American Journal of Physical Medicine & Rehabilitation:
Frontal Contusions Imaging and: Behavioral Consequences
Zafonte, Ross D. DO; Ricker, Joseph PhD; Yonas, Howard MD; Wagner, Amy MD
From the Departments of Physical Medicine and Rehabilitation (RDZ, JR, AW) and Neurological Surgery (HY), University of Pittsburgh, Pittsburgh, Pennsylvania.
All correspondence and requests for reprints should be addressed to Ross Zafonte, DO, Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 201, Pittsburgh, PA 15213.
A 38-yr-old man was involved in a motor vehicle crash and was noted to have an initial postresuscitation Glasgow Coma Scale score of 7. Computerized tomographic imaging revealed bifrontal hemorrhagic contusions. The patient began to follow commands at day 5, but he remained in posttraumatic amnesia for several weeks. Memory dysfunction and deficits in executive control persisted throughout the acute rehabilitation period.
Frontal contusions are often the result of sufficient inertial loading and acceleration combined with a sudden stop (i.e., head impact or abrupt change in the direction of the head’s movement, which is often referred to as deceleration). This series of events may cause the brain to come into abrupt contact with one or more internal surfaces of the skull. Because the posterior areas within the skull are relatively smooth, primary contusion injuries in the posterior portions of the brain are rare in the absence of direct trauma to the occiput or posterior skull regions. More frequently, however, the anterior and inferior portions of the brain (the frontal poles, orbitofrontal cortex, and anterior temporal lobes) become contused against the bony prominences of the skull (e.g., sphenoid wing and temporal fossa). The expansion (or blossoming) of the contusion may result in extensive frontal edema and hemorrhage either early after injury or even days later and may require neurosurgical intervention.
The above example demonstrates a case of acute frontal contusions (Fig. 1) that evolve to show a wide area of frontal hemorrhagic edema (Fig. 2) and, subsequently, signs of early bifrontal encephalomalacia. This case demonstrates a version of hemorrhagic edema blossoming, as depicted in Figure 2. This injury pattern may result in localized contusion of the cerebral cortex and immediate underlying white matter. In the more chronic phase, such lesions are better demonstrated via magnetic resonance imaging.
Functionally, the frontal cerebral cortex is known to be involved in numerous cognitive activities, among them, executive control and memory. The construct of executive control encompasses numerous functions, but it is generally defined as the capacity to organize, plan, execute, and change cognitive functions. Executive control is a critical aspect of cognition that is commonly impaired after traumatic brain injury.1,2 In fact, although individuals and clinicians often report or emphasize memory as being a primary functional concern, executive control dysfunction might be the most disabling aspect of cognitive compromise after brain injury.3,4 The prefrontal cortex is of great importance in the processing of episodic memory. Finally, injury to the frontal cortex may lead to disturbances of mood and behavior.
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