DEFINITION OF MILD TRAUMATIC BRAIN INJURY DEFINITION OF CONCUSSION SYMPTOMS OF A BRAIN INJURY/CLOSED HEAD INJURY THE HEALTHY BRAIN CAUSES OF BRAIN INJURY/CLOSED HEAD INJURY The Doctor told you that your MRI of the brain, CT scan and skull x-rays are normal. He said that you have just suffered a mild concussion. You did not suffer extended loss of consciousness and you can not remember hitting your head on anything. You should be fine in a couple of days, right? Wrong! Weeks later you realize that you still have trouble with ringing in your ears, blurry vision, forgetfulness, tiredness, irritability, getting lost, nausea or headaches. What was considered a mild concussion that should have been over in a few days, is now, post-concussion syndrome. Mild traumatic brain injury is often not detected or diagnosed by emergency personnel because it is usually not visible on MRI, CT or x-rays. The damage to the brain is microscopic and has occurred diffusely throughout the brain to nerve fibers or axons that can not be seen on diagnostic radiology films. Patients at the emergency room also usually complain of other symptoms that are more painful and those injuries receive more immediate attention and diagnoses. People who have suffered from mild brain injury often look very normal. Therefore, the diagnoses of mild traumatic brain injury or post concussion syndrome may not be made until weeks or months later when the patient returns to school or work and notices a decline in mental, emotional or behavioral functioning. At the Traumatic Brain Injury Law Group we make sure that every client is screened for mild brain injury and receives the appropriate diagnoses by qualified physicians. DEFINITION OF MILD TRAUMATIC BRAIN INJURY A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following: 1. any period of loss of consciousness; 2. any loss of memory for events immediately before or after the accident; 3. any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused); and 4. focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following: a. Posttraumatic amnesia (PTA) not greater than 24 hours b. After 30 minutes, an initial Glasgow Coma Scale (GCS) or 13-15; and c. Loss of consciousness of approximately 30 minutes or less. Published in the Journal of Head Trauma Rehabilitation 1993:8(3): 86-87 Developed by the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary special Interest Group of the American congress of Rehabilitation Medicine. Top of Page DEFINITION OF CONCUSSION The American Academy of Neurology defines concussion as any alteration in consciousness such as: 1. Vacant stare 2. Delayed verbal and motor response (slow to answer questions or follow instructions) 3. Confusion and inability to focus attention (easily distracted and unable to follow through with normal activities) 4. Disorientation (walking in the wrong direction; unaware of time, date, place) 5. Slurred or incoherent speech (making disjointed or incomprehensible statements) 6. Gross observable incoordination (stumbling, inability to walk straight) 7. Emotions out of proportion to circumstances (crying for no apparent reason) 8. Memory deficits (exhibited by the repetition of questions or inability to memorize and recall 3 of 3 words or 3 of 3 objects in 5 minutes) 9. Any period of LOC (Neurology 1997:48-581-585) Top of Page SYMPTOMS OF A BRAIN INJURY/CLOSED HEAD INJURY Whether the initial brain injury is mild, moderate or severe, the various symptoms of a brain injury may or may not occur for shorter or longer lengths of time. Symptoms of brain injury generally fall into one of three categories: (1) Physical, (2) Cognitive and (3) Emotional/Behavioral. They are described as follows: 1. The physical impact of a brain injury may include: decreased motor control, coordination, gait, balance and posture. It may include paralysis, weakness, spasticity, contractures, seizures, taste, smell or vision disturbances, fatigue, slurred speech, difficulty chewing, swallowing or speaking, sleep disturbance, bowel changes and temperature changes. 2. The cognitive impact of a brain injury may cause impairment to the following brain functions: attention, concentration (focusing, blocking out distractions), executive function (planning, initiating, organizing, problem solving), memory (receiving, storing and retrieving information), communication (understanding, recalling words and expressing them), abstraction and judgment (misapplication of specifics to generalities, non-comprehension of consequences, inability to differentiate subtle variances), learning, and lack of motivation or impulse control. 3. The behavioral/emotional impacts of a brain injury may include: agitation, frustration, aggression, mood swings, depression, anger, lack of interest, crying, disinhibition, impulsiveness and loss of self-esteem. These symptoms can cause life-long impairments to a person's physical, cognitive or emotional function. Tragically they are sometimes not medically diagnosed in the case of mild brain injury. In fact, it may be the nuero-lawyer that first identifies the nature and extent of a brain injury. When the neuro-lawyer interviews the client in an in-depth manner and researches medical records and accident reports she is able to identify clues to the cause of a client's current symptoms and poor function. Top of Page THE HEALTHY BRAIN In order to understand the cause and effects of brain injury, one must first understand the brain. The brain controls all bodily functions through the central nervous system. This complex network originates in the brain and continues through the spinal cord and the nervous system. The brain controls conscious functions such as skipping, running, reaching etc. and unconscious functions such as sweating, heart rate and perception of pain. The brain also controls perception (such as visual or auditory), memory, learning, emotion and the integration of speech, behavior or other functions. Even microscopic damage to the brain can disrupt these functions. The brain is an approximate three-pound miraculous bundle of more than 100 billion microscopic nerve cells. The neurons are very long nerve cell fibers that connect electrochemical impulses throughout the brain. Chemicals in the neurons, called neurotransmitters, help convey electrochemical messages from the body to the brain and visa versa. The neurons are composed of a long axon, which may reach three feet long, and a dendrite, which is a branching part on top of the axon (Similar to a tall tree). These neurons connect different areas of the brain to allow the integration of thought and brain function. The brain has different physical regions or "lobes" which are distinct in function and structure. While the lobes are distinct they communicate with and depend on each other by the long neurons. These lobes are grossly responsible for certain individual brain functions. The frontal lobe is responsible for personality, character and the highest functions of thinking like reasoning, planning, organizing and problem solving. The parietal lobe is related to language and spatial relationships. The occipital lobe is associated with visual recognition and the temporal lobe is related to memory function. Each lobe is paired with a corresponding one MILD BRAIN INJURY OR CONCUSSION on the opposite hemisphere of the brain. A neurolawyer must have a thorough understanding of normal brain function and structure in order to appreciate subtle brain dysfunction. Top of Page CAUSES OF BRAIN INJURY/CLOSED HEAD INJURY The brain can be injured many ways. It may be injured by disease (infections, tumors, stroke, etc.), direct blow to the skull (falls, gunshots, car accident, abuse), or by a closed head injury (like shaken baby syndrome). The brain resides within the skull surrounded by a protective cushion of cerebrospinal fluid. This fluid usually protects the brain from the bony ridges within the skull. However, when the brain is suddenly accelerated and decelerated as in a car accident whiplash injury, the neurons connecting the different regions of the brain can be stretched and torn. This damage is usually microscopic and can not be seen on MRI or CT. Additionally the brain can be damaged when sudden movements like a whiplash cause it to strike against the rough bony inner surface of the skull. Closed Head Injury is caused by the gravitational forces of acceleration/ deceleration movement within the skull that tears and stretches neurons diffusely throughout the brain. A Doctor may refer to this as a "shear" injury because the long axon is torn from this movement within the skull. The brain may also develop a "coup contra coup" type of closed head injury when the brain bruises at the front and the back after suddenly striking the interior of the skull. The head does not have to be struck for a closed head injury to occur! A Bio-mechanical Engineer can be helpful to the attorney in proving that the gravitational forces were sufficient on the head to cause this type of closed head injury. Damage to the brain may occur at the time of injury as just discussed or it may worsen due to secondary causes from the initial impact. Cerebral edema or brain swelling causes additional pressure within the skull that can squeeze healthy brain matter causing injury to it also. Bleeding or intracerebral hemorrhage also causes pressure within the skull and can cause damage to the other healthy brain tissue. Exitotoxicity injury is microscopic and can not be seen on CT or MRI. This type of damage occurs when the damaged nerve fibers release excessive concentrations of chemicals that were used to transmit messages. Other healthy neurons nearby may be damaged days after the initial injury as this degeneration continues. The effect of a closed head injury may actually worsen after the first few hours as nerve degeneration and blood pooling occurs. Blunt head trauma is caused by a direct blow to the head. It may result in external skull fractures or may also cause internal brain damage. If the fracture is depressed the brain covering (dura) may be torn and cerebral spinal fluid may leak out. Subdural hematomas may develop after a blunt head trauma. This bleeding and bruising within the brain can cause brain swelling, increased brain pressure and coma. Brain Injury occurs every 15 seconds in the U.S. and is the leading cause of death or disability to people under the age of 45. Young males are the most likely to sustain a TBI and long term disability is often a consequence. People suffer brain injuries as a result of automobile accidents, falls, bicycle accidents, oil well accidents, train crossing collisions, carbon monoxide poisoning, drowning, domestic violence, child abuse, firearms, sports and other causes. A lawyer representing a person with a brain injury must not only be knowledgeable about the biomechanics of how brain injury is caused, but, it is vital that she understand the neurologic, cognitive, behavioral and emotional consequences of mild, moderate and severe traumatic brain injury. This knowledge will affect your ability to obtain full damages from the person that negligently caused your injuries. A life-care plan for future treatment can run several million dollars and that does not reflect lost earnings, past medical care, or pain and suffering. Roberta Robinson is an experienced neurolawyer who understands the causes and consequences of brain injury and she advocates aggressively for recovery both physically and financially. Top of Page