A Collection of Medical & Legal Information About Brain Injury

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A Warning about White Matter Damage

I recently gave a lecture at the North American Brain Injury Society (NABIS) speaking about what many perceive as a wide spread problem in our health care system involving TBI. The problem is that most radiologists in the United States have decided they do not want to be involved in TBI cases. Why do I say this and what does it mean? Let me explain:
 

1. The most common method of brain injury in the world arising from trauma is called Diffuse Axonal Injury (DAI), this occurs when the brain is subjected to rapid acceleration or deceleration though a high speed motor vehicle accident, for example. We now know that DAI can and does occur in the full spectrum of TBI – from mild to severe. However, the fact that DAI occurs in mild to moderate TBI is a fairly recent finding and many radiologist were not trained to know this.
 

2. Radiologist, like other physicians, are suppose to attempt to identify the illness or cause of illness, through a process known as “differential diagnosis.” This is done by ruling out different possible causes of say an abnormality shown in the brain on MRI, until a proven cause can be found.
 

3. The problem arises when identifying an abnormality on brain MRI known as “white matter hyperintensities” (WMH). These small white areas on an MRI are what damage due to DAI looks like, but there are numerous other non-traumatic causes for WMH. These include: the aging process (starting at 45 to 50); smoking; high blood pressure; Lymes disease; Lupus; vasculitis; migraines, headaches, some mental disorders; and MS.
 

4. The problem is that currently a radiologist will identify WMH on an MRI following a patient’s trauma but will describe the findings as “non-specific.” That means that there are many causes for the abnormality – not that there is no abnormality. Sometimes following this statement the radiologist will give a short list of possible causes, most commonly “demyelinating disease” (MS), migraine, or ischemic disease (vascular degeneration). But what they will generally not say is that another possibility is trauma.
 

5. It is therefore imperative that someone who has suffered a TBI and has ongoing symptoms for more than six months to be certain that the brain MRI is not showing an undiagnosed TBI. How do you do this? Certainly if a person is under the age of 45, and has no history of the above conditions, than trauma should be suspected. A comprehensive blood test can be ordered which can help rule in or rule out certain autoimmune diseases, Lyme disease, Lupus, and other possible causes.
 

6. It is also important for your treating physician to talk to you about where these WMH’s are in your MRI. Location is vitally important in determining the cause of WMH. If they are described as being located in the “deep white matter” then they are less likely to be caused by trauma than by one of the above conditions. However, if they are located at the gray-white junction, than trauma should be suspected. Brain injury occurs in this region due to the differential indensity between the gray matter (which is like the thick skin of a grapefruit) and the white matter, which are the long fibers that connect different areas of the brain together (the inside of the grapefruit). Because of this differential, when the brain is twisted or shaken the white matter often shows damage close to this area. In fact, a recent study in China of over 700 healthy 60 to 64-year olds showed zero WMH within four millimeters of the gray white junction. We can therefore infer that following a trauma, abnormalities found in this region are due to trauma. Even if 10% of the WMH are in this area, it would be consistent with trauma. Be aware that your treating radiologist and/or lawyer will not be aware of this information.
 

What can be done? A film can be reread by another radiologist. A better scan of the brain can be obtained. By this I mean an MRI that has a 3.0 teslor magnet instead of a 1.5. an MRI that includes Susceptibility Weighted Imaging (SWI), as well Diffuse Tensor Imaging (DTI). SWI can identify tiny microhemorrhages in the brain which not coincidently, look like WMH. Survivors of severe brain trauma can have hundreds of these microhemorrhages show up on SWI, whereas zero or only a few show up on standard MRI. DTI looks at white matter injury and a description of DTI can be found elsewhere on the website.
 

The single most important thing in brain injury litigation is objectification of injury. Once there is a picture of damage to the brain, the tables are turned on the insurance company. They can no longer call the victim crazy, a liar, a drug addict so easily. A picture is indeed worth a thousand words.

Sports Injury: Return to Play (RTP)

In the last ten years it has become clear that high school, and even junior high school, sports such as football, soccer and lacrosse pose a danger of acute or chronic brain injuries. The autopsies of football players as young as 16 years-old have shown evidence of CTE (Chronic Traumatic Encephalopathy).
 

CTE is caused by repeated subconsussive trauma to the brain from physical contact. The repeated trauma creates tangles and plaques in the brain which are similar to those found in Alzheimer’s patients. Not everyone, of course, develops CTE. It is not yet proven but it is suspected that genetic and other traits can make individuals more or less susceptible to developing CTE.
 

While CTE development is a chronic condition that may or may not include an event involving a concussion, the most common danger involves an athlete being returned to play while suffering from a previous concussion. The increasingly complicated and delicate question of “Return to Play” (RTP) is an issue which is still being fully developed. It has been shown that athletes and others who suffer a second concussion while still symptomatic from an earlier concussion, can develop serious and permanent brain injury. There is also evidence that physical exertion immediately following a concussion can lead to amplification of concussion symptoms and an incomplete recovery. Fortunately, most high schools in the United States now employee trainers who have undergone specialized education in dealing with and identifying athletes with concussions and how to deal with these. Yet – problems continue for the following reasons:
 

1. There is an immense amount of peer pressure from teammates, friends and parents on an athlete to perform and continue to play.
 

2. The pressure of year round training and year round leagues, some connected with the hope of college scholarships, adds to the pressure as well as the amount of trauma received per year.
 

3. Athletes can be uncooperative in a school’s attempt to get a “baseline” function (see below).
 

4. Trainers and coaches are under their own set of pressures to win games and showcase talented individuals on the playing field.
 

One of the new tools used by schools is called ImPACT testing. This test of motor and cognitive skills was developed by neuropsychologist and neurologist with a great deal of experience in sports injuries. The ImPACT test is given very widely, but parents should keep in mind the following:
 

1. There should be a “baseline” ImPACT test before the season starts. That way, following a possible concussion, the student can be retested to see if there are deficits in cognitive or motor abilities.
 

2. Be aware that athletes can often attempt to “dog” the test and achieve a low baseline score, which in effect will keep them in the game even if they have a mild concussion. Review the ImPACT test with your child’s trainer or at least educate yourself on the scoring. There are indications on the testing as to whether or not full effort was given by the student. If there is any question about the validity of your child’s baseline score – ask the trainer to retest the student.
 

3. Sometimes it’s up to the moms. It is not uncommon for the father of an athlete to be more likely to agree to let the athlete return to play. If either parent has any questions about their child’s return to play, friends of the student as well as boyfriends or girlfriends, should be questioned. The student may be more likely to describe symptoms such as headache, dizziness or foggy thinking to friends than to parents or coaches.
 

4. Another precaution would be to perform the “gaze nystagmus” test on the student who might have suffered a concussion. This test is also performed by doctors and trainers when appropriate. You simply have the student follow the tip of a pencil with their eyes back and forth, looking for jerking movements of the eyeball at the left and right extremes. The more the jerking occurs, away from the extremes, the more likely there may be a problem. Be aware that some drugs and alcohol can cause this symptom as well.

Training Your Immune System

It has become well known that our brains are not a fixed and static blob of material that we are born with. To the contrary, our brains are constantly changing, a notion called plasticity. For Example, the idea of “making a lawyer out of a student” after three years of a specific type of cognitive bombardment turns out to be truer than expected. Every occupation and lifestyle results in the building of a particular type of brain, which can physically change if the environment and stimulus changes.
 

It was never thought that a human could, without drugs, alter in any significant way their own immune system. The immune systems change, get stronger or weaker, depending on the health and genetics of an individual. However, a Dutchman by the name of Wim Hof, also known as “The Iceman” has changed this idea completely. For years he has been known as a person who, through meditation, breathing methods and exposure, is able to withstand far lower painful temperatures than any other human. At a University in the Netherlands, his methods were put to analytical science. They found that his system of resistance involved his ability to consciously raise the level of adrenaline in his blood stream. Twelve healthy volunteers were trained in Hof’s techniques. When the blood levels of adrenaline in the trained volunteers was measured, it was significantly higher than controls. These people were also increasingly able to withstand cold temperatures like their teacher does.
 

Skeptics, which were almost universal, now have to come to grips with our ability to alter our own immune systems through practice, meditation, and concentration. This is an exciting breakthrough which may lead to additional non evasive, therapeutic types of training which could, for example, make patients less susceptible to the pain of a chronic disease, the distraction of pain, and increases in infectious responses during illness.
 

In a related, but very different experiment, a lungfish from Africa was taken out of its normal environment to see if that would have an effect on its biology. Lungfish can live for some time out of water and can “walk” across dry land, usually to get from lake to lake. Scientist asked the question if a lungfish spends most of its life out of water and just a small percentage in water (reversed life style) whether this would have any effect on the biology of the lungfish. They found out that the lungfish, which stayed out on land the longest, had changes in their biology that allowed them to “walk” more efficiently than other lungfish. This is yet another exciting part of the “plasticity revolution” that is going through all of the biological sciences. We can change our brains, our bodies, and our immune systems and that is very exciting.

Advances in Sleep Science

A study published this year opens up some profound doors in explaining the relationship between sleep and the brain. Until now, the actual physiological reason for sleep in humans was not known. People assumed it was to rest the body or to rest the mind. Research showed both of these to be incorrect. Yet we know that humans can die if kept awake for more than a week without sleep. Why?
 
The recent study showed that during sleep the cerebral spinal fluid that surrounds the brain and spinal cord is cleaned. This cleansing and rejuvenation of this very important fluid does not occur if sleep is prevented or is profoundly disrupted. This will open up whole new worlds of speculation in research – do sleep problems cause psychiatric problems because of this mechanism? What are the ramifications of failure to fully cleanse the fluid because of disrupted sleep.
 
Sleep research has been hindered through the years by a couple of things. First, when a human subject is asleep there is no obvious method of communication. Also, the reliability of reporting on what is happening during sleep by the sleeper himself is froth with problems. Secondly, the early research on the stages of sleep as recorded by brain EEG (Alpha, beta, REM sleep, etc) has been ingrained in physicians and researchers. Problems or difficulties which occur outside of these known parameters were dismissed as psychiatric. For example, a small group of person that suffer from a sleep disorder whereby they feel as if they have not sleep at all, but in sleep labs all of the known tests show that they are “sleeping like a baby.” By going beyond the standard tests, the scientists finally determined that these individuals have unusually high alpha waves firing during sleep. Alpha waves are those which occur primarily during active waking hours. Now they can try to solve the problem, instead of ignoring it.
 
Persons that suffer from TBI very commonly have disruptive sleep and other sleep problems. It is highly recommended for TBI victims to go to a sleep lab and see if there is something there that could be corrected, if the problem is known. The problem with a TBI victim living with a sleep disorder, is that the sleep disorder will give rise to worsening of cognitive and psychiatric problems, already at hand, because of the initial brain injury. We know that sleep disruption causes a decrease in the neurogenesis of new memory brain cells in the hippocampus. We now, see above, know that disruptive sleep results in the incomplete cleaning of the cerebral spinal fluid. Sleep apnea has shown to shorten the human life span and cause cognitive deficits. If you have any questions about sleep affecting your present condition, by all means go get it checked out.

TBI AND “THE UNCANNY VALLEY”

In 1970, a Japanese robotics expert, Masahiro Mori, coined the term “The Uncanny Valley.” What he was describing was how humans interacted with and felt about robots. When robots looked very little like a real human being, the viewers emotional response was increasingly positive as they moved toward humans. However, when a robot looked, say 80% human, the negative emotional response poured in and viewers felt that these “near human” robots were creepy and scary. The chart that describe Mori’s term is often used to describe why we find zombies so horrifying.
 
Unfortunately, some of the negative aspects of the “Uncanny Valley” can occur in the context of TBI. Consider, for example, the difference between our response to a person in a wheelchair and a person who is walking with an extreme limp. Mori, and others who have researched this phenomenon, suggest that persons who appear human, but are physically or neurologically impaired in some way, trigger a response in the viewer which says “that person is pathological or sick.” This also may account for the negative feelings that arise when a TBI victim is 70% or 80% of the pre-accident person, but has frontal lobe injuries that have changed the personality and cognitive functioning. The most common description, in my experience with TBI, from a spouse of a TBI victim is “that’s not the person I married.”
 
Studies using functional MRI have verified these emotional responses in the human brain – whereby as what is being viewed becomes more and more human, the emotions fall off the cliff at a certain point near fully human. Hopefully, our future research can find ways around this ingrained human response so that TBI victims do not have to deal with it. In the meantime, it needs to be taken into account as one of the problems to be faced on a daily basis by victims of TBI.

Big Brain Project

Researchers in Germany and Canada have produced a new map of the human brain which is considered to be fifty (50) times as detailed as the best previous effort. A human brain was sliced into 7400 sections and photographed at the microscopic level.
 

This is not the same as the brain initiative from the Obama administration, which seeks to show the connectivity of the brain and the expression of genes. However, this massive new exemplar of the brain will be significant in the following ways:
 

• It will give researchers additional information as to where to look in smaller regions of the brain for specific deficits, especially those found in TBI.
• New relationships between different parts of the brain inner-connectivity will be established.
• These anatomical breakthroughs will be able to be matched up with functional information (which parts of the brain light up during different activities on functional MRI).
• New structures can be found.
 

The increasingly minute looks we can now have at the human brain are getting us ever closer to seeing the often “invisible” cellular damage suffered after so called “mild TBI.”

VA Acknowledges Dementia and Parkinson’s After TBI

A new proposed rule by the Veterans Affairs Department issued in late 2012, changes the service connection of illnesses after service related TBI. A recent report from the National Academy of Sciences entitled “Gulf War and Health,” Volume 7: Long-term Consequences of Traumatic Brain Injury Showed the Association Between TBI and Five Diagnosable Illnesses. Parkinson’s, Pre-senile dementia of the Alzheimer’s type, and post traumatic dementia. They noted “reported cases showed that individuals with TBI often are diagnosed with dementia at ages younger than their early 50’s and within fifteen years of their injuries.”
 

Therefore the changes are to make it easier for Veterans to obtain medical benefits and disability following a moderate to severe TBI in the following instances:
 

1. Parkinsonism following moderate or severe TBI.
2. Unprovoked seizures following moderate or severe TBI.
3. Dementia within fifteen years of moderate or severe TBI.
4. Depression if manifest within three years of moderate or within twelve months of mild TBI.
5. Diseases of hormone deficiencies that result from changes within twelve months of moderate or severe TBI.
 

This goes to show that medical sciences now establishing that TBI is a chronic disease and not a static injury. Societal changes regarding this fact will take time but will represent an important shift in the way our society views this prevalent injury.
 

Food Therapy for TBI

Most neurologists agree that the omega acids in fish oil are beneficial to the brain. Therefore, I would recommend that all TBI victims try to include that in their everyday supplements. However, there is also a new and more organic option available, Purslane.
 

Purslane is a common succulent vine that grows plentifully and easily in most climates. Astonishingly, purslane has an extraordinarily high level of omega 3 acids, second only to eating fish. All this in a tasty plant. Purslane can be purchased in nurseries, grown in pots, and can be grown easily in one’s backyard.
 

I would recommend for anyone who has suffered a TBI to plant and consume as much purslane as possible on a daily basis. Many recipes for purslane can be found on the internet. It is excellent in salads, stir-fries, or on sandwiches.
 

People that live near a beach or a man-grown swamp can enjoy “Sea Purslane,” which actually picks up a salty flavor from the ocean. A pre-salted snack! Purslane contains more omega-3 fatty acids than any other leafy vegetable plant. Research showed that it contains .01mg/g of EPA, an important omega-3 acid found mostly in fish, some algae and flax seeds, one cup of fresh purslane leaves contains 300 to 400 mg of alpha-linolenics, 90mg of calcium, 561 mg of potassium and lots of vitamin A.
 

“Purslane I Collected Growing at the Seashore. Eaten in a Fish
Sandwich. Delicious!”

 
Purslane is commonly eaten in most parts of the world outside of the United States, especially in Greece, the mid east, Asia and Mexico. It is also used in traditional Chinese medicine – used to treat insect or snake bites, sores, pain from bee stings, diarrhea, hemorrhoids and intestinal bleeding.
 

Purslane is an excellent companion plant, which provides grown cover in a humid micro-climate for nearby plants. Plant some now. Let us know your results.

Gun Violence and the NRA

The following essay of mine was published in the Op-ed pages of the Orlando Sentinel on January 10, 2013. I weight it against the unreasonableness of the NRA:
 
In 1989, in response to the Stockton school shooting, in which five children were killed and 29 were wounded by an assailant with an assault rifle, I wrote a newspaper essay describing the utter stranglehold the NRA had over our politicians and Constitution. Rereading the article today, I am struck not only by the utter lack of progress on gun control in the last twenty-three years, but that things have gotten shockingly worse. I wrote, in part:
 

“If Thomas Jefferson or George Washington could visit the scene of the recent massacre of children in Stockton, Calif., they would likely weep. They would weep not only for the gun-downed children of Vietnamese refugees seeking a sanctuary from war, but also for the Constitution itself.

 

“They could not imagine in their wildest fantasies that the Second Amendment could become as warped and perverted as to immerse their precious country in any bloody sea of AK-47 assault rifles and Uzi machine guns. They would weep to find that, alone among the Western democracies, the United States offers death by gunfire as an everyday occurrence.”

 

“Behind this historical perversion, wrapped in bloodstained flags of deranged patriotism, stands the National Rifle Association.

 
The shocking complacency of our society for twenty-three years is only exceeded by the NRA’s Wayne Lapierres antidote for bullets buzzing as thick as flies – more bullets. The NRA is actively trying to cram loaded and concealed weapons into the last hallowed venues left in our lives – churches, the work place and schools. I am trying to imagine a venue in this country where the NRA would agree that guns are inappropriate. I would venture to say baby cribs, but I remain unsure.
 
What has happened to our politicians in the twenty-three years since Stockton? They are, I feel, collectively suffering from the “Stockholm Syndrome,” a condition whereby prisoners or abductees begin to admire their captures. To say that our politicians at the time of the Stockton massacre were captives of the NRA would be an understatement. But to describe the situation just prior to the Connecticut school shooting is difficult, since the notion of senators and representatives as slaves is such a paradox. I picture them as the captive zombies in the “Walking Dead,” neutered, with nose rings, being led quietly across an apocalyptic landscape.
 
Even our Supreme Court (surprise) in Columbia V. Heller, has given its Constitutional blessing to reasonable gun control legislation. But when even the most tepid whiff of reasonable legislation is brought up, the NRA screeches about the “slippery slope” which ends in black helicopters and UN led house to house searches for guns. This is childish. Horrifically enough, the motivation behind this argument springs not from its member’s fear of criminals, but fear of the U.S. government itself. So, in essence, we are witnessing the most powerful lobby in the country reserving and expanding the rights of those who want the option to use military grade firearms against our current government sometime in the future. What a noble cause. What sort of nightmare have we sleepwalked our way into?
 
The original core of the NRA, the hunters, have been quietly left behind by the NRA as they are an aging and shrinking block of support. This explains the NRA’s two decade pandering to the paranoid right. While all other industrialized democracies in the world have moved toward rational restrictions on guns, far beyond what will or should occur here, we continue to stockpile a cache of almost 400 million weapons because of the fantasies of a fearful minority that these guns will be taken. A deadly snake has swallowed its tail.
 
In the early 1950’s, during the “Red Scare” Senator Joseph McCarthy similarly bullied this country and cowed our politicians. He finally went too far and was publicly called down by Army lawyer Joseph Welch, who said, as McCarthy blindly attacked an accused “You have done enough. Have you no sense of decency, sir, at long last? Have you left no sense of decency?” Similarly, we need to demand decency and true citizenship from the NRA. Our zombies/politicians needed a ____ slap in the face. If the deaths of these children won’t’ wake them up out of graveling serfdom to the NRA, nothing ever will. Let’s at long last be adults about this – no one is going to break down gun owners doors and hysteria over reasonable restrictions should be treated for what it is – selfish, unthinking and unpatriotic.

This Story was Written by a Client who Suffered a Severe TBI During a Car Accident

 

Let’s start with my name, it is Michael Jason Saranko, but most people call me Mike. At the present time, I am a full time student at Hillsborough Community College, and a proud father of my son Alexander Nathaniel Saranko. From time to time, I often think about what my true goals are in life, and what I hope to accomplish by going to college now, and in the future. I have come to realize that there are differences between what I need to do, and what I want to do. In a few simple words one could say, “I do the things I need to do, to get to where I want to be in life.” Saying that has made a huge difference among the things I have chosen to write about.
 

To begin with, my for most important goal is to ensure my son has everything he would ever need and most of the things he may want, and to ensure his health and happiness. At the same time, I want to maintain a happy and healthy life for myself. In order to do so, one of the goals I want to accomplish would be to graduate from college, then pursue a degree somewhere in the field of law possibly becoming a lawyer. Becoming a lawyer has been a long time goal of mine since I was a child. I can recall times as a child watching my father at the law library studying case law to win, or get out of any lawsuits he may have been involved in. I soon came to realize law is just a bunch of paper work in defending a point of view for whatever reason a person may have. Basically, saying who ever did the most ‘homework’ for their case, and got the best facts usually won. Incidentally, an obstacle I am currently dealing with, and have had to try to overcome happened nearly five years ago on August of 2007. This event happened only two months after I had graduated from high school, and was in the process of moving into my own apartment to begin college. It was a normal day just like any other. Everything was going well as I was driving about to make a left turn to enter a gas station, when out of nowhere my life changed forever as I was involved in a motor vehicle collision in the middle of my turn. My vehicle was only traveling around five miles per hour. As I turned another vehicle ran a red light and plowed into me going nearly sixty miles per hour hitting me on my right passenger side. The impact folded the passenger side of the vehicle onto the driver side. I suffered many injuries including, but not limited to a sub-dural hematoma, a right collapsed lung, and two fractures in my top two vertebra. I was very lucky to have survived, seeing how the top two vertebras I fractured controlled my breathing, and motor functions. Shortly after the collision, a homicide crew came to investigate my wreck as if I was not going to survive. The result, lead to me being in a coma for around eight days before I awoke to the worst head-aches anyone could ever imagine as my brain swelling receded. I awoke not knowing that this whole experience would change my life forever, but I soon realized as time progressed that it did. This experience to date would be one of the most difficult points in my life I have had to overcome. Many people have said to me that the person I was before my wreck, and the person I was when I awoke were two different people, but sadly more for the worst than the best. Around thirty days after staying in the hospital I was released, having to wear a neck brace for the following five months. I have had to overcome a great deal having to cope with the great strain of a brain injury that left me with seventy eight micro-mili-meters of hemorrhages throughout my brain. Basically, saying that seventy eight micro-mili-meters of my brain was damaged beyond repair, and I had to re-learn what I had lost. From this point on, some aspects of my life changed forever. However, the real long term goals I have always had since the beginning have not changed, but have become harder to achieve.
 

Another goal I have always had is to become a private pilot. Not to work as a pilot, but to fly myself, and friends from place to place. The year prior to my collision I was attending flight lessons at a nearby airport. But unfortunately, after my collision I lost all ambition to fly, for fear that I would not be able to perform my duties as a pilot. As time progressed, I have been able to overcome that fear. Currently, I have started flight lessons again taking one per week. As the years passed following my collision I lost all interest on the important things I needed to do in life to get to where I want to be in life. Mostly in the years following my collision I was in a care free phase in my life, because school was too hard, and focusing on anything was too difficult for me. It wasn’t until August of 2010 when my son was born I had realized I was taking things for granted I shouldn’t have, but also gave up on things I should have tried harder to achieve. My son has given me “that spark” I had lost since the motor vehicle collision I was involved in. I thank God for blessing me with my son; he is the fuel for mostly everything I do.
 

Overall, life is full of up and downs. No one should ever lose sight of the true things in life they want and desire. If you fall get back up, and push harder. My goals in life are to do good in college and someday possibly become a lawyer. While at the same time, being the best father I can be in every way possible. In the meantime, I am taking flight lessons to someday become my own private pilot. Everyone has dreams, no one should ever lose sight of them. In my view, life is about finding happiness in what I do, and fulfilling my dreams. Life is too short to stress over the small things. I try to enjoy every day as it could be my last, keeping my head up and moving forward in this dream I like to call life.

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