 (Suppl. 1): 5–11.
28. Holbourn AHS. Mechanics of head injuries. Lancet 1943; 2: 438–41.
29. Imajo T, Challener RC, Roesmann U. Diffuse-axonal injury by assault. Am J Forensic Med Pathol 1987: 8 (3): 217–9.
30. Jellinger K. Pathology and pathogenesis apalicsyndrom following closed head injuries. In: Theapalic syndrome. Eds. G.D.Ore et al. Berlin: Springer, 1977; p. 128–42.
31. Jennett B. The vegetative state. Cambridge: Cambridge University Press, 2002.
32. Jennett B, Plum F. Persistent vegetative state after brain damage. Lancet, 1972; i: 734–7.
33. Kuzma BB, Goodman JM. Improved identification of axonal shear injuries with gradient echo MR technique. Surg Neurol 2000; 53 (4): 400–2.
34. Lang DA, Teasdale GM, Macpherson P, Lawrence A. Diffuse brain swelling after head injury: more often malignant in adults than children? J Neurosurg 1994; 80 (4): 675–80.
35. Lee TT, Galarza M, Villanueva PA. Diffuse axonal injury (DAI) is not associated with elevated intracranial pressure (ICP). Acta Neurochir (Wien) 1998; 140 (l): 41–6.
36. Levin HS, Handel SF, Goldman AM et al. Magnetic resonance imaging after Diffuse non-missile head injury. Acta Neurol 1985; 42: 963–8.
37. Liu AY, Maldjian JA, Bagley LJ et al. Traumatic brain injury: diffusion-weighted MR imaging findings. AJNR Am J Neuroradiol 1999; 20 (9): 1636–41.
38. Lobato RD, Cordobes F, Rivas JJ et al. Outcome from severe head injury related to the type of intracranial lesion, A computerised tomography study. J Neurosurg 1983; 59: 762–74.
39. Meaney DF, Smith DH, Shreiber DI et al. Biomechanical analysis of experimental diffuse axonal injury. J Neurotrauma 1995; 12 (4): 689–94.
40. Mittl RL, Grossman RI, Hiehle JF et al. Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT findings. AJNR Am J Neuroradiol 2000; 21 (5): 808–9.
41. Nakazawa C, Kobayashi S, Yokota H et al. A clinical study of diffuse axonal injury. In: Book of Abstracts. Eds. R.Bhatia, S.Bhatia. New Delhi, 1989; p. 257.
42. Ong L, Selladurai BM, Dhillon MK et al. The prognostic value of the Glasgow Coma Scale, hypoxia and computerised tomography in outcome prediction of pediatric head injury. Pediatr Neurosurg 1996; 24 (6): 285–91.
43. Parizel PM, Ozsarlak, van Goethem JW et al. Imaging findings in diffuse axonal injury after closed head trauma. Eur Radiol 1998; 8 (6): 960–5.
44. Posner JB, Saper CB, Schiff ND, Plum F. Plum and Posner’s diagnosis of stupor and coma. 4-th edition, Oxford University Press, 2007.
45. Povlishock JT. Traumatically induced axonal damages without concomitant in focally related neuronal somata and dendrites. Acta Neuropathol 1986; 70 (1): 53–9.
46. Povlishock JT, Becker DP, Cheng CLY et al. Axonal change in minor head injury. J Neuropathol Exp Neurol 1983; 42: 225–42.
47. Sahuquillo-Barris J, Lamarcav-Ciuro J, Vilalta-Castan J et al. Acute subdural hematoma arid diffuse axonal injury after severe head trauma. J Neurosurg 1988; 68: 894–900.
48. Shimura Т, Nakazawa S, Kobayashi S et al. Clinicopathological studies of diffuse axonal injury (five autopsy cases). No Shinkei – Geca 1988; 16 (5): 647–53.
49. Slazinski T, Johnson MC. Severe diffuse axonal injury in adults and children. J Neurosci Nurs 1994; 26 (3): 151–4.
50. Smith DH, Nonaka M, Miller R et al. Immediate coma following inertial brain injury dependent on axonal damage in the brainstem. J Neurosurg 2000; 93 (2): 315–22.
51. Wang H, Duan G, Zhang J, Zhou D. Clinical studies on diffuse axonal injury in patients with severe closed head injury. Chin Med J (Engl) 1998; 111 (1): 59–62.
Авторы
Л.Б.Лихтерман*
ФГАУ НИИ нейрохирургии им. акад. Н.Н.Бурденко Минздрава России. 125047, Россия, Москва, 4-я Тверская-Ямская ул., д. 16.
*elkina@nsi.ru
________________________________________________
L.B.Likhterman*
N.N.Burdenko Scientific-Research Institute of Neurosurgery of the Ministry of Health of the Russian Federation. 125047, Russian Federation, Moscow, 4-ia Tverskaia-Iamskaia ul., d. 16
*elkina@nsi.ru