Quantification of Primary and Secondary Lesions in Severe Head Injury

  • D. I. Graham
  • J. H. Adams
  • D. Doyle
  • I. Ford
  • T. A. Gennarelli
  • A. E. Lawrence
  • W. L. Maxwell
  • D. R. McLellan
Conference paper
Part of the Acta Neurochirurgica book series (NEUROCHIRURGICA, volume 57)



The current trend is to classify brain damage due to non-missile head injury as focal or diffuse. Quantitative findings will be discussed and reference will be made to both human and experimental non-human primate.

Focal Injury

Contusions: Based on the concept of an index which takes into account the depth and extent of contusions in various parts of the brain, it has been determined that contusions are most severe in the frontal and temporal lobes; they may be entirely absent in a patient dying as a result of a head injury; there is no correlation between their severity and the nature of the injury; the concept of contrecoup must continue to be questioned; they are more severe in patients who have a fracture of the skull in comparison to those who do not; they are more severe in patients who do not experience a lucid interval than in those who do; and they are less severe in patients with diffuse axonal injury than in those who do not have diffuse axonal injury.

Raised intracranial pressure: It has been established that the pathognomonic feature of a high ICP due to a supratentorial expanding lesion is the presence of a wedge of pressure necrosis in one or both parahippocampal gyri. Pressure necrosis of this type was seen in every patient known to have had an ICP of more than 5.3 kPa (40 mm Hg) during life, and most of the patients with an ICP between 2.7 and 5.3 kPa (20–40 mm Hg), and in no patient with an ICP of less than 2.7 kPa (20 mm Hg).

Diffuse Injury

Axonal injury (DAI): Increasing experience in man has allowed of the identification and grading of 122 cases of DAI in a series of 434 fatal non-missile head injuries — 10 Grade 1, 29 Grade 2 and 83 Grade 3. In our earlier studies of severe DAI, not one of the patients was able to talk after their injury: it is of interest therefore that 17 (14%) of the 122 cases — all with less severe DAI — were known to have talked soon after their injury. Evidence of lesser degrees of DAI were also found in the Penn 2 model of axonal injury.

Ischemic damage: This was found in the brains of 92% of 151 cases of fatal non-missile head injury dying between 1968–72 and in 88% of 112 cases dying between 1981–82. There was no statistical difference in amount of moderately severe and severe ischemic damage in the two groups, 55% and 54% respectively. There was evidence that an increased number of patients with severe ischemic brain damage was admitted in 1981–82 as a result of a change in the admission policy of the Department of Neurosurgery that resulted in an increased detection of intracranial haematomas.


Head injury contusion index intracranial hypertension axonal injury secondary ischemia 


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  1. 1.
    GrahamDI, Adams JH, Gennarelli TA (1987) Pathology of brain damage in head injury. In:Cooper PR (ed) Head injury. Williams and Wilkins, Baltimore, pp 72–88Google Scholar
  2. 2.
    Becker DP, MillerJD, Greenberg RP, Young HF, Sakalas R (1977) The outcome from severe head injurywith early diagnosis and intensive management. J Neurosurg 47: 491–502PubMedCrossRefGoogle Scholar
  3. 3.
    Seelig JM, BeckerDP, Miller JD, Greenberg RP, Ward JD, Choi SC (1981) Traumatic acute subduralhaematoma. N Engl JMed3O4: 1511–1518CrossRefGoogle Scholar
  4. 4.
    Miller JD, BeckerDP (1982) Secondary insults to the injured brain. J Roy Coll Surg Edinb 27:292–298PubMedGoogle Scholar
  5. 5.
    Teasdale G,Galbraith S, Murray L, Ward P, Gentleman D, McKean M (1982) Management oftraumatic intracranial haematoma. Brit Med J 285: 1695–1697CrossRefGoogle Scholar
  6. 6.
    Klauber MR,Marshall LF, Toole BM, Knowlton SL, Bowers SA (1985) Cause of decline in headinjury mortality rate in San Diego County, California. J Neurosurg 62: 528–531PubMedCrossRefGoogle Scholar
  7. 7.
    Reilly PL, GrahamDI, Adams JH, JennettB(1975) Patients with head injury who talk and die. Lancet 2: 375–377PubMedCrossRefGoogle Scholar
  8. 8.
    Adams JH (1984)Head injury. In: Adams JH, Corsellis JAN, Duchen LW (eds) Greenfield’sneuropathology, 4th Ed. Arnold, London, pp 85–124Google Scholar
  9. 9.
    Gennarelli TA, Spielman GM,Langfitt TW,Gildenberg PL,Harrington T, JaneJA, MarshallLF, Miller JD, Pitts 1H (1982) Influence of the type of intracranial lesion onoutcome from severe head injury. J Neurosurg 56: 26–36PubMedCrossRefGoogle Scholar
  10. 10.
    Adams JH, GrahamDI, Gennarelli TA (1983) Head injury in man and experimental animals -neuropathology. Acta Neurochir (Wien) [Suppl] 32: 15–30Google Scholar
  11. 11.
    Gennarelli TA(1983) Head injury in man and experimental animals — clinical aspects. ActaNeurochir (Wien)[Suppl]32: 1–13Google Scholar
  12. 12.
    Adams JH, Murray MF (1982) Atlas of post-mortem techniques. Cambridge University Press,CambridgeGoogle Scholar
  13. 13.
    AbelJ, Gennarelli TA, Segawa H (1978) Incidence and severity of cerebral consussionin the rhesus monkey following sagittal plane angular acceleration. In:Proceedings of 22nd Stapp Car Crash Conference. Society of AutomotiveEngineers, New York, pp 35–53Google Scholar
  14. 14.
    Gennarelli TA,Adams JH, Graham DI (1981) Acceleration induced head injury in the monkey. I.The model, its mechanical and physiological correlates. Acta Neuropathol (Berl)[Suppl] 7: 23–25CrossRefGoogle Scholar
  15. 15.
    Gennarelli TA,Segawa H, WaldU,Czernicki Z, Marsh K, Thompson C (1982) Physiological response to angularacceleration of the head. In: Grossman RG, Gildenberg PL (eds) Headinjury: basic and clinical aspects. Raven, New York, pp 129–140Google Scholar
  16. 16.
    LindenbergR, Freytag E (1960) Themechanism of cerebral contusions. Arch Pathol 69: 440–469PubMedGoogle Scholar
  17. 17.
    LindenbergR(1971) Trauma of meninges and brain. In: Minckler J (ed) Pathology of thenervous system, Vol 2. McGraw-Hill, New York, pp 1705–1765Google Scholar
  18. 18.
    Dawson SL, Hirsch CS, Lucas FV,Sebek BS (1980) The contrecoup phenomenon: reappraisal of the classic problem.Hum Pathol 11: 155–166PubMedCrossRefGoogle Scholar
  19. 19.
    Adams JH, DoyleD, Graham DI, Lawrence AE, McLellan DR, Gennarelli TA, Pastuszko M, Sakamoto T(1985) The contusion index: a reappraisal in human and experimental nonmissilehead injury. Neuropathol Appl Neurobiol 11: 299–308PubMedCrossRefGoogle Scholar
  20. 20.
    Gennarelli TA,Abel J, Adams JH, Graham DI (1979) Differential tolerance of frontal andtemporal lobes to contusion induced by angular acceleration. In: Proceedings of23rd Stapp Car Crash Conference. Society of Automotive Engineers, New York, pp561–586Google Scholar
  21. 21.
    Adams JH, GrahamDI (1976) The relationship between ventricular fluid pressure and theneuropathology of raised intracranial pressure. Neuropathol Appl Neurobiol 2:323–332CrossRefGoogle Scholar
  22. 22.
    Graham DI, Lawrence AE, Adams JH, Doyle D, McLellan DR (1987) Brain damage innon-missile head injury secondary to high intracranial pressure. NeuropatholAppl Neurobiol 13: 209–217CrossRefGoogle Scholar
  23. 23.
    Harper CG, Doyle D, AdamsJH, Graham DI (1986) Analysis of abnormalities in pituitary gland innon-missile head injury: study of 100 consecutive cases. J Clin Pathol 39:769–773PubMedCrossRefGoogle Scholar
  24. 24.
    GrahamDI, Lawrence AE, Adams JH, Doyle D, McLellan DR (1988) Brain damage in fatalnon-missile head injury without high intracranial pressure. J Clin Pathol 41:34–37PubMedCrossRefGoogle Scholar
  25. 25.
    Teasdale E,Cardoso E, Galbraith S, Teasdale G (1984) CT scan in severe diffuse headinjury: physiological and clinical correlations. J Neurol Neurosurg Psychiatry 47: 600–603PubMedCrossRefGoogle Scholar
  26. 26.
    Strich SJ (1970) Lesionsin the cerebral hemispheres after blunt head injury. J Clin Pathol 23 [Suppl 4]166–171CrossRefGoogle Scholar
  27. 27.
    Peerless SJ,Rewcastle NB (1967) Shear injuries of the brain. Can Med Assoc 96: 577–582Google Scholar
  28. 28.
    Adams JH,Mitchell DE,GrahamDI, Doyle D (1977) Diffuse brain damage of immediate impact type. Itsrelationship to “primary brain stem damage” in head injury. Brain100: 489–502PubMedCrossRefGoogle Scholar
  29. 29.
    Zimmerman RA,Bilaniuk LT, Gennarelli TA (1978) Computed tomography of shearing injuries ofthe cerebral white matter. Radiology 127:393–396PubMedGoogle Scholar
  30. 30.
    Grcevic N (1982)Topography and pathogenic mechanisms of lesions in ’inner cerebral trauma’. Rad Jug Acad ZnamUnig Od medNauke 402: 265–331Google Scholar
  31. 31.
    Jellinger K,Seitelberger G (1970) Protracted post-traumatic encephalopathy: pathology,pathogenesis and clinical implications. J Neurol Sci 10: 51–94PubMedCrossRefGoogle Scholar
  32. 32.
    Jellinger K(1977) Pathology and pathogenesis of apallic syndrome following closed headinjuries. In: Ore GD, Gerstenbrand F, Lücking CH, Peters G, Peters UH (eds)The apallic syndrome. Springer, Berlin Heidelberg New York, pp 88–103Google Scholar
  33. 33.
    Peters G,Rothamund E (1977) Neuropathology of the traumatic apallic syndrome. In: OreGD, GerstenbrandF,Lücking CH, Peters G, Peters UH (eds) The apallic syndrome. Springer, BerlinHeidelberg New York, pp 78–87CrossRefGoogle Scholar
  34. 34.
    Adams JH, GrahamDI, Murray LS, Scott G (1982) Diffuse axonal injury due to non-missile headinjury in humans: an analysis of 45 cases. Ann Neurol 12: 557–563PubMedCrossRefGoogle Scholar
  35. 35.
    Oppenheimer DR (1968) Microscopic lesions in the brain following head injury. J Neurol Neurosurg Psychiatry 31: 299–306PubMedCrossRefGoogle Scholar
  36. 36.
    Pilz P (1983) Axonalinjury in head injury. Acta Neurochir (Wien) [Suppl] 32:119–123Google Scholar
  37. 37.
    Adams JH, DoyleD, Ford I, Gennarelli TA, Graham DI, McLellan DR (1989) Diffuse axonal injuryin head injury. Definition, diagnosis and grading. Histopathology 15: 49–59PubMedCrossRefGoogle Scholar
  38. 38.
    Adams JH, GrahamDI, Gennarelli TA (1981) Acceleration induced head injury in the monkey. II.Neuropathology. Acta Neuropathol (Berl) [Suppl] 7: 26–28CrossRefGoogle Scholar
  39. 39.
    Adams JH, GrahamDI, Gennarelli TA (1982) Neuropathology of acceleration-induced head injury inthe subhuman primate. In: Grossman RG, Gildenberg PL (eds) Headinjury: basic and clinical aspects. Raven, New York, pp 141–150Google Scholar
  40. 40.
    Graham DI,Lawrence AE, Adams JH, Doyle D, McLellan D, Gennarelli TA (1989) Pathology ofmild head injury. In: Hoff JT (ed) Mild to moderate head injury. Contemporaryissues in neurological surgery, Vol 3. Blackwell Scientific,BostonGoogle Scholar
  41. 41.
    Jane J, Stewart O,Gennarelli TA (1985) Axonal degeneration induced by experimental non-invasiveminor head injury. J Neurosurg 62: 96–100PubMedCrossRefGoogle Scholar
  42. 42.
    Gennarelli TA, Thibault LE,Adams JH, Graham DI, Thompson CJ, Marcincin RP (1982) Diffuse axonal injury andtraumatic coma in the primate. Ann Neurol 12: 564–574PubMedCrossRefGoogle Scholar
  43. 43.
    Gennarelli TA,Adams JH, Graham DI (1986) Diffuse axonal injury — a new conceptual approach toan old problem. In: Baethmann A, Go KG, Unterberg A (eds)Mechanisms of secondary brain damage. Plenum, New York London, pp 15–28Google Scholar
  44. 44.
    Gennarelli TA, Thibault LE, TomeiG, Wiser R, Graham DI, Adams JH (1987) Directional dependence of axonal braininjury due to centroidal and non-centroidal acceleration. 31 st Stapp Car CrashConference. Society of Automotive Engineers, New York, pp 49–53CrossRefGoogle Scholar
  45. 45.
    Povlishock JT,Becker DP, Cheng CLY, Vaughan GW (1983) Axonal changes in minor head injury. JNeuropath Exp Neurol 42: 225–242CrossRefGoogle Scholar
  46. 46.
    Gennarelli TA(1987) Cerebral concussion and diffuse brain injuries. In: Cooper PR (ed) Headinjury, 2nd Ed. Williams and Wilkins, Baltimore, pp 108–124Google Scholar
  47. 47.
    Graham DI, AdamsJH, Doyle D (1978) Ischaemic brain damage in fatal non-missile head injuries. JNeurol Sci39:213–234CrossRefGoogle Scholar
  48. 48.
    Gentleman D, Jennett E (1981) Hazardsof inter-hospital transfer of comatose head-injured patients. Lancet 2: 853–855PubMedCrossRefGoogle Scholar
  49. 49.
    Teasdale G,Galbraith S, Murray L, Ward P, Gentleman D, McKean M (1982) Management oftraumatic intracranial haematoma. Brit Med J 285: 1695–1697CrossRefGoogle Scholar
  50. 50.
    Becker DP, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R (1977) The outcome from severehead injury with early diagnosis and intensive management. J Neurosurg 47:491–502PubMedCrossRefGoogle Scholar
  51. 51.
    Bowers SA,Marshall LF (1980) Outcome in 200 consecutive cases of severe head in jurytreated in San Diego County: a prospective analysis. Neurosurgery 6: 237–242PubMedCrossRefGoogle Scholar
  52. 52.
    Bricolo AP, Pasut M (1984)Extradural haematoma: toward zero mortality. A prospective study. Neurosurgery 14: 8–11PubMedCrossRefGoogle Scholar
  53. 53.
    Graham DI, FordI, Adams JH, Doyle D, Teasdale GM, Lawrence AE, McLellan DR (1989) Ischaemicbrain damage is still common in fatal non-missile head injury. J NeurolNeurosurg Psychiatry 52: 346–350CrossRefGoogle Scholar
  54. 54.
    Gennarelli TA,Marcincin RP, Thibault LE, Thompson CJ (1983) Effect of direction of headmovement on ICP in experimental head injury. In: Ishii S, Nagai H, Brock M(eds) Intracranial pressure V. Springer, Berlin Heidelberg New York Tokyo, pp483–486CrossRefGoogle Scholar
  55. 55.
    Povlishock JT(1985) The morphologic responses to experimental head injury of varyingseverity. In: Becker DP, Povlishock JT (eds), Central nervous system traumastatus report. National Institute of Neurological and Communicative Diseasesand Stroke. National Institutes of Health, U.S.A.Google Scholar
  56. 56.
    Dietrich WD,Busto R, Ginsberg MD (1984) Cerebral endothelial microvilli: formationfollowing global forebrain ischaemia. J Neuropathol Exp Neurol 43: 72–83PubMedCrossRefGoogle Scholar
  57. 57.
    Maxwell WL,Irvine A, Adams JH, Graham DI, Gennarelli TA (1988) Response of cerebralmicrovilli to brain injury. J Pathol 155: 327–336PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 1993

Authors and Affiliations

  • D. I. Graham
    • 1
  • J. H. Adams
    • 1
  • D. Doyle
    • 1
  • I. Ford
    • 1
  • T. A. Gennarelli
    • 3
  • A. E. Lawrence
    • 2
  • W. L. Maxwell
    • 2
  • D. R. McLellan
    • 2
  1. 1.Departments of Neuropathology, StatisticsUniversity of GlasgowScotland, UK
  2. 2.Departments of Neuropathology, AnatomyUniversity of GlasgowScotland, UK
  3. 3.Division of NeurosurgeryHospital of the University of PennsylvaniaPhiladelphiaUSA

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