Traumatic brain injury (TBI) cases can be extremely challenging due to the lack of objective testing to prove the existence of common types of brain damage. Brain damage is often microscopic such that it can only be shown by a pathologist on autopsy, particularly in cases of mild TBI. Nonetheless, mild TBI can have a profound effect on an individual’s future ability to work, medical costs, relationships, and personal and financial security.
Microscopic brain damage is not visible on MRI or CT imaging. Sometimes, but not always, brain injury can be seen when imaging shows edema (swelling) or hemorrhage (a brain bleed), but these findings are rarely present except in the most severe cases. Neuropsychological testing can show deficits in memory, attention, intellect and so-called executive function, but these tests are subject to interpretation and raise as many questions as they answer in litigation. Further, neuropsychological testing does not show when the deficits arose or the person’s pre-injury level of function.
As a result of these limitations in diagnostic modalities, unsophisticated doctors frequently overlook brain injury altogether. For example, one study shows that ER personnel miss the diagnosis over 50% of the time. Alternately, they may misdiagnose patients as having depression or PTSD when they report symptoms of brain injury. A careful physician who is presented with a history of new onset of symptoms associated with TBI following a significant head injury should attribute those symptoms to the head injury in the absence of another obvious explanation.
Likewise, a careful personal injury lawyer can be helpful in recognizing these injuries even when negligent caregivers miss or misdiagnose them. TBI should be suspected in any significant car or truck accident, explosion, electrocution, fall or other event involving an impact to the head when the client answers “yes” to any of the following:
- Were you diagnosed with a concussion?
- Have you had any abnormal head imaging?
- Do you remember the accident?
- Did you lose consciousness?
- Was there significant damage to the vehicle?
- Did the airbag deploy?
- Did you hit your head/face?
- Do you have headaches?
- Difficulty with memory or concentration?
- Confusion or slow thinking?
- Visual disturbance?
- Anger outbursts or unusual irritability?
- Loss of smell or taste?
- Light or sound sensitivity?
- Sleep disturbance?
- Mood swings? Change in behavior?
While there is still no imaging study or EEG that can be used to objectively prove the existence of mild TBI, recent advances in medicine may soon change this. For example, researchers at the University of Wisconsin and the Human Connectome Project are using an advanced MRI to map the complex pathways of white matter within the brain. Eventually, this information will be useful in showing when these pathways are disrupted due to injury. In addition, PET imaging shows promise in measuring changes in brain metabolism following brain injury. PET “Tau” scans can show tauopathy which is pathognomonic for chronic traumatic encephalopathy (CTE).
The Center for Disease Control and Prevention (CDC) estimates that about 1.7 million new cases of TBI occur each year in the United States. As a result, TBI is receiving increasing attention from the medical community. Recent developments include the following:
- Dickstein, et al., Cerebral [18 F]T807/AV1451 Retention Pattern in Clinically Probable CTE Resembles Pathognomonic Distribution of CTE Tauopathy, See comment in PubMed Commons belowTransl Psychiatry, (2016), vol. 6, no. 9, reports that PET Tau scans can show tauopathy – the pathological scarring seen on autopsy in individuals with CTE. Tau scans will likely be at the center of future TBI litigation, once further research is done to correlate imaging findings to pathology findings and to measure the rate of disease progression.
- In Bavisetty, et al., Chronic Hypopituitarism After Traumatic Brain Injury, Neurosurgery (2008), vol. 62, no. 65, pp. 683-688, the authors showed that 20% of patients with TBI suffer a concurrent pituitary injury and dysfunction. Hypopituitarism can be tested for by an endocrinologist and, when present, provides objective evidence of pituitary injury following head trauma. See also Kelly, et al., Prevalence of Pituitary Hormone Dysfunction, Metabolic Syndrome, and Impaired Quality of Life in Retired Professional Football Players, J Neurotrauma (2014), vol. 31, no. 13, pp. 1161–1171.
- In Rea, et al., Pupillary Dysfunction in Post Traumatic Headache, (2016) ANA Journal, Abstract M307, the authors reported that dysfunction of the sympathetic nervous system following trauma may play a role in post-traumatic headaches. Sympathetic nerve dysfunction can be assessed by measuring pupillary dilation. Post-traumatic headaches, unlike migraines, are notoriously persistent and refractory to treatment.
- In August, 2016, the FDA approved the ImPact and ImPact Pediatric tests to assess cognitive function following a concussion. The test assesses memory and reaction time, and compares them with an age-matched control database. The FDA specified that the test is “not intended to diagnose concussions or determine appropriate treatments.”
Ohio brain injury lawyers need to review medical journals for updates about rapidly changing medical technologies used to diagnose TBI. Recognition of this potentially devastating injury can be useful to the client and his/her family members who have to cope with the injured person.
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