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Hemorrhagic Shearing Lesions in Children and Adolescents with Posttraumatic Diffuse Axonal Injury: Improved Detection and Initial Results¹

¹ From the Departments of Radiology (K.A.T., B.A.H., D.K.K.), Pediatrics (S.A.), and Neurology (L.A.S.), Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354; and the MRI Institute for Biomedical Research, St Louis, Mo (G.H., E.M.H.). Received February 28, 2002; revision requested April 24; final revision received October 3; accepted October 14. Address correspondence to K.A.T. (e-mail: ktong@ahs.llumc.edu).

View larger version (80K): [in a new window]   Figure 1. Patient 2. A, Transverse GRE (fast imaging with steady-state precession, 500/18, 15° flip angle, 78 Hz per pixel, two signals acquired, 4-mm-thick sections) and, B, SW (three-dimensional fast low-angle shot, 57/40, 20° flip angle, 78 Hz per pixel, 32 partitions, one signal acquired, 2-mm-thick sections reconstructed over 4 mm) MR images obtained in an 11-year-old boy who was injured in a motor vehicle accident. Small hemorrhagic shearing injuries (arrows in B), such as those commonly seen in the subcortical junction of gray and white matter, were often seen only on the SW MR images.

View larger version (111K): [in a new window]   Figure 2. Patient 4. A, C, Transverse GRE MR images (fast imaging with steady-state precession, 500/18, 15° flip angle, 78 Hz per pixel, two signals acquired, 4-mm-thick sections) obtained at two different levels of the corpus callosum in a 14-year-old girl who was injured in a motor vehicle accident. B, D, Corresponding transverse SW MR images (three-dimensional fast low-angle shot, 57/40, 20° flip angle, 78 Hz per pixel, 32 partitions, one signal acquired, 2-mm-thick sections reconstructed over 4 mm) obtained in the same girl show hemorrhagic shearing lesions with variable sizes and shapes in the corpus callosum. The smallest lesions (small arrow in B and D) are seen only on the SW MR images. The larger lesions (large arrow) are more visible on the SW MR images owing to greater hypointensity and are only slightly larger on these images than on the GRE MR images.

View larger version (63K): [in a new window]   Figure 3. Patient 2. A, Transverse GRE (fast imaging with steady-state precession, 500/18, 15° flip angle, 78 Hz per pixel, two signals acquired, 4-mm-thick sections) and, B, transverse SW (three-dimensional fast low-angle shot, 57/40, 20° flip angle, 78 Hz per pixel, 32 partitions, one signal acquired, 2-mm-thick sections reconstructed over 4 mm) MR images obtained in an 11-year-old boy who was injured in a motor vehicle accident. Brain stem lesions (small arrow) often were either poorly visualized or invisible on the GRE images compared with their appearance on the SW MR images. The mild increase in blooming artifact (large arrow) on the SW MR images also accentuates the magnetic susceptibility effects from the bones of the skull base.

View larger version (50K): [in a new window]   Figure 4. Patient 2. A, Transverse fluid-attenuated inversion-recovery (9,000/110, one signal acquired, 5-mm-thick sections); B, transverse GRE (fast imaging with steady-state precession, 500/18, 15° flip angle, 78 Hz per pixel, two signals acquired, 4-mm-thick sections); and C, transverse SW (three-dimensional fast low-angle shot, 57/40, 20° flip angle, 78 Hz per pixel, 32 partitions, one signal acquired, 2-mm-thick sections reconstructed over 4 mm) MR images obtained in an 11-year-old boy who was injured in a motor vehicle accident. Some shearing lesions do not show substantial amounts of hemorrhage but are primarily visible as areas of hyperintensity (arrow) on fluid-attenuated inversion-recovery (A), T2-weighted (not shown), GRE (B), and SW (C) MR images.

View larger version (20K): [in a new window]   Figure 5. Graph illustrates regional distributions of numbers of hemorrhagic lesions depicted by GRE and SW MR imaging (SWI) with the visual counting method. In all brain regions, the numbers of lesions visible on the SW MR images were consistently higher than the numbers of lesions visible on the GRE MR images. Differences were greatest in the frontal white matter (F WM) and in the brainstem and cerebellum (BS/Cerebell). BG/Thal = basal ganglia and thalami, CC = corpus callosum, F GM = frontal gray matter, PTO GM = parietotemporo-occipital gray matter, PTO WM = parietotemporo-occipital white matter.

View larger version (37K): [in a new window]   Figure 6. Graphs illustrate mean lesion number (A) and mean apparent hemorrhage load (B) according to GCS score group. At both GRE and SW MR imaging (SWI), mean values were higher, although not significantly higher, in the group of patients with a GCS score of 8 or lower. However, the differences in lesion number and apparent hemorrhage load between the groups were more apparent when measurements were made by using SW MR images.