- Richard L. Duquette
Brain Injuries & Bicycling
Diagnosing a Brain Injury
The evolution of medicine has allowed us to diagnose brain injuries of all magnitudes. In the 1800’s we looked for broken bones; then x-rays allowed us to see the broken bones. Thereafter, Cat scans showed us tissue damage. Now an MRI is like cranking down a microscope, you see basically 10 billion axons in the brain, but we can not see all the axons which are white matter. Modernly, PET scans and EEG’s are cutting edge technology – allowing us to even see chemical changes in the brain.
Axons are damaged due to the sheering effect of trauma in the brain. Stretching and tearing of the Axons causes damage because the Axons are blood poor. The lack of bleeding in the grey and white matter does not mean that stretching or tearing did not occur. When Axons are torn, basically it limits the ability of the brain to send messages. Axons look like little spider webs in the brain.
Science says a blood trail or product is not necessary; the defense will concede this. Defenses to brain damage cases are malingering, you’re a bad guy or the client has a pre-existing depression.
Types of Brain Injuries:
The key to winning is to teach the jury to make a diagnosis of a traumatic brain injury:
Mild (cerebral contusions)
Moderate [traumatic and axoxic closed head (no fracture) injuries]
Severe brain injury (open head skull fracture, that penetrates the brain and disrupts the brain fluids.)
Geographic areas of the Brain:
The Frontal Lobe, deals with the executive function and the ability to multi task when it is mashed. The frontal lobe also regulates higher executive functions, i.e. conscious thought memory, intelligence, concentration, behavior, personality and aggression.
The Temporal Lobe, Parietal Lobe and Occipital Lobe are other areas of the brain that can be damaged.
The left hemisphere or Parietal Lobe results in deficits in language and word function, as well as executive function like calculating finances, computer use, sports, and recreational activities.
Symptoms of Brain Damage:
Some cognitive symptoms of brain damage are forgetfulness, lack of concentration, slowed work performance, poor reading comprehension, problem solving problems and fatigue. Other symptoms include job demotion, functional release, loss of libido, un-consciousness, cadence of speech, and slowed mental process. Ask the client what does he/she see in their mind, what visual images? Headaches, migraines, double vision. “phono” i.e. loud sound phobia or “photo” i.e. bright light phobia. Hearing fuzzy noises and breathing difficulty. Also, depression due to a chemical reaction, headaches, cognitive symptoms, fatigue and emotional issues may surface. Food tastes flat, things smell funny, personality changes. i.e. The wife states… “She’s married to a different person”. The Olfactory region deals with the sense of smell and taste, which if affected is evidence of a traumatic brain injury.
Symptoms can develop when the soft lobe hits the rigid brain bones. This may cause a cerebral contusion. The brain tissue becomes swollen and bruised. Blood vessels break and combine with swollen tissue. A contrecoup is a form of brain contusion that results when the brain comes in contact with the skull.
When diagnosing a traumatic brain injury, a MRI is used, but it’s not sensitive enough to detect damaged Axons. If you suffer a contusion, you may also experience a diffused axonal injury. Nerves in the brain tissue are damaged. Whereas, a CAT scan will determine a blood trail, but not mild traumatic brain injury. A PET scan is sensitive to cellular damage. A Spec Scan defines the course of treatment. EEG’s are also used. It’s a medical issue.
Proof of a Brain Injury in Court:
It’s important to show the before and after “cause and effect” symptoms to prove a case in court. In other words, how did the crash cause injury that wasn’t there before? For proof, you need someone reliable to show before and after effects. Normally there is improvement & rehabilitation. You can use a psychiatrist to discuss a workers compensation rating as a formulation of damage. Further, pain management is an issue, as is future medical care and treatment. Fear of re injury and someone being more susceptible to an injury is also a concern. In terms of future injury, traumatic brain injury patients have a higher incidence of epileptic seizures. In terms of treatment and tests, often a neurologist will refer a client to a neuro-psychologist for testing. The neuropsychological tests are the cornerstone of the case. For example, the Halstead and Raytan tests are frequently used. This is objective factual proof of an objective injury.
The defense will counter with the claim that your client is malingering. Again, patients do show improvement over time, but at some point they don’t improve. Note the MMPI (Minnesota Multiphasic Personality Inventory) tests checks against malingering.
Furthermore, it’s often good to have the client reevaluated a second time to confirm the injuries and the MMPI result.
Neurobiology of a Traumatic Brain Injury:
According to Dr. Hovda of Web M.D., following a traumatic brain injury, cells that are not bio mechanically irreversibly damaged are exposed to a number of chemicals and ions which increase the demand for energy. Unfortunately the brain uses glucose as its primary fuel and glucose can not be stored in the brain. Therefore the only way that fuel can get to the cells in the brain that has been damaged is through an increase in cerebral flow. So, following an injury the brain has an increase in energy demand and unfortunately it does not have the ability to supply the fuel that it needs to get this energy demand satisfied. After an accident, the lack of glucose and oxygen, which is delivered via the blood, causes damage. The energy component of the cells that are responsible for making the energy is an organelle call mitochondria.
An organelle is an anatomical term referred to the structures within another structure. So a mitochondria is where the cell uses oxygen to produce energy that the glycolysis has contributed to. The problem is that following traumatic brain injury calcium which is one of the ions that the cells are exposed to goes into the mitochondria and prohibits or interferes with its use of oxygen. So, by way of analogy, if a car has a dirty carburetor, when you step on the gas, its not going to go because it won’t burn the fuel. Similarly, when you step on the gas the engine requires fuel, but if the fuel line is clogged, the car runs inefficiently. This inefficiency of metabolism is what creates cells in the brain to be dysfunctional. This can be explained by what we call cell death or neurological deficient. Further, this dysfunction also explains why cells that have survived initial injury are extremely vulnerable to any additional insult or stimulation. This is the inefficiency of metabolism.
Locations in the Brain that are most Critical to Injury:
These are determined by the geographic orientation as well as their neuro chemical characteristics. So, when the brain is damaged within the skull from violent movement, like you would see in a car accident, it’s very much like an ice cube that is shook in a drink when a glass is moved back and forth. This creates strains and pressures on the particular parts of the brain. The base of the human skull is very rough, it’s made up of three plateau’s which have bony ridges and when the brain is shaken, these ridges tear into the brain. So, the areas that are most frequently damagedare the temporal lobes and frontal lobes when the brain is rotated as well as moved violently back and forth, the brain twists much like a water balloon would twist. i.e., if you took both ends of the water balloon and rotated them in different directions. What twists the most is the middle and this is near what we call thebrain stem. This area has many fibers and connections called axons. This type of injury results in what called a diffused axonal injury. It is the most common kind of devastating head injury.
When Axons are sheered, the Axons are stretched and they slow down information. Visually when you look through colored glass, it slows down what you see. So, you must try the case on a cellularlevel. The key is to compare before and after the accident and the symptoms thereof.
The Big Three Memory Issues:
Remember that there are three memory issues to deal with. The brain needs to:
The sheering of Axons is caused by an abrupt acceleration or deceleration of the brain tissue. The outer part moves at a different pace than the inner part because it’s soft. When a person sustains a concussion, it can be a stunning, damaging or shattering effect and can result from a hard blow. This results in a disturbance of the cervical function. Agitation and shaking will cause damage. By way of example, a brain is a soft structure in a hard box. When a blow is sustained, the brain recoils and re strikes the interior of the skull. This extreme motion causes a sheering and can result in axonal nerve injury due to the stretching of the Axons. In extreme cases, bleeding is caused. All brain injury is traumatic to some degree.
A cerebral concussion can be described as a movement, a bio mechanical movement of the head which causes the cells in the brain to fire spontaneously. Following this, the brain goes into a state of depression. The amount of force that will induce this is extremely mild. We all know that it’s not necessary for humans to have lost consciousness in order to have sustained a cerebral concussion. Many people who have had a mild blow may be disoriented for a brief period of time. This constitutes receiving a concussion. In fact, many investigators use the term “mild traumatic brain injury” instead of concussion to emphasize the seriousness of the mild blow to the head.
In terms of making the grade, one of the first steps is to determine the grade of the injury according to Doctors, Neurologists. A grade one is a concussion commonly referred to as “getting your bell rung” doesn’t normally result in a loss of consciousness, but does involve the haziness and disorientation normally associated with head injuries. Grade twoconcussions have similar symptoms but last 15 minutes. A grade three concussion is determined by a loss of consciousness. It usually takes about a month before you recover from a grade three concussion. Note, that bicycle helmet safety institute estimates that helmets can reduce the risk of serious injury by up to 85% in all age groups. Note, there are over 2 million closed head injury cases a year.
Treatment of a Brain Injury:
Besides immediate medical attention and possibly surgery to reduce swelling and hemorrhaging in or near the brain, there are many forms of therapy and treatment. For example:
Depending on the nature, extent and area of the brain injury you doctor may prescribe a referral to a….
Psychiatrist who can prescribe medication and counsel you and your family.
Psychologist who can test and counsel you and your family.
Neurologist who might test your body functions to refine your diagnoses.
Speech, Physical, Recreational or Occupational therapist.
Alife care planner and social worker.
One great example of the inner workings of the mind and brain in bicycling is an IMAX movie called “Wired to Win, surviving the Tour de France” which is/was playing at the Ruben H. Fleet Space Theater in Balboa Park, San Diego. This may be a good demonstrative piece of evidence to show how the brain works. Further, PBS may also have another video on this issue. Consider http://www.wiredtowinthemovie.com. The Ruben H. Fleet Space Theater can be reached by calling 619-238-1233 if you want to purchase the disc.
Also consider online resources:
The brain injury resource center,
Brain injury association of America
Traumatic brain injury keyword search
Web MD or the Med line Medical encyclopedia
Brain injuries are serious and warrant appropriate compensation. Part of my role as your experienced trial lawyer is to research similar jury verdicts to your injuries and any loss of income flowing from your disabilities. I’m very interested in this process and would value the opportunity to assist you and your family.
Ride Safe – Ride Strong!