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.
Is a Concussion a Brain Injury? and What is a Concussion?
A concussion is defined by the United States Center for Disease Control and they say a concussion is a type of traumatic brain injury, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can occur from a motor vehicle accident, a fall or a blow to the body that causes the head and brain to move quickly back and forth, even though the head itself has no trauma.
Brain injuries can cause a wide range of functional short-term or long-term changes which affect thinking, sensation, language, and sometimes emotions.
A brain injury can affect Thinking is described as memory and reasoning. Sometimes it can be short term memory or long term memory. Reasoning can be a lack of judgment.
A brain injury can affect Sensation which is a change, or usually a loss of touch, taste, hearing, smell, or a change in vision.
A brain injury can affect Language which is a change in the ability for the injured person to understand language, or a loss of expression, or a difficult time in communicating.
A brain injury can affect Emotional Changes which can be seen as newly acquired depression, anxiety, aggression, acting out, social inappropriateness and personality changes.
Some brain injuries cause epilepsy and increase the risk for Alzheimer’s disease, Parkinson’s disease, and other brain disorders that show up years later.
We have all heard about professional boxers, hockey players and even football players having long term brain damage from repeated head trauma. Multiple mild traumatic brain injuries occurring over an extended period of time can cause cumulative neurological and cognitive losses. Centers for Disease Control and Prevention (CDC). Sports-related recurrent brain injuries—United States. MMWR 1997;46(10):224–227.
Mild traumatic brain injuries are a result of microscopic damage throughout the brain that in turn initiates a cascade of biochemical events that leads to the subsequent formation of Alzheimer’s like plaques. World Alzheimer Congress 2000. American Journal of Epidemiology.
The bottom line is this: any concussion is an injury to the brain. Some brain injuries are very minor, and others are quite severe. We also know that repetitive concussions lead to severe loss of brain function over time.
Leading Causes Of Traumatic Brain Injuries are:
- Falls (35.2%)
- Motor vehicle traffic accidents (17.3%)
- Struck by/against events (16.5%) and
- Assaults (10%).1
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 are chemical exposures, 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 palsey. 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.
Closed Head Mild Traumatic Brain Injuries:
Let’s focus on closed head injuries where the trauma does not fracture the skull, but the brain is damaged by a sudden shaking or movement of the brain inside. If a person’s head and brain has a sudden shake, they will have what is commonly called an “Axonal Sheering Injury.” This injury happens when the axons (very small nerves) connecting the white and gray brain matter are stretched and damaged.
Your brain is made up of two types of brain cells, grey and white matter. The center of your brain is “white brain matter”, which is dense and heavy compared to the surrounding grey matter. The grey brain matter is much softer and lighter that the heavy white matter. The white and grey matter are connected by axons, which are billions of microscopic nerve fibers that transfer information from the grey brain matter to the white brain matter, and vice versa.
To help us understand how the brain is injured in a sudden acceleration or deceleration accident, it is helpful to think about Newton’s laws of physics. Newton’s law of physics says that “things in motion will remain in motion, until another force is introduced to change the motion” What this means is that since our brains are soft and they are made of 2 different types of tissue, white matter and gray matter, that when our head is hit, the skull moves as a direct result of the force, but the brain remains still (Newton’s law) until the force on the brain causes it to move to catch up with the skull. And more importantly, the gray matter (which is softer and lighter) moves more than the (heavy) white brain matter, so in the areas where white meets gray, there is a sheering of the connections between the two different types of brain cells. This difference in mass causes a shearing of the axonal nerve connections between the two types of brain cells. The axons are the micro small nerve fibers that connect the two parts of the brain, so that gray and white brain cells can communicate. When the axons are stretched, (due to the gray and white matter moving at a different speeds) they suffer micro tears and over time, the tears to the axon cells do not heal, but begin to deteriorate and break down until the axon breaks into two pieces and cut off any communication between that gray and white brain cell served by that specific axon.
It used to be puzzling why a brain would be injured in locations other than around the outer edges of the brain, close to the skull. But we now understand that the varying densities of the brain tissue (grey and white matter) means that the two types of brain cells have different inertial characteristics. Because of the differences in their inertial characteristics, one part moves more than the other. Therefore in the places where the white and gray matter connect, there is damage caused by one part moving more than the other. This is why we find damaged brain cells in the areas where the gray and white meet and not in the outside areas of the brain. The axons that connect the gray and white matter are damaged due to the way they move in a traumatic event.
What is an Axon? Axons are the long, slender highways of brain nerve cells. Axons are key in sending signals within, to and from the brain. They transmit the impulse from one nerve cell to the and next from gray to white brain cells.
Mild, Moderate and Serious Brain Injuries
75% of brain injuries are classified as mild brain injuries. However, the definition is not very comforting if you are the one with the “mild brain injury.”
Many emergency department doctors call a concussion a “mild” brain injury because concussions are usually not life-threatening. Even though a concussion is not usually a life ending injury, it can have a life altering effect.
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
- head pain
- Nausea near the time of the trauma
- any loss of consciousness
- lightheadedness / dizziness
- blurred vision or tired eyes
- ringing in the ears
- bad taste in the mouth
- fatigue or lethargy
- a 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:
- a headache that gets worse or does not go away
- repeated vomiting or nausea
- convulsions or seizures
- an inability to awaken from sleep
- dilation of one or both pupils of the eyes
- slurred speech
- weakness or numbness in the extremities
- loss of coordination
- increased confusion, restlessness, or agitation
Mental Disturbances caused by a traumatic brain injury may include:
- Attention problems
- Memory problems
- Speed of information processing
- Speech or language problems
- Mental organization
- Task efficiency
- Executive functions
Physical Symptoms of a traumatic brain injury may include:
- Sleep disturbance
- Lack of energy
- Ringing in the ears
- Blurred vision
Behavioral Changes caused by a brain injury may include:
- Angry outbursts
- Rapidly changeable mood
- Poor social judgment
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 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.
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.
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 scan of a normal 20-year-old brain.
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. (see images or Richard Rubino’s PET scan)
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 are 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, brain injury is classified as:
- Severe, with Glasgow sore below 8,
- Moderate, with Glasgow between 9 and 12,
- Minor, with a Glasgow score greater than 13.
“The widespread adoption of the Glasgow Coma Scale has made it easier to classify severe injuries, but it was not intended as a means of distinguishing among different types of milder injury. Many of these patients are oriented by the time they are assessed, and therefore, score at the top of the Glasgow scale. Yet some of these patients have had a period of altered consciousness, either witnessed or evidenced by their being amnesic for events immediately following injury. Impairment of consciousness is indicative of diffuse brain damage, but there can also be marked local damage without either alteration in consciousness or amnesia;” Mild Head Injury, ©Oxford, 1989, page 24. B. Jennett from Mild Head Injury
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.
Axonal Shearing to Brain Cells:
Axonal Shearing happens when the brain is violently shaken in the skull. The neuron which is the main cell of the brain has a long nerve fiber is called an Axon. Our Axons are arranged in tracts or clusters in our brain providing the connectivity between brain cells and different parts and areas of our brain. After a trauma, the single cell neuron may swell, and this causes a disconnection between the cell body and the axon. This process of micro cell death takes place within the first 24 to 48 hours after a trauma. This type of trauma never happens to just one brain cell, it happens across many areas where the white and gray brain matter come together. Because of their different weight and masses, the axons connecting the gray and white brain matter are sheared in the trauma. Diffuse Axonal Injury (DAI) is the term that doctors use to explain why the damage is a person’s brain is scattered over many areas of the brain rather than in one specific area.
Proving Brain Injuries in a Court Room
The most typical way we 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 radiologist 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.
Neuropsychological testing for 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
Costs of Traumatic Brain Injuries
Direct medical costs and indirect costs such as lost productivity of TBI totaled an estimated $60 billion in the United States in 2000. Finkelstein E, Corso P, Miller T and associates. The Incidence and Economic Burden of Injuries in the United States. New York (NY): Oxford University Press; 2006.
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
- Follow directions
- 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
Whiplash Trauma and Chiari Syndrome – Brain Injury caused by Whiplash Car Accidents
There are new MRI imaging techniques that prove that people are suffering mild traumatic brain injuries caused by relatively minor motor vehicle crashes. Doctors have started using the Fonar, upright MRI, to see how the brain stem is positioned in a patient’s skull. It has been discovered by Dr. Scott Rosa, Dr. Michael Freeman and Dr. David Harshfield, M.D., that after some car accidents the brain stem and the tonsils of the brain (lowest part of the brain) quite often are being displaced and permanently move lower in patient’s skulls. This is called Chiari Syndrome. This syndrome causes compression of the spinal cord and brainstem causing a variety of neurological problems. By using an upright Fonar MRI, we can image a person’s brain, brain stem, and spinal cord while it is under the effects of gravity. This is the best way to determine if someone has experienced traumatically induced Chiari syndrome.
Cerebral Spinal Fluid CFS flow studies are done with upright MRI. This is the best way to show how bad the Chiari syndrome is affecting a patient. Dr. Rosa works with the engineers at Fonar to develop imaging techniques that show the disruption of the normal flow of CSF. When the brain stem is lower that it should be, the brain stem acts like a cork in a bottle, and stops the normal flow of cerebral spinal fluid from flowing around the brain and down the spinal canal.
There is some good news for patients suffering from this condition. Research has been performed and by using a technique called atlas orthogony, the condition can be dramatically improved.