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Abstract
Keywords
The authors describe the mechanisms of traumatic brain injury (TBI), examining in
depth the characteristics of closed head, penetrating, and blast-related TBI. Events on a
structural as well as cellular level are reviewed. Blast-related brain injury, in particular,
affects military service members preferentially, but is also relevant in cases of industrial
accidents as well as terrorist events.
DOI http://dx.doi.org/
10.1055/s-0035-1549095.
ISSN 0271-8235.
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Fig. 1 Pressure diagrams demonstrate the blast overpressure wave in outdoor (A) and indoor (B) environments.56
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cerebral vasospasm is associated with the presence of pseudoaneurysm and poorer outcomes at discharge.49,70
Gross pathology of neuronal damage in the brain is
characterized by white matter lesions that resemble diffuse
axonal injury (DAI) or cerebral contusion.56 Lesions in bTBI
are distinct from other TBI etiologies in that they are focal and
scattered throughout the brain, independent of the direction
of blast loading.71 The number of low fractional anisotropy
voxels measured in diffuse tensor imaging (DTI) showed
diffuse and global damage in a heterogeneous distribution
across military who had sustained blast mTBI.72 However,
several studies have suggested that damage is concentrated in
the cerebellum and brainstem.73,74 Neuronal damage is characterized by increased perineuronal space, cytoplasmic vacuolization, myelin deformation, and axoplasmic shrinkage.75
Disrupted axonal transport causes focal axonal swelling.75
In addition to tissue necrosis associated with primary
brain damage, signicant damage to neuronal structures
can be attributed to secondary injury mechanisms. The
brains reaction to these injuries involves activation of multiple pathways that damage cells through oxidative stress, the
inammatory response, and metabolic dysfunction.
Free-radical generation promotes apoptosis in neurons
and endothelial cells through calcium-mediated pathways.58,68 Activation of inducible nitric oxide synthase
(iNOS) contributes to oxidative damage.75 Elevated NO can
react with superoxide anions to form peroxynitrite, a highly
reactive species that harms the endothelium and affects
vascular reactivity.69
Gene expression array studies that have found robust
changes in gene expression in brain tissue of animals exposed
to blast, including upregulation of genes involved in neuronal
proliferation and differentiation, neuronal NOS, and several
metabolic pathways.76 A separate study analyzing gene expression 24 hours after blast exposure reported increased
genes in inammatory pathways, including glial brillary
acidic protein (GFAP) and complement component 1.77 Comparing gene expression in rats exposed to blast at 1, 4, and
7 days after injury found that most signicant changes in gene
expression occurred 1 and 4 days after injury, suggesting
normalization at day 7.78
Cytokine assays provide evidence that an immune response is mounted following bTBI. Opening of the blood
brain barrier (BBB) results from the loosening of tight junctions due to severe edema secondary to Na/K ATPase
dysfunction, high intracranial pressure and matrix metalloproteinase activation.53,58,79 Unlike what is seen in blunt
TBI, the opening of the BBB occurs immediately following
blast injury, and is not delayed.71 Subsequent activation of the
microglia initiates cellular injury and repair mechanisms by
complement-mediated apoptosis and phagocytosis.58,68,80,81
Quantication of proinammatory markers and other
cytokines in the brain following blast injury in animals has
not produced consistent results on the timing of this response
following injury. Garman et al reported opening of the BBB
(measured by IgG reactivity) at 24 hours post injury and
occurring in regions distal to axonal injury.73 IgG reactivity
was no longer found at 3 days; however, axonal injury seemed
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Conclusions
Traumatic brain injury is a prominent injury occurring in
sports, war, and life. Blunt, blast, and penetrating TBI share
many common features in the potentiation of injury through
secondary injury mechanisms and physical and neuropsychological outcome. However, as indicated by the biophysics
and experimental examination of cell biology, signicant
differences in pathophysiological pathways, gross neurologic
damage, and the time scale of neurodegeneration exist.
Animal model experiments have contributed greatly to resolving what these differences are and the impact they have
on neuronal cell survival, but further research is warranted.
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