Sunday 19 November 2017

Jules Bianchi injury Q&A - what is a Diffuse Axonal Injury and what are the chances of Marussia driver recovering?

Consultant Neurosurgeon Peter Hamlyn spoke to the Telegraph's Gareth A Davies about the Diffuse Axonal Injury suffered by Formula One driver Jules Bianchi at the Japanese Grand Prix.

What is an Diffuse Axomal Injury?

A diffuse axonal injury is an injury in which the wires which connect the cells in the brain, get damaged. If you rapidly accelerate and then decelerate the head, the brain is forced up against the frontal lobe, then pushes back and rattles around inside the head. As it distorts, the axons, which are the wires which connect each nerve cell, get torn - either physiologically, or actually anatomically.

Let me start from the process of assessing an acute head injury. If you do a scan of someone's head after an acute head injury, you are looking to assess two things: is the pressure inside the head raised? And if it is raised, is it a blood clot or some other area of brain damage which you can remove in order to bring the pressure down?

There are three types of things that can happen after a head injury: one is the diffuse axonal injury, another is obvious physical damage to the brain, and bleeding into the brain, and the third is starvation of oxygen, because the victim does not breathe properly. And the starving of oxygen and the diffuse axonal injury cannot be seen on the scan, because it is happening at a microscopic level, and it explains all the brain damage you see outside of blood clots and bruising.

If you go back to Michael Watson, the boxer, for example, part of what he suffered was hypoxia, and part of it would have been the diffuse axonal injuries from the blows.

But we know the diffuse axonal injury in Watson’s case was minor, because he was still standing up at the end of the fight, saying: 'I want to carry on'. His primary brain injury was a blood clot.

What we know of Jules Bianchi is that the blood clot is minor, because he has not had an operation to remove a blood clot. What we don't know is whether his clinical condition is diffuse axonal injury or hypoxia.

He has highly trained doctors around him, with state of the art facilities, so it is pretty unlikely it was hypoxia. It's almost certainly going to be diffuse axonal injury.


What is the likely recovery from diffuse axonal injury?

It is massively unpredictable at this stage. The doctors will be looking at all the scans and measuring various parameters, depending on his physiology and how well he is: his blood pressure, his heart rate, the pressure inside his head.

But to a very large extent, they will be in the dark. It's just impossible to know at this stage. I suspect that even those caring for him will not be able to say - they will still be studying the situation.


How is it treated?

You cannot go back in and connect these neurons microscopically so what you hope is that the diffuse axonal injury, a disturbance to the microscopic structure of the brain, is a physiological disturbance. In other words, you have rattled it so the nerve cell is unconscious, and not cut, because the brain has very little capacity to re-grow its axon.

The treatment is really to keep the brain in as physiologically as healthy an environment as possible. They will be doing that by keeping the oxygen levels up, by keeping the carbon dioxide levels down, and by making sure the blood salts are absolutely perfect. They will also make sure his temperature is right - sometimes they super-cool people, for example.

They will be giving Bianchi intensive support, intensive care in its truest sense. And wait for nature to reveal itself.


What is the time-frame?

They will have a good idea of whether they are in this for the long haul within a few weeks. But neurological recovery can go on for years and years. You are always into very serious business if you are in it for the long haul.

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