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Chapter 2. Neuropathology

Colin Smith, M.D.
DOI: 10.1176/appi.books.9781585624201.671834

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Traumatic brain injury (TBI) remains a major cause of morbidity and mortality throughout the world, affecting young and old alike. Pathological data have been developed through observations of human autopsies and developing animal models to investigate its mechanisms. One always has to be aware of the limitations of both these approaches: autopsies, in most cases, provide information relating to the most severe end of the clinical spectrum of TBI, fatal outcome; animal models do not represent the polypathology of human brain injury; and there are likely to be significant differences in the anatomical basis of injury and cellular responses between species.

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Figure 2–1. An area of cortical laceration secondary to a penetrating head injury. In this case the penetrating injury was a metal rod that entered the brain in the occipital region (arrow) and extended through the brain, exiting in the inferior frontal region.

Figure 2–2. Acute cortical contusions involving the inferior frontal lobes.On the left side, the contusions involve the full thickness of the cortex (black arrow), extending into underlying white matter. On the right side, there is more extensive tissue damage resulting in a laceration (white arrow).

Figure 2–3. Old cortical contusions involving the inferior aspect of the frontal lobes.The pathology is most obvious on the left-hand side of this image; the discoloration (arrow) is secondary to hemosiderin accumulation.

Figure 2–4. An acute extradural hematoma, revealed by removing the skull cap.The hematoma lies on the surface of the dura and is well circumscribed.

Figure 2–5. An acute subdural hematoma.The dura has been incised and reflected upward, revealing diffuse bleeding between the dura and the brain. The cut edges of the dura are highlighted by arrows.

Figure 2–6. Subfalcine herniation.The cingulate gyrus has been forced below the free edge of the falx cerebri, producing a notch (arrow). The herniated tissue shows the dusky discoloration of infarction.

Figure 2–7. Sections from different levels of the pons showing extensive hemorrhagic infarction within the brain stem secondary to axial displacement.This is commonly seen as a terminal event secondary to mass lesions, particularly extradural and subdural hematomas.

Figure 2–8. Medial occipital cortical infarction secondary to a tentorial hernia compressing the posterior cerebral artery.The right medial occipital cortex, involving the primary visual cortex, shows dusky discoloration. The area of infarction is outlined by arrows.

Figure 2–9. A wedge-shaped area of infarction involving the parahippocampal gyrus (arrow) is indicative of a previous episode of tentorial herniation.

Figure 2–10. In diffuse traumatic axonal injury, corpus callosal hemorrhage typically extends to involve the lateral white matter bundles (arrow).Hemorrhage secondary to infarction in cases with subfalcine herniation is more typically limited to the midline.

Figure 2–11. Eosinophilic axonal spheroids indicating axonal degeneration (arrows).Presence is not indicative of trauma as spheroids will also be seen secondary to a number of other pathologies, particularly ischemia (hematoxylin and eosin stain x40).

Figure 2–12. Degenerating axon (arrow) identified with beta-amyloid precursor protein (-APP) immunohistochemistry.The beaded appearance is typical in degenerating axons (β-APP immunohistochemistry x40).

Figure 2–13. Hemorrhagic infarction in relation to the tract of a penetrating head injury.

Figure 2–14. Gliding contusions in a child'€™s brain, with a survival of approximately 2 years after a period of traumatic brain injury.The contusions lie in the parasagittal white matter and are often, as in this case, bilateral (arrows).
Table Reference Number
Table 2–1. Mechanisms of traumatic brain injury
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Table 2–2. Classification of traumatic brain injury
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Table 2–3. Causes of subdural hematoma (SDH)
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Table 2–4. Main neuropathological features associated with boxing

References

Adams JH, Graham DI, Scott G, et al: Brain damage in fatal non-missile head injury. J Clin Pathol 33:1132–1145, 1980
[PubMed]
 
Adams JH, Graham DI, Jennett B: The neuropathology of the vegetative state after an acute brain insult. Brain 123:1327–1338, 2000
[PubMed]
 
Adams JH, Graham DI, Jennett B: The structural basis of moderate disability after traumatic brain damage. J Neurol Neurosurg Psychiatry 71:521–524, 2001
[PubMed]
 
Blumbergs PC, Scott G, Manavis J, et al: Staining of amyloid precursor protein to study axonal damage in mild head injury. Lancet 344:1055–1056, 1994
[PubMed]
 
Bullock R, Teasdale G: Surgical management of traumatic intra-cranial hematomas, in Handbook of Clinical Neurology, Vol 15: Head Injury. Edited by Brackman R. Amsterdam, Elsevier, 1990, pp 249–298
 
Corsellis JAN, Bruton CJ, Freeman-Browne D: The aftermath of boxing. Psychol Med 3:270–303, 1973
[PubMed]
 
Dolinak D, Smith C, Graham DI: Global hypoxia per se is an unusual cause of axonal injury. Acta Neuropathol 100:553–560, 2000a
 
Dolinak D, Smith C, Graham DI: Hypoglycaemia is a cause of axonal injury. Neuropathol Appl Neurobiol 26:448–453, 2000b
 
Duhaime AC, Margulies SS, Durham SR, et al: Maturation-dependent response of the piglet brain to scaled cortical impact. J Neurosurg 93:455–462, 2000
[PubMed]
 
Duhaime AC, Hunter JV, Grate LL, et al: Magnetic resonance imaging studies of age-dependent responses to scaled focal brain injury in the piglet. J Neurosurg 99:542–548, 2003
[PubMed]
 
Durham SR, Raghupathi R, Helfaer MA, et al: Age-related differences in acute physiologic response to focal traumatic brain injury in piglets. Pediatr Neurosurg 33:76–82, 2000
[PubMed]
 
Elder GA, Cristian A: Blast-related mild traumatic brain injury: mechanisms of injury and impact on clinical care. Mt Sinai J Med 76:111–118, 2009
[PubMed]
 
Farkas O, Povlishock JT: Cellular and subcellular change evoked by diffuse traumatic brain injury: a complex web of change extending far beyond focal damage. Prog Brain Res 161:43–59, 2007
[PubMed]
 
Fleminger S, Oliver DL, Lovestone S, et al: Head injury as a risk factor for Alzheimer's disease: the evidence 10 years on: a partial replication. J Neurol Neurosurg Psychiatry 74:857–862, 2003
[PubMed]
 
Freytag E: Autopsy findings in head injuries from blunt forces: statistical evaluation of 1,367 cases. Arch Pathol 75:402–413, 1963
[PubMed]
 
Friess SH, Ichord RN, Owens K, et al: Neurobehavioral functional deficits following closed head injury in the neonatal pig. Exp Neurol 204:234–243, 2007
[PubMed]
 
Geddes JF, Vowles GH, Nicoll JAR, et al: Neuronal cytoskeletal changes are an early consequence of repetitive head injury. Acta Neuropathol 98:171–178, 1999
[PubMed]
 
Geddes JF, Hackshaw AK, Vowles GH, et al: Neuropathology of inflicted head injury in children, I: patterns of brain damage. Brain 124:1290–1298, 2001a
 
Geddes JF, Vowles GH, Hackshaw AK, et al: Neuropathology of inflicted head injury in children, II: microscopic brain injury in children. Brain 124:1299–1306, 2001b
 
Gennarelli TA: Cerebral concussion and diffuse brain injuries, in Head Injury, 3rd Edition. Edited by Cooper PR. Baltimore, MD, Williams & Wilkins, 1993, pp 137–158
 
Gennarelli TA, Thibault LE: Biomechanics of acute subdural hematoma. J Trauma 22:680–686, 1982
[PubMed]
 
Gennarelli TA, Thibault LE, Adams JH, et al: Diffuse axonal injury and traumatic coma in the primate. Ann Neurol 12:564–574, 1982
[PubMed]
 
Graham DI, Adams JH, Doyle D: Ischaemic brain damage in fatal non-missile head injuries. J Neurol Sci 39:213–234, 1978
[PubMed]
 
Graham DI, Lawrence AE, Adams JH, et al: Brain damage in non-missile head injury secondary to high intracranial pressure. Neuropathol Appl Neurobiol 13:209–217, 1987
[PubMed]
 
Graham DI, Ford I, Adams JH, et al: Fatal head injury in children. J Clin Pathol 14:18–22, 1989
 
Graham DI, Adams JH, Murray LS, et al: Neuropathology of the vegetative state after head injury. Neuropsychol Rehabil 15:198–213, 2005
[PubMed]
 
Griffin WST, Sheng JG, Royston MC, et al: Glial-neuronal interactions in Alzheimer's disease: the potential role of a "cytokine cycle" in disease progression. Brain Pathol 8:65–72, 1998
[PubMed]
 
Hortobágyi T, Wise S, Hunt N, et al: Traumatic axonal damage in the brain can be detected using beta-APP immunohistochemistry within 35 min after head injury to human adults. Neuropathol Appl Neurobiol 33:226–237, 2007
 
Kemp AM: Investigating subdural haemorrhage in infants. Arch Dis Child 86:98–102, 2002
[PubMed]
 
Lang DA, Teasdale GM, MacPherson P, et al: Diffuse brain swelling after head injury: more often malignant in adults than children? J Neurosurg 80:675–680, 1994
[PubMed]
 
Leung LY, VandeVord PJ, Dal Cengio AL, et al: Blast related neurotrauma: a review of cellular injury. Mol Cell Biomech 5:155–168, 2008
[PubMed]
 
Maxwell WL, MacKinnon MA, Smith DH, et al: Thalamic nuclei after human blunt head injury. J Neuropathol Exp Neurol 65:478–488, 2006
[PubMed]
 
McIntosh TK, Vink R, Noble L, et al: Traumatic brain injury in the rat: characterization of a lateral fluid-percussion model. Neuroscience 28:233–244, 1989
[PubMed]
 
Millar K, Nicoll JA, Thornhill S, et al: Long term neuropsychological outcome after head injury: relation to APOE genotype. J Neurol Neurosurg Psychiatry 74:1047–1052, 2003
[PubMed]
 
Morales DM, Marklund N, Lebold D, et al: Experimental models of traumatic brain injury: do we really need to build a better mousetrap? Neuroscience 136:971–989, 2005
[PubMed]
 
Mortimer JA, French LR, Hutton JT, et al: Head injury as a risk factor for Alzheimer's disease. Neurology 35:264–267, 1985
[PubMed]
 
Raghupathi R, Graham DI, McIntosh TK: Apoptosis after traumatic brain injury. J Neurotrauma 17:927–938, 2000
[PubMed]
 
Reichard RR, Smith C, Graham DI: The significance of beta-APP immunoreactivity in forensic practice. Neuropathol Appl Neurobiol 31:304–313, 2005
[PubMed]
 
Roberts GW, Gentleman SM, Lynch A, et al: Beta A4 amyloid protein deposition in brain after head trauma. Lancet 338:1422–1423, 1991
[PubMed]
 
Ryan GA, McLean AJ, Vileneus ATS: Brain injury patterns in fatally injured pedestrians. J Trauma 36:469–476, 1994
[PubMed]
 
Saatman KE, Duhaime AC, Bullock R, et al: Classification of traumatic brain injury for targeted therapies. J Neurotrauma 25:719–738, 2008
[PubMed]
 
Saljo A, Bao F, Haglid KG, et al: Blast exposure causes redistribution of phosphorylated neurofilament subunits in neurons of the adult rat brain. J Neurotrauma 17:719–726, 2000
[PubMed]
 
Sherriff FE, Bridges LR, Sivaloganathan S: Early detection of axonal injury after human head trauma using immunocytochemistry for beta-amyloid precursor protein. Acta Neuropathol 87:55–62, 1994
[PubMed]
 
Svetlov SI, Larner SF, Kirk DR, et al: Biomarkers of blast-induced neurotrauma: profiling molecular and cellular mechanisms of blast brain injury. J Neurotrauma 26:913–921, 2009
[PubMed]
 
Thornhill S, Teasdale GM, Murray GD, et al: Disability in young people and adults one year after head injury: prospective cohort study. BMJ 320:1631–1635, 2000
[PubMed]
 
Williams AJ, Hartings JA, Lu XC, et al: Characterization of a new rat model of penetrating ballistic brain injury. J Neurotrauma 22:313–331, 2005
[PubMed]
 
Williams AJ, Hartings JA, Lu XC, et al: Penetrating ballistic-like brain injury in the rat: differential time courses of hemorrhage, cell death, inflammation, and remote degeneration. J Neurotrauma 32:1828–1846, 2006
 
Williams S, Raghupathi R, MacKinnon MA, et al: In situ DNA fragmentation occurs in white matter up to 12 months after head injury in man. Acta Neuropathol 102:581–590, 2001
[PubMed]
 
Yamashima T, Yamamoto S: How do vessels proliferate in the capsule of a chronic subdural hematoma? Neurosurgery 15:672–678, 1984
[PubMed]
 
Zwienenberg M, Muizelaar JP: Severe pediatric head injury: the role of hyperemia revisited. J Neurotrauma 16:937–993, 1999
[PubMed]
 
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