Proton MR Spectroscopic Imaging Depicts Diffuse Axonal Injury in Children with Traumatic Brain Injury
Barbara A. Holshousera,
Karen A. Tonga and
Stephen Ashwalb
a Department of Radiology, Section of Neuroradiology, Loma Linda University School of Medicine, CA
b Department of Pediatrics, Division of Child Neurology, Loma Linda University School of Medicine, CA
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FIG 1. Mean NAA/Cr and Cho/Cr ratios from all voxels plotted as a function of the neurologic outcome assigned by a pediatric neurologist based on the PCPC score 6–12 months after injury. CTL indicates control; MOD, moderate disability; NL, normal; SEV, severe disability; and VS, vegetative state.
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FIG 2. Total mean metabolite ratios plotted by neurologic outcomes or control (CNTL). Ratios were calculated from all voxels including those containing hemorrhagic and nonhemorrhagic DAI lesions for patients with TBI. Asterisk indicates P = .01; double asterisk, P = .000.
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FIG 3. Regional mean metabolite ratios from MRSI data collected in a transverse plane through the level of the CC plotted by neurologic outcomes compared with control (CNTL); * indicates P = .00–.05; +, P < .02.
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FIG 4. 15-year-old female adolescent ejected from a car. Patient had a good outcome (GOS score = 1, normal) at 12 months after injury. Total mean metabolite ratios are 1.63 (normal) for NAA/Cr, and 1.67 for NAA/Cho, and 1.06 (increased) for Cho/Cr.
A and B, T2-weighted MR image (A) corresponding SWI (B) show hemorrhagic lesions in the body of the CC and bifrontal extra-axial collections. A with grid overlay shows the 160-mm FOV and 54 (6 x 9)-voxel volume of interest (rectangle). Boxes indicate corresponding voxels in C.
C, Spectral map from 54 voxels in the volume of interest shows a (1) spectrum from normal-appearing brain in the anterior CC with decreased NAA (2.0 ppm), (2) a spectrum with reduced metabolite signal intensity due to a small hemorrhagic lesion in the mid CC, and (3) a spectrum from parietal white matter with normal metabolite ratios.
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FIG 5. 12-year-old boy hit by a car. Patient had a poor outcome (GOS score = 4, severe disabilities) at 12-month follow-up. Total mean metabolite ratios from MRSI were 1.14 (decreased) for NAA/Cr, 1.13 for NAA/Cho, and 1.11 (increased) Cho/Cr.
A and B, Contiguous SWI images show a moderately large hemorrhagic lesion in the deep right frontal lobe.
C, Corresponding T2-weighted MR image shows the lesion (circle) with an overlay of the volume of interest (rectangle). Boxes indicate corresponding voxels in D.
D, Spectral map shows loss of metabolite signal intensity in area of the lesion (circle) and (2) a spectrum from normal-appearing left FWM with markedly decreased NAA/Cr and increased Cho/Cr, as compared with (3) a spectrum from normal-appearing parietal white matter with decreased NAA/Cr and normal Cho/Cr.
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FIG 6. Mean metabolite ratios from visibly injured (hemorrhagic, Hem) brain and normal-appearing (Nrm) brain were significantly different from those in control subjects (CNTL). Asterisk indicates P < .02. NAA/Cr from normal-appearing brain was the only ratio that differentiates between good- and poor- outcome groups; + indicates P = .01.
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