Traumatic Brain Injury.  T.B.I.  Closed Head Injury.  Concussion.  Coup-contra coup.

Basically, they all stand for the same thing:  an injury to the brain of the human being, with or without a skull fracture.  TBI is sometimes called the “most under-diagnosed injury in America”, because brain injuries most often cannot be seen on images like MRIs, x-rays, or CT scans.  TBI has been in the news a lot more over the last ten years or so because of two big stories:  1)  veterans of the wars in Afghanistan and Iraq coming home with post-concussion symptoms after being hit by shock/blast waves from IEDs; and 2) research into NFL athletes who have had multiple concussions playing football.  But, most often, you or a doctor still cannot “see” a brain injury the way you can “see” a fracture, a tumor, or a damaged internal organ.  If you or a family member have had a traumatic injury to the brain, though, you’re likely to be living with some pretty nasty consequences.

Image result for tbi

Causes of Closed-head Brain Injuries

The skull, and a fluid-filled lining of the skull called the meninges, protect the brain from infection and from trauma.  But, when subjected to a blow to the head, or sudden acceleration/deceleration, the brain bounces off the inside of the skull.  This can create a bruise to the brain (contusion), or bleeding (hemorrhage/hematoma).  These can both be seen with a CT scan (computerized tomography) or MRI (magnetic resonance imaging).

More subtle injuries, however, are invisible to these types of imaging.  We all have neuronal axons connecting the nerve cells in our brains.  They can be quite long, but are typically only about 1 micron (.001 millimeter) in diameter.  They can only be seen, therefore, microscopically, and we don’t have a way to visualize individual nerve cells or their connecting axons in a live person with today’s imaging techniques.

So, suppose you’re driving in a car and you get hit from behind.  Your head, at first, remains where it was when your car was hit.  Then, as the car is jammed forward, your neck and head snap back relative to the interior of the car.  Next, your head and neck whip forward, which is why people in car wrecks get “whiplash” injuries.

But, it’s also why they get TBI.  It’s called “coup-contrecoup”.  Here’s an illustration:

Image result for coup contrecoup whiplash

When this occurs, the neuronal axons that connect memory cells, autonomic function centers, and the various lobes and centers of the brain to one another are torn or stretched, damaging the normal interconnectivity of the human brain.

Here’s what that looks like in a microscopic pathology slide — normal brain cell and axons on the left, damaged cell and axons on the right:

You don’t have to lose consciousness to have TBI.  You do not need to have amnesia of the incident to have TBI.  You do not have to have a brain bleed or bruise to have TBI.  What causes TBI is trauma:  a sudden shock, blow, or acceleration/deceleration force to the head, damaging and changing the function of the brain which is the center and soul of the human being.

Signs and Symptoms of TBI

Closed head injuries cause both physical and psychological symptoms.  Some of the most common ones are

  • unusual, persistent headaches
  • daytime drowsiness/sleepiness
  • dizziness, nausea, and vertigo
  • loss of coordination, especially fine motor coordination
  • rapid mood swings
  • short-term memory loss
  • word-finding difficulty (aphasia)
  • depression
  • PTSD

In more severe cases TBI can cause personality changes, loss of reasoning ability, decreased intelligence, and inability to administer to one’s self-care needs.  A particularly tragic case was a young client who was injured in a head-on crash on the scenic highway that winds through the Wichita Mountains Wildlife Preserve.  She was 19 years old, a straight A student in college, and planning to be a medical doctor.  In addition to severe orthopedic injuries, she had a brain injury.  She lost about 20 points of IQ, had to be taught language and reading all over again, and, of course, had to modify her chosen career path significantly.  Another client’s personality was so altered that his wife said it was basically like learning to live with an entirely different person who still looked like the same person.  A less-severely injured client, a young man studying animal husbandry at a Big 12 college on a football scholarship, had a closed-head injury in a car wreck that left him with migraines so severe that all he could do when one hit was to lie in bed with the lights out, the drapes closed, in total silence until the migraine went away.

I try to avoid making psychological injury claims for my clients, because in litigation that opens up their prior psychological history, including prior psychological trauma.  Fill in the blanks, or not, as you will, because all of us have had some mental trauma somewhere along the way.  However, known sequelae of brain injury include psychological symptoms.  Many of our troops coming back from war have flashbacks, nightmares, depression, and adaptation disorders.  Rape victims and sexual abuse victims usually have similar symptoms.  Similarly, it is not infrequent that people in nasty wrecks have flashbacks, fear of driving, and nervous, fearful reactions when they are on the road and confronted with situations that resemble what occurred when they got injured.

Diagnosis and Treatment, and proof

How do you diagnose an “invisible injury”?  At the Emergency Room, if you are AOx3 (alert and oriented times three, meaning you know the date, the city, and the name of the President), you’re probably not going to be diagnosed with a head injury.  If your PCP suspects head injury, he may refer you to a neurologist (specialist in diseases and injuries of the nervous system).  The “neuro” may order an MRI, or referral to a neuropsychologist/neuropsychiatrist.  A “neuropsych” will conduct a series of tests including psychological testing (MMPI and others), IQ, memory tests, fine-motor testing, balance and coordination testing, to evaluate your mental and neurological health compared to various norms.  Specific responses to certain kinds of stimuli and tests help to infer whether you have injury to the brain, and if so, to what parts of the brain.

In 1997 we were in trial in federal court in a case where my client, a very precise and accurate bookkeeper, had a “mild organic brain injury” caused by a chemical exposure.  On the stand, when I asked him his daughter’s phone number (he called her multiple times every day), Carl’s face worked into spasms of frustration when he repeatedly tried, and could not remember, his own daughter’s phone number.  A neuropsychologist testified that he had tested Carl, and concluded he had brain damage including short term memory loss.  On cross-examination, the defense asked whether Dr. Whatley had failed to take into account the medication effects of some prescriptions my client took.  I’ll never forget Dr. Whatley’s response:  “No sir, no sir, no sir, nor sir!  I’m so very sorry to say it, but Carl L. has organic brain injury; it will never heal, and he will never be the same.”

There is a Department of Defense Social Media page called TBI:  “To Be Improved”.  It’s written by a veteran who suffered TBI from an IED in Iraq.  Cognitive impairment and other issues caused by TBI typically improve for about a year, but after that, the injured person usually needs to plan on making adjustments and changes to help adapt to and deal with the injury.  You have to carry a notepad around with you to keep track of your appointments; or where you put your keys; or your address; or what you went into the kitchen for.

Come to think of it, I KNOW I came into this office a couple of hours ago to do some kind of errand.  Now, what was it?

Image result for forgetfulness

Anyway, I’ve really enjoyed writing this column/blog on this chilly cloudy day in central Oklahoma.  If I can help you, send me a message and I’ll get back to you ASAP. or