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Brain Injuries

One of the most often missed post trauma diagnosis is the brain injury.  A victim who presents to a hospital or medical provider for fractures and lacerations may not be diagnosed or properly diagnosed with a a brain injury.  In fact, mild or moderate traumatic brain injuries can be misdiagnosed or missed altogether. Weeks or months later, headaches, personality change, memory loss, sleep disturbance or other symptoms might develop and might be ignored. Some of these symptoms might be confused with depression, chronic fatigue, attention deficit disorder, hysteria or malingering.  What is often called a "mild traumatic brain injury" is actually a significant injury to the brain which has not been accompanied by obvious structural damage (for example, fractured skull) to the anatomical landmarks.


Ferrara Law Offices, P.C.works closely with clients and their treating physicians to make sure that all aspects of your injuries are identified, diagnosed and treated, thus creating a legal-medical team who can present forensic evidence to help support damages claims in brain injury cases.  Brain injury symptoms and consequences are taken into full account in developing and presenting your claim for damages, which will include the expenses of future treatment and rehabilitation as needed.  


Brain injury cases are highly disputed.  In defending such actions, insurance companies often retain "hired gun" doctors to distort the medical literature relating to brain injuries and/or to minimize the existence or severity of a brain injury. 

What is a Brain Injury?

Trauma to the head during a collision sets the brain in motion inside the skull.  Depending upon the severity and direction of the forces, the brain can be damaged in a variety of ways. These types of brain injuries include: surface injuries caused by the initial force, and the rebound caused within the skull; or stretch to the microscopic structures like axons, dendrites and blood vessels.  The primary "mechanical" injury to brain structures is often followed by secondary damage arising from the brain's response to the injury. Secondary damage typically arises from a reduction in blood flow within the cerebral part of the brain, reduction in glucose metabolism within the brain, swelling and/or scar tissue formation.  Depending upon the type of secondary damage, cells distant from the site of the trauma may die over  a period of days, weeks, months or years. This can be tracked in a small percentage of cases with functional neuro-imaging.  But, in most mild traumatic brain injury cases, it is well accepted within the medical community that both MRI's and CT scans will be negative.  If you have been told that you have a negative MRI or CT, it does not mean that you do not have a legitimate mild traumatic brain injury.    


The specialized cells called "neurons" that do the processing work of the brain (such as thinking) are most highly concentrated in the outer layer of the cortex, known as the gray matter.  The neurons also exist in dense clusters within the white matter of the brain.  The axons (which are long, hollow tubular structures) for the "wiring" of the neurological circuitry that links neuronal processing centers.  These axons carry neural messages at speeds of 1/10,000th of a second, because they are coated with a fatty substance called myelin that functions like a conductive insulation material.  The nerve impulse starts as an "action potential", an electric charge that goes down the axon and triggers the release of chemical substances called "neurotransmitters" to flow across the gap between one axon and 100 to 10,000 dendrites arrayed to receive chemical messages.


The human brain is vulnerable to trauma, both mechanically (due to the initial trauma) and chemically (secondary to the trauma). Both can change how and what we perceive, remember, think, feel and act.  Brain chemistry may be radically altered by microscopic damage to the axons of the brain that is not detectible on the modern MRI or CT scans. This is a huge problem both clinically and legally because physicians and lawyers who do not understand this (or do understand but choose to advocate "no injury") will likely judge or advocate that victims of mild traumatic brain injuries "TBI's" with negative MRI and/or CT results are faking, exaggerating or over-reacting to a blow to the head. Indeed the so-called "mild" TBI, which makes up 80% of all cases, never produces a visible abnormality on CT or MRI study.  This is because the tissue damage occurs on a cellular level, which is visible only under the microscope and is widely diffused, leaving blood vessels and major structures intact. Sadly, mild traumatic brain injuries are one of the nation's most seriously under-diagnosed and under-treated conditions.


The exterior of the brain is vulnerable to focal contusions (bruises) secondary to the shaking of the head, which bounces the brain against the inner walls of the skull. If the trauma is very significant, cerebral arteries can be constricted, creating an oxygen deprivation injury similar to stroke, and the brain is vulnerable to damage from stretching and tearing of axons, known as a diffuse shear.


Evidence of a brain injury may also be indicated by a victim having a loss of smell (a condition called anosmia) because their olfactory nerve (cranial nerve I) is damaged by being rubbed between the base of the frontal lobes and the rough bony shelf beneath it called the cribiform plate.


Brain injuries often affect the frontal lobes, which lie behind the forehead and eyes, because vehicle collisions tend to involve contact between the forehead and a hard surfaces.  In such injuries, the inner surface of the skull next to the frontal lobes contains a series of sharp, knife-like ridges. This type of contact, and the cognitive deficits which arise from it, are called Post Concussion Syndrome.


More severe frontal lobe injuries can diminish "executive function".  When confronted with a stimulus (for example, a social interaction, a job, an interview or first date) we use our frontal lobe, and executive function, to evaluate the situation and act appropriately.  Executive function considers our options in the context of social norms, our immediate goals and motivations, and the expected consequences. Further, it helps us plan responses, issues commands to our muscles of speech and movement, monitors the outcome and changes our course of conduct based upon feedback. Frontal lobe injuries frustrate executive function and, further, interfere with the planning, execution and monitoring of everyday tasks, and can reduce motivation and cause apathy. Victims of these types of injuries often know what they need to do, but cannot accomplish their goals due to a "break in the connection" between acquired knowledge and the skills and capacity for action.


Most traumatic brain injuries are "closed head" (meaning that the skull has not been openly penetrated) and tend to be "diffuse" and involve a more generalized "global" disruption of brain function .  Global dysfunction is rarely evident in a standard neurologic exam on mental status, motor control, reflexes and sensation, but are more likely detected in neuropsychological evaluation of cognitive functioning.   


The importance of understanding a brain injury from a legal-medical perspective is critical to prosecuting an injury case in which it is believed that the victim suffered such an injury. The right experts need to evaluate the victim and the full scope of injury. Call Ferrara Law Offices, P.C. for a free consultation.