Multiple focal vascular injury in head trauma.

Dear Editor,

Traumatic brain injury (TBI) remains a global health problem, exerting great socioeconomic impact worldwide.[12] Despite the socioeducational programs to prevent accidents, TBI is still the main responsible for mortality and neurological sequelae among young people.[1] Among traumatic injuries, there is a very rare brain lesion. Usually, a postmortem diagnosis called multiple focal vascular injury (MFVI). Tomlinson[3] described this type of injury in cases of head injury with instant death and radiology record these injuries are very rare.

CASE REPORT

A 20-year-old man admitted in our emergency department after a car accident, brought by air rescue service. The patient had been intubated at the trauma scene and was assisted according to ATLS protocol. He was hemodynamically stable, presenting six points in Glasgow Coma Scale, with miotic pupils. A computed tomography (CT) scan [Figure 1] showed diffuse hemorrhagic points in the white matter suggestive of MFVI. He underwent to intracranial pressure monitoring. Patient evolved with refractory intracranial hypertension despite all intensive care measures, presenting brain death after 3 days. An autopsy confirmed MFVI [Figure 2].

Figure 1

(A) Head computed tomography scan showing diffuse hemorrhagic points in the white matter suggestive of multiple focal vascular injury after emergency department admission. (B) Head computed tomography scan performed 2 days after trauma showing brain hypoperfusion signs

Figure 2

(A) Image in autopsy with a segment of the brain showing multiple micro-hemorrhagic points in the frontal lobe. (B) Magnified view showing diffuse hemorrhagic foci in the white matter

DISCUSSION

This is a rare case with specific pathological diagnosis. These lesions were associated with microhemorrhages in the white matter and brainstem.[34] Tomlinson[1] suggested that intracerebral small vessels are torn diffusely. This is more severe traumatic injury than diffuse axonal injury,[5] usually observed in autopsy series,[4] radiological recording are uncommon. This case is interesting because it allowed monitoring the clinical course with intracranial hypertension, as well as analyze the image pattern in CT.