The Center for Disease Control says: on average, approximately 1.7 million people sustain a traumatic brain injury each year in America.
Definition of Traumatic Brain Injury
A traumatic brain injury is caused by a bump, blow or jolt to the head. This trauma or head injury disrupts the brain's normal ability to function. Not all blows or jolts to the head result in a traumatic brain injury. The severity of a brain injury can range from “mild,” like, a brief change in mental status to “severe,” an extended period of unconsciousness or amnesia after the injury. Most traumatic brain injuries are concussions.
Leading Causes Of Traumatic Brain Injuries are:
Motor vehicle traffic accidents (17.3%)
Struck by/against events (16.5%) and
Falls are the leading cause of Traumatic Brain Injury (35.2%). Falls cause half (50%) of the brain injuries among children aged 0 to 14 years and 61% of all the brain injuries in adults aged 65 years and older.
Motor Vehicle-Traffic Crashes are the second leading cause of brain injuries (17.3%) and resulted in the largest percentage of brain injury related deaths (31.8%). (Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010)
Trauma, falls, car accidents, sports, acceleration/deceleration, is the most common physical cause of a brain injury, and after trauma the second largest cause of brain injuries is chemical exposure, like carbon monoxide poisoning and dangerous chemicals that are neuro toxins such as lead, solvents and insecticides.
Lack of oxygen is the next largest cause of brain injuries. They range from birth injuries, which is commonly known as cerebral palsy (CP). CP is caused by medical mistakes, it is not a disease, virus, or birth defect. It is usually quite preventable. Proper monitoring of an infant in the womb can show stress or lack of oxygen, and if the doctors act quickly the child will be fine, but any delay in recognizing the stress of the child will cause permanent brain injury.
Stroke is next on the list of causes of brain injuries. When blood flow is blocked to the brain causing a lack of oxygen, some brain cells will die. Or an internal brain bleed will quickly damage brain cells.
Open head injuries are next on the list for causes of brain injuries. When the skull is penetrated or fractured from violence, such as a gun-shot wound, or fragments from an explosion or a high speed motor vehicle crash, this will cause serious brain injuries.
Brain Injuries - What To Do Immediately after a trauma
Get to an Emergency Room immediately. Brain injury symptoms get worse over the first 24 hours because brain injuries involve a cascade of events that take time to manifest. So if a person is seen in a hospital ER and are sent home but seem to be getting worse, it is best to return to that same ER, so they can assess the changes. Don't wait for a doctor's appointment days later.
You may recall when Natasha Richardson was skiing with her family in Canada. She was skiing a beginners slope when she fell and hit her head.
She initially said she felt fine and did not show any signs of any injury. The ski resort followed emergency protocol by escorting Richardson back to her hotel to make sure she was okay and recommend she see a doctor, which she refused. Although no one is quite sure whether or not she lost consciousness, an hour later she started to feel poorly and developed a headache. Her condition worsened and within 48 hours of her fall she died of an epidural hematoma. She did not realize that she had internal bleeding in her skull which put pressure on her brain. The pressure became so great that it caused her death. So even a simple blow to the head, without a loss of consciousness, can lead to death.
Common Signs of Brain Injury
Nausea near the time of the trauma
Any loss of consciousness
Lightheadedness / dizziness
Blurred vision or tired eyes
Ringing in the ears - Tinitus
Bad taste in the mouth
Fatigue or lethargy
Change in sleep patterns
Behavioral or mood changes
Trouble with memory, concentration, attention, or thinking
A person with a moderate or severe brain injury may also have:
Headaches that worsen or do not go away
Repeated vomiting or nausea
Convulsions or seizures
Inability to awaken from sleep
Dilation of one or both pupils of the eyes
Weakness or numbness in the arms or legs
Loss of coordination
increased confusion, restlessness, or agitation
Mental Disturbances caused by a traumatic brain injury may include:
Speed of processing information
Language or Speech problems
Physical Symptoms of a traumatic brain injury may include:
Lack of energy
Ringing in the ears
Sensitivity to light
Behavioral Changes caused by a brain injury may include:
Poor social judgment
Rapidly changing moods
Dis-inhibition or lack of self control or restraint
Objective Proof of Brain Injuries With Radiological and Electronic Testing
Micro Structural Brain Damage can now be seen by doctors when and if the right tests are performed. The following types of testing can show injury to the brain. The Radiology tests are listed in order of least sensitive test to more sensitive tests. In other words, the American College of Radiology suggests that when attempting to diagnose a brain injury, doctors should be aware of the sensitivity of each type of test and use the most appropriate test based upon the circumstances of each person.
X-Ray and Brain Injuries-This is an easy fast way to look at our bones. X-Ray is the least effective way to show a closed head brain injury, but X-Ray is the best test if there is a broken bone or obvious skull fracture or bullet type wound. X-Ray clearly shows broken bones, which is a strong indicator of a resulting brain injury. It is excellent at showing the bone structures, but terrible at showing us the soft tissues in our bodies, especially the soft tissue of our brains.
CT and CAT Scans and Brain Injuries-The next and more sensitive test is a CT or CAT Scan which stands for Computed Tomography. This is done with a rotating X-Ray machine combining X-Ray images with a computer to create a three dimensional representation of the structures in our head. CT scanning of the head is typically used to detect infarction, tumors calcifications, hemorrhage and bone trauma. CT shows us the bones very well and it does show some soft tissue, but it is not a very sensitive test to show brain damage. If the CT does show signs of brain injury, then you can be sure that other more sensitive tests will show the injury better.
MRI and Brain Injuries-The next and more sensitive Radiological test is the MRI which stands for Magnetic Resonance Imaging. This is a more sophisticated test to show brain damage. Unfortunately, MRI cannot pick up mild brain injuries very well but it is an excellent at showing moderate damage. We can see the anatomy of the brain in very good detail, but in many brain injury cases, the damage is so small, that it won't be seen on an MRI. One great advantage to the MRI, is there is no radiation. No harmful effects to the human body. MRI is an excellent way to see our anatomy, but again it is not extremely sensitive to show mild brain injuries. If you want to learn more about how MRI works, please watch my two videos. How MRI Works Part I and How MRI Works Part 2.
Brain Injury and DTI or Diffusion Tensor Imaging-This is done with the MRI machine. It shows us the consistency or disruption of the flow of the brain's white matter tracts. It measures the restrictions or disruptions of water diffusion in our brains. Brain axons are situated in parallel bundles and their myelin covering (sheath) causes water to flow next to the axons in uninterrupted relatively straight lines. So in a healthy brain, the water patterns are long and curved like spaghetti strands. But if a person has suffered a brain injury, like a coup contra coup from a whiplash type injury, then the myelin coverings or axon sheaths will be broken, torn or disrupted. This can be seen on DTI because the water tracts will be interrupted by the shearing injury, and instead of long spaghetti like strands, it will appear like broken small pieces of spaghetti.
Imaging and interpretation of water diffusion have improved with the development of diffusion tensor imaging. Diffusion tensor imaging allows direct examination of the axon fibers through the flow of water molecules. Therefore, if there is microstructure tissue damage in the brain, we can see it. Diffusion tensor imaging provides excellent details of the white brain matter tracts and we can tell by any disruption if there is damage or injury to the brain.
Brain Injury and Susceptibility Weighted Imaging (SWI)-Susceptibility Weighted Imaging uses the MRI to show differences in brain matter from one small area to the next small area. By making tissue comparisons in very small areas, slight differences can be easily seen with SWI. Signals from substances with different susceptibilities than their neighboring tissues (such as venous blood or hemorrhage, for example) will look different than the brain cells next to it. The computer can detect these differences and show them quite easily. SWI shows small areas of the brain that have signs of trauma because there will be residue of iron deposits and calcium left where there is brain injury.
Brain Injury and SPECT (Single-photon Emission Computed Tomography)-SPECT is a nuclear medicine technique using gamma rays. With a computer and camera, we can see where the brain is working and where it is not working. With the help of a computer, we can see a three dimensional picture of our brain. Most common SPECT images are cross-sectional slices through the brain like the MRI, but the difference between MRI and SPECT is that SPECT images show function of the brain rather than anatomy. With SPECT, we don't look at the brain tissue, instead, we see where the brain is using blood. This is done by giving a person an injection of a radioactive material which is carried in the blood. The SPECT camera then takes pictures of the radioactivity coming from the brain. Since blood only goes to the parts of the brain that need it, we get a good picture of where the brain is working and where it is not. The more radioactivity coming from specific areas in our brain, the more the brain cells are using blood. The brain function is shown by using different colors to represent the varying amounts of blood use in the brain. SPECT scans are a form of brain imagery that can pinpoint exact areas of the brain that are not functioning in the "normal" range. Typically, the actual brain testing takes less than 20 minutes and costs about $3,500.00.
Brain Injury and PET-CT or Positron Emission Tomography-PET is similar to SPECT scan, but uses sugar to carry the radioactive isotope. The greatest benefit of PET scanning is that it shows blood flow, oxygen use and glucose metabolism (use of sugar) in the tissues of the working brain. The tests clearly shows the amount of brain activity in the various regions of the brain and allow us to see what parts of the brain are not functioning at full capacity. Again, this is a functional test, not an anatomical one which is much more help in making a diagnosis of brain injury.
A computer counts the number of radioactive rays that come from each part of our brain and uses the data gathered by the sensors to create multicolored 3-dimensional images that show where the radioactive material is being used in the brain.
Brain Injury and MEG or Magnetoencephalography-MEG is an technique used to measure the magnetic fields produced by our brains electrical activity. MEG measures direct brain cell activity. Each time a brain cell synapses (works), it gives off a slight magnetic pulse. The advantage of measuring the magnetic fields produced by brain cell activity is that there is no distortion by surrounding tissue, unlike the electric fields measured by EEG (particularly the skull and scalp). The patient is put in a special room that has no magnetic energy in it. Then a bowl shaped like a helmet which contains over a hundred small antennas is placed over your head. Then all you do is sit there for about 30 minutes.
Because the helmet is round and contains over a hundred antennas, each time your brain has a synapse, a slight amount of magnetic energy is given off. Since the antennas are arranged like a bowl, the computer can measure the energy from each synapse and triangulate the exact location of the brain synapse. By measuring variations, it can draw a very detailed map of brain activity and show the exact areas of brain damage. Pioneering research using the MEG has been done at the University of California in San Diego by Dr. Rowland Lee, M.D. Ph.D.
Brain Injury and EEG and QEEG or Electroencephalogram and quantitative Electroencephalogram-EEG and QEEG is similar to the MEG, but instead of using antennas to measure brain activity, it uses wires which are attached to the skin on the patient's head. During normal function of our brain, small electrical pulses are created. The EEG measures and records these small electrical pulses as an electroencephalogram . The EEG tracings are examined by a neurologist for abnormal waveforms or spikes appearing in the tracings from one or more electrodes that might show a brain disorder. Another way of analyzing an EEG is through the use of a computer which analyze the frequency and amplitude characteristics of the brain waves as well as other complex information that may be derived from the raw EEG and produce something called a QEEG brain map.
MEG is far superior to EEG and QEEG because the measurement of the electrical patterns using an MEG is without the interference of skin, hair, scalp, and bone. Therefore the MEG is much more accurate in measuring brain function.
Glasgow Coma Scale as a Measure of Brain Injury-Glasgow Coma Scale or GCS is a neurological test that is a reliable and objective way of measuring the consciousness of a person. The patient's consciousness is measured and scored based upon their ability to respond to three types of stimuli. First is Visual, second is Verbal, and the third is Physical or Motor Responses. Each of the three tests is scored separately and then the three scores are added together for a total Glasgow Coma Scale score. Three is the lowest possible score, which would indicate the patient is in a coma or is dead. A score of 15 means the patient is fully awake.
The Glasgow Coma Scale Visual scoring is as follows:
No eye opening.
Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supra-orbital and sternal pressure or rub may be used)
Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3)
Eyes opening spontaneously
The Glasgow Coma Scale Verbal scoring is as follows:
No verbal response is made by the patient.
Incomprehensible sounds. (Moaning but no words)
Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
Confused. (The patient responds to questions coherently, but there is some disorientation and confusion)
Oriented. (The patient responds coherently and appropriately to questions such as their name and age, where they are and why, the year, month, etc.)
There are six grades of Motor Response in the Glasgow Coma Scale:
No motor response.
Extension to pain (abduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response)
Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate reponse)
Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nail bed pinched)
Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure is applied.)
Obeys commands. (The patient does simple things as asked.)
Generally the Glasgow Coma Scale score for a brain injury is classified as:
There are numerous tests that qualified neuropsychologists can administer to assess brain function. Below is just a few tests commonly used to diagnose and treat brain injuries.
Beck Depression Inventory
Beck Anxiety Inventory
Folstein Mini Mental Status Exam
Halstead-Reitan Neuropsychological Battery
Luria-Nebraska Neuropsychological Battery
Personality Assessment Inventory III
Millon Clinical Multiaxial Inventory
Rorschach Ink Blot
Wechsler Memory Scale
Wechsler Adult Intelligence Scale
Fake Bad Scale
Proving Brain Injuries in a Court Room
The most typical way the lawyers at Powell and Espat prove mild traumatic brain injuries are by assembling the medical personnel who treated our client. We start with any Emergency Rescue workers to describe the condition of our client at the accident scene. Then the hospital Emergency Room doctors who talk about their examination, testing and treatment of our client. Then we usually call our client's treating neurologist. The neurologist will talk about the various testing that was done. They may explain the mechanism of injury and explain the axonal shearing. We usually have one or two radiologists who will show the brain studies and explain them to the jury. Then we will have the treating neuropsychologist who explains how and where the brain is not functioning through the psychological testing that was done. The key to helping a jury understand a mild traumatic brain injury is to use lots of demonstrative aids such as animations of the brain trauma and axon shearing. We use images from the PET-CT scan or MEG, and any other radiological tests. It is important that all of the witnesses who are called to court are comfortable teaching their area of expertise to a jury. The key is communication. If the doctors can explain the injury in such a way that a jury can understand what they are talking about, then the client has a good chance of winning the case.
A key part of any mild traumatic brain injury trial are the before and after witnesses. These are witnesses who knew our client well before the accident and they can talk about the changes they have seen in our client since the accident. Great witnesses are employers, co-workers and friends.
We will call to the witness stand our financial experts, such as vocational experts and economists who can help the jury understand the cost of the treatment needed in the future, as well as the loss of earnings or earning capacity that our client will suffer from their injury.
Any mild traumatic brain injury case is complicated and expensive to present to a jury. The experts charge a lot of money for their time away from their practice. It is not uncommon for the expert witnesses costs in a mild traumatic brain injury case to be over $50,000.00.
Loss of Consciousness and Brain Injuries
A common question is: Can there be brain injury without a Loss of Consciousness? The answer is yes. A brain injury can and does occur without a person being knocked unconscious. There is the famous case of Phineous Gage's brain injury. In 1848, Pineas was working on a railroad when an explosion occurred and sent a three foot long iron rod through his head. He was rushed to a doctor who found Phineous to be "in full possession of his reason and free from pain." He was eventually able to return to work, however, he underwent a total transformation of his personality.
Today, most doctors will agree that a brain injury does not require a loss of consciousness, however, in the courtroom, most defense experts will say that without a loss of consciousness there can be no brain injury. The good news is that medical literature continues to expand and clarify that brain injury does happen without a loss of consciousness.
Vocational Management of Brain Injuries:
Traumatic brain injuries usually change the course of an individual's life plans, including vocational abilities. Working is important in meeting economic needs, but our careers are important in self esteem and meeting social needs. Some victims of traumatic brain injuries are able to return to work, however their job requirements should be taken into consideration.
Common requirements for most jobs
Maintain attention to short tasks
Move with flexibility from one task to another
Meet specific on the job requirements
Independently organize a task
Make judgments and decisions independently
Perform with adequate working speed
Maintain attention to the task at hand
Communicate effectively with other individuals
Some people with mild traumatic brain injuries are able to accomplish many or most of the common requirements for maintaining a meaningful job. Some victims of brain injury are unable to maintain their occupation.
If you have questions about a brain injury, please call us at Powell & Espat to talk with us about your case. We will be glad to give you a free consultation. If you have a case that we can accept, we will take your case on a contingency fee basis, which means you don’t pay us anything up front. We only get paid when we make a recovery for you. Call us. We are experienced personal injury attorneys helping people and families for over 20 years with all types of serious accidents.
Powell & Espat - Personal Injury Attorneys
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