Traumatic Brain Injury: Diagnosis, Treatment and Recovery

Brain injury is the leading cause of death for those under the age of 45.

Many who suffer mild to moderate brain injury do not appear to be injured and they have few outward physical manifestations of personal injuries.

In short, they “look” good, despite the fact that they have suffered a severe personal injury that can mean the loss of employment, the destruction of personal relationships and the anguish that accompanies the knowledge of all that has been lost. I have seen this repeatedly as a personal injury lawyer representing TBI survivors.
Survivors of  mild and moderate traumatic brain injury routinely are reassured by doctors that they will recover from their fatigue, slowness in thinking, and reduced memory, just as they expect to recover from cuts, bruises and broken bones.

The all too common belief is that time heals all wounds.

For every rule there is an exception and unfortunately time does not heal all traumatic brain injuries.

Over time doctors address objective physical injuries, but the head injury does not receive the special attention it requires and TBI goes undiagnosed. As a result, many head injury patients with permanent brain impairments never receive a full evaluation by a neuropsychologist, including neuropsychological testing.  Without testing by a neuropsychologist, traumatic brain injury cannot be diagnosed and these patients never receive appropriate care and treatment for their physical, cognitive, psychological, sexual and social impairments.

Family members must take the initiative to purchase a complete copy of the survivor’s medical records including the rescue and ambulance service, emergency room and hospital records if there was an admission. A complete set is critical because it contains all of the detailed evaluations and objective measurements made by emergency medical technicians, E.R. nurses and doctors and neurologists that are necessary to understand the nature and extent of traumatic brain injury.

Carefully read these records, as I do, with a medical dictionary at hand to know exactly what personal injuries have been suffered:

• Skull fracture
• Hematoma – A pool of blood forms and clots the lining around the brain. This clot can push down on the brain with enough pressure to cause serious, sometimes fatal, damage. Strokes are a common cause of hematomas.
• Contusion and concussion – often related. A contusion is a bruise, which can be the result of a fall, such as a bump against the dashboard in an auto accident. A concussion is the result of a sudden blow to the head. There can be damage at the point of impact, but there can also be damage where the brain strikes the skull as the blow pushes it back and a rebound injury, or contrecoup, occurs opposite the initial impact. Incidentally, neurologists have found permanent brain damage in individuals who have received multiple blows to the head over a period of years. Boxers, soccer and football players are among the most prominent examples.
• Diffuse axonal injury – This is caused when the head is torqued, and the delicate fibers of the brain are stretched and twisted. The injury usually figures in both shaken baby syndrome and whiplash. Because the damage is often microscopic, it is very unlikely that diffuse axonal injury will show up on a CT or MRI.
• Toxins and loss of oxygen to the brain – Carbon monoxide poisoning is one of the most common causes of brain damage in this category.
• Medical conditions – If the brain swells (called “edema”), the pressure may cause brain damage in much the same way that a hematoma affects the brain.

Since the brain regulates our state and level of consciousness, we can learn much about the extent of a brain injury by evaluating  loss of consciousness itself. If the level of consciousness is other than normal, the head injury is serious, no matter what a physical examination or other evidence may indicate. The categories of altered consciousness are:

• Confusion – The mildest form of altered consciousness, in which individuals have difficulty thinking coherently. For example, they may not be able to solve a simple math problem or remember what they ate for breakfast. Often they will seem disoriented and may not speak much.
• Stupor – At this level, individuals are often close to a comatose state and are unresponsive to normal stimuli. They can only be aroused by intense or painful stimulation, such as having their toe squeezed or being stuck with a pin. They may open their eyes, but only if they are vigorously forced to respond.
• Delirium – This intense state of altered consciousness often is the result of exposure to a toxic substance. People suffering from delirium are disoriented, afraid, irritable and over-reactive. They don’t have a grasp of what they are seeing or hearing, and they are prone to visual hallucinations.
• Coma – The most serious form of altered consciousness, in which a person is completely unconscious and unresponsive to any sort of stimuli.

More important is to simply ask this question: When did clear, continuous memory re-start?  Many survivors of TBI will speak to doctors, nurses and family in the ER and yet not regenerate continuous clear memory until many hours later, or even the next day.  That is a red flag, in conjunction with later concerns, to evaluate for permanent brain injury

Physicians use a system called the Glasgow Coma Scale (GCS) to precisely evaluate and describe patients’ levels of consciousness. To understand the seriousness of a brain injury, the patient’s condition at the first evaluation is significant. The more severe the initial presentation, the more severe the injury and the likelihood of a full and complete recovery is reduced. The scale is based on three individual responses measuring eye, verbal and motor responses. Physicians consider expression of a total GCS score of limited interest; what is more important is the score in each of the three individual categories. Each level of response indicates the degree of brain injury.

The Rancho Los Amigas Cognitive Scale describes levels of function and is used to assess the efficacy of treatment programs. The scale scores cover deep coma to appropriate functioning. Most survivors will demonstrate characteristics from several levels at once.

• Level I: no response to pain, touch, sound or sight.
• Level II: generalized reflex response to pain.
• Level III: localized response to pain. Blinks to strong light, turns toward or away from sound, responds to physical discomfort, inconsistent response to commands.
• Level IV: confused/agitated. Alert, very active, aggressive or bizarre behaviors, performs motor activities but behavior is non-purposeful, extremely short attention span.
• Level V: confused/non-agitated. Gross attention to environment, highly distractible, requires continual redirection, difficulty learning new tasks, agitated by too much stimulation. May engage in social conversation but with inappropriate verbalization.
• Level VI: confused/appropriate. Inconsistent orientation to time and place, retention span/recent memory impaired, begins to recall past, consistently follows simple directions, goal-directed behavior with assistance.
• Level VII: automatic/appropriate. Performs daily routine in highly familiar environment in a non-confused but automatic robot-like manner. Skills noticeably deteriorate in unfamiliar environment. Lacks realistic planning for own future.
• Level VIII: purposeful/appropriate.

The most common of brain injuries is a quiet and elusive one. Called post-concussion syndrome, this personal injury is most often caused by what seems to be innocuous damage to the head. Individuals may sustain an injury, but never lose consciousness and appear to be doing just fine. The difference between a post-concussion syndrome and traumatic brain injury is that PCS is temporary. TBI is not. Days or weeks later, individuals will experience problems with memory, reasoning or judgment, or they may simply report feeling “off” and not being the same person they were before the accident. These injuries are not readily reported in the injured survivor’s medical records, but they are well understood by family members, close friends, and co-workers who know that the survivor is “not the same person” s/he was before this serious personal injury changed their lives.

In today’s world of short medical visits, doctors don’t have the time, and in many cases the training, to ask the patient about detailed changes in their ability to cope after a head injury. Since many people improve over time, reassurance is the common form of medical care provided by a family physician or general practitioner. The result is that “reassurance” denies the patient treatment because it fails to secure an honest diagnosis.

Family members are the first to recognize deficits and changes caused by a head injury, well before the patient is prepared to admit to chronic deficits, but unfortunately this significant information is not fully reported to doctors. In addition, by definition, asking a memory impaired person details of their cognitive losses is problematic. It is the equivalent of asking a patient “how long were you knocked out?” Once you lost consciousness, you don’t know and rarely does anyone instantly regain full consciousness. Coming in and out of acute consciousness is common. For the same reasons, asking a memory-impaired person what they don’t remember is not helpful. And there is no bright line between depression, fatigue, irritability and memory lapses caused by brain injury or from other causes, although these symptoms are the hallmarks of a brain injured patient. This is why it is so very important for a spouse, parent or sibling with first hand knowledge to attend follow up medical exams.

After 3 to 6 months, if deficits persist, or improvement is slower than expected, report the most significant deficits in writing to the primary care provider and request a referral to a neuropsychologist for evaluation of traumatic brain injury.

In many cases, as the attorney for the head injury survivor, I have worked with family members to prepare a detailed letter to a treating doctor that identifies changes in learning and communication skills, among others, suffered by the patient and as a result have obtained a referral to a neuropsychologist for TBI evaluation and testing.

Obtaining proper medical care and treatment, especially for TBI survivors, requires the intervention and support of family members, and often times a skilled attorney who knows and understands the signs and symptoms of brain injury.

A word of caution. Do not be deterred by a physician declining to order neuropsychological testing because a CT Scan, or an MRI, does not show injury, i.e. the images are read as being within normal limits.

First, CT Scans cannot be used to diagnose TBI except in the most aggravated cases of fractures and hematomas. Second, the same is true for most MRIs. Unless the MRI was performed on a T-3 machine (newest and most powerful MRI on the market), employs the latest generation of sophisticated software to provide diffuse tensor imagery and fiber tracing which is studied and interpreted by a neuroradiologist trained in this protocol, the MRI report is not definitive.

Note that an MRI utilizing a T-3 by itself is not sufficient unless software providing diffuse tensor imagery and fiber tracing is used. This combination of the latest hardware and software allows specially trained professionals to identify axonal shears and other finite injuries, otherwise unseen on MRIs conducted on T-1 or T-1.5 machines. More importantly, MRIs are not the first step in diagnosing traumatic brain injury. The recognized method for diagnosing the residuals of traumatic brain injury is through testing by a neuropsychologist trained to evaluate TBI.

When should you expect a recovery and to what extent?

The general rules is that the shorter the time it takes for brain injury recovery, the more complete the recovery will be. While every person is different, patients tend to recover sensory, motor and language skills faster and more readily than writing and math skills, memory, attention, general intelligence and social/emotional balance. In addition to the longer recovery time, the loss of these skills and abilities are usually more devastating.

Motor and speech recovery usually occurs within three to six months of injury. Attention and memory tend to be the most difficult to recover.

The pace of recovery is usually greatest during the first three months. Recovery from brain injury then tends to slow over the course of the balance of the first year. This is one reason why it is valuable to obtain a neuropsychological evaluation shortly after the personal injury is suffered and to use this baseline for comparison with later tests to measure changes and to understand the extent of improvement.

In general, after six months some improvement can occur, but usually it is not significant.  That is what i have seen in my work with TBI survivors.  After that point, there is no healing in the conventional sense. Damaged brain nerve cells and pathways do not regenerate. People can and do learn to compensate for their brain injuries by using other skills and that is where rehabilitation specialists are very helpful.

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Onward,

Richard Alexander