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I Got Hit in the Head. Now What?
Traumatic brain injury or “TBI” is one of the most frightening injuries to suffer. Our very existence, the “I am” part of philosopher Rene Descartes’ famous observation “I think, therefore I am” vanishes if we are no longer able to think due to an injury. The sum of all that makes up our human conscious existence is located in our brain, an organ of immense complexity. Theoretical neuroscientist Kenneth D. Miller described the staggering complexity of our brain in a New York Times article, explaining, “Neurons are the cells in the brain that electrically carry information: Their electrical activity somehow amounts to your seeing, hearing, thinking, acting and all the rest. Each neuron sends a highly branched wire, or axon, out to connect or electrically “talk” to other neurons. The specialized connecting points between neurons are called synapses. Memories are commonly thought to be largely stored in the patterns of synaptic connections between neurons, which in turn shape the electrical activities of the neurons.”[1] Another New York Times’ article reporting on Sebastian Seung’s attempt to create an atlas of the human brain, noted, “A typical human neuron has thousands of connections; a neuron can be as narrow as one ten-thousandth of a millimeter and yet stretch from one side the head to the other.”[2] In the United States, traumatic brain injuries take a terrible toll on those injured, their families, their friends, our communities, and on our scarce healthcare resources and Nation as a whole.
The number of persons who suffer a traumatic brain injury each year is alarmingly high. According to a surveillance by the Centers for Disease Control and Prevention (CDC)[3] , in 2014 approximately 2.53 million people in the United States went to an emergency department for a traumatic brain related injury, including 812,000 children. There were approximately 288,000 traumatic brain injury related hospitalizations, including over 23,000 children, and 56,800 traumatic brain injury related deaths, including 2,529 involving children. Falls, being struck by or against an object, motor vehicle crashes, blows or blasts to the head from sports or combat are the leading causes of traumatic brain injury.[4]
According to a CDC report to Congress, approximately 16 percent of all injury hospitalizations and one-third of injury deaths involved a traumatic brain injury.[5] Costs are huge. According to the American Association of Neurological Surgeons, the direct and indirect costs of treating traumatic brain injuries are $76.5 billion annually.[6]
What is a traumatic brain injury?
According to the CDC, it is “a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head or a penetrating head injury…Explosive blasts can also cause TBI, particularly among those who serve in the U.S. military. Observing one of the following clinical signs constitutes an alteration in brain function…:
- Any period of loss of or decreased consciousness;
- Any loss of memory for events immediately before (retrograde amnesia) or after the injury (post-traumatic amnesia);
- Neurologic deficits such as muscle weakness, loss of balance and coordination, disruption of vision, change in speech and language, or sensory loss;
- Any alteration in mental state at the time of the injury such as confusion, disorientation, slowed thinking, or difficulty with concentration.”[7]
Experiencing a blow or rapid frontward/backward movement to the head coupled with signs and symptoms of brain injury either immediately or shortly after the trauma “—is sufficient to classify a person as having sustained a TBI…”[8]
What happens to the brain that causes injury?
Traumatic brain injury occurs in two ways: by something penetrating the skull, e.g., a bullet or by movement of the brain inside the skull due to an outside force, e.g., a car crash, fall, blow or blast.[9] A non-penetrating injury is called a “closed head” injury. Brain damage can be confined to a specific area of the brain (“focal injury”) or involve many areas (“diffuse injury”). Immediate injury involves bruising, stretching, tearing and bleeding of brain tissue. The injured tissue in turns causes inflammation, chemical changes and swelling. The most common injury is to the brain’s white matter, which is composed of bundles of nerve fibers individually known as neurons. These nerve fibers form pathways over which the different parts of the brain communicate. In a traffic collision, for example, shearing forces from sudden twisting or back and forth motion of the head bruise, stretch and tear these nerve bundles. If enough of these nerves are damaged and can no longer carry messages to other parts of the brain, our ability to think, speak, see, hear, act and remember events is impaired.[10]
The severity of TBI is commonly classified as mild, moderate, or severe on the basis of clinical presentation of a patient’s neurologic signs and symptoms.[11]
The symptoms of TBI vary individually and although some symptoms might resolve completely, others, especially because of moderate and severe brain injuries, can result in symptoms that persist, resulting in partial or permanent disability. “Wide variations in the clinical manifestations of TBI are attributable to the complexity of the brain, and to the pattern and extent of damage, which depend on type, intensity, direction, and duration of the external forces that cause TBI.”[12]
Severe and moderate traumatic brain injuries are usually self-evident while mild traumatic brain injuries, including concussions, require greater awareness to accurately assess. As the CDC notes on its website, concussions are a mild form of traumatic brain injury which need to be taken seriously.[13] “Medical providers may describe a concussion as a “mild” brain injury because concussions are usually not life-threatening. Even so, the effects of a concussion can be serious.” Mild traumatic brain injury or concussion “can lead to persistent physical, neuropsychiatric, and cognitive symptoms that have a major impact on function and quality of life of the injured patient”.[14]
Studies have shown an association between the occurrence of concussion and emotional disturbances and with an increased risk of diagnosis of attention-deficit hyperactivity disorder (ADHD), mood and anxiety disorders (MADs), dementia and Parkinson’s disease later in life.[15] The Lancet Commission on dementia prevention recently added traumatic brain injury as a risk factor for dementia as have other studies.[16]
Mild traumatic brain injury, or concussions “can cause a headache or neck pain, nausea, ringing in the ears, dizziness, and tiredness. People with a moderate or severe TBI may have those, plus other symptoms, including: A headache that gets worse or does not go away; Repeated vomiting or nausea; Convulsions or seizures; Inability to awaken from sleep; Slurred speech; Weakness or numbness in the arms and legs and Dilated eye pupils”[17] 80 percent of all traumatic brain injuries are categorized as mild head injuries.[18] Traumatic brain injury, including concussions, are often called a “silent epidemic” because the injured person often appears physically healthy.[19] “It is estimated that 15 percent of individuals will continue to report persistent symptoms for more than 3 months post concussion. Symptoms may persist for months to years post injury and may be permanent in some cases. mTBI can result in a wide range of physical, cognitive, psychological and social impairments that affect a person’s ability to recover post injury and resume life roles and activities of daily living, such as return to play or work.”[20] Another study found patients with mild traumatic brain injury seeking help at major hospitals “commonly report difficulties in aspects of day-to-day functioning to at least 12 months post injury, especially with TBI-related symptoms and interpersonal functioning, suggesting that this injury is not always benign.”[21] Yet another scientific paper found “recent studies revealed that patients develop depression, anxiety, and fear years after injury, which greatly contributed to a decreased quality of life.”[22]
Twenty-five percent of all mild traumatic brain injury patients have what is known as post-concussive symptoms “or other cognitive deficits that persist beyond 1 year …. This number is greater than the annual incidence of multiple sclerosis, Parkinson’s disease, myasthenia gravis, and Huntington’s disease combined.”[23] According to the Mayo Clinic, people can develop post-concussion syndrome even if they never lost consciousness.[24] Symptoms commonly include “headache, depression, difficulty concentrating, and fatigue.”[25] Although most people improve with time, some people do not recover, “leading to potentially prolonged suffering, impaired quality of life, and increased risk of post-traumatic” aftereffects.[26] They are sometimes referred to as the “miserable minority” or “walking wounded”.[27] One alarming study found that “that no patient recovered who had [post-concussive syndrome] lasting 3 years or longer. Only 27 percent of our population eventually recovered and 67 percent of those who recovered did so within the first year. The finding that PCS may be permanent if it lasts longer than 3 years suggests that it may be critical to treat PCS appropriately in the early stages.”[28] Thus the classification of “mild” should not be mistaken as a descriptive for the human damage suffered by the victim. “What is becoming clear though, is that “mild” is indeed a misnomer for this disease, because many patients experience significant and persistent symptoms. For these patients, mTBI is anything but mild.”[29]
Traumatic brain injury can cause a wide range of health problems, including “short- or long-term changes affecting thinking, sensation, language, or emotions.
- Thinking (i.e., memory and reasoning);
- Sensation (i.e., touch, taste, and smell);
- Language (i.e., communication, expression, and understanding); and
- Emotion (i.e., depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).”[30]
As noted, in addition to mental health problems, mild traumatic brain injury, “carries increased risk of developing epilepsy and neurodegenerative disorders, such as Alzheimer’s disease, Parkinson’s disease, and chronic traumatic encephalopathy.”[31] Repeated concussions within hours, days or weeks “can be catastrophic or fatal.”[32]
Effective treatment of TBI requires “immediate assessment by a professional who has experience evaluating head injuries. A neurological exam will assess motor and sensory skills and the functioning of one or more cranial nerves. It will also test hearing and speech, coordination and balance, mental status, and changes in mood or behavior, among other abilities.” Emergency room imaging typically involves Computed tomography or CT scans and Magnetic resonance imaging (MRI).[33] Even with mild brain injuries, CT abnormalities are in fact not uncommon with one study finding 16.1 percent of patients with mild brain injury had an intracranial lesion (subdural hematomas, subarachnoid hemorrhages, and contusions). Severe, moderate and even some mild traumatic brain injury may require surgery and hospitalization.[34]
Milder traumatic brain injury is more difficult to detect, as the brain injury is subtler and beyond the range of standard imaging technology. Unlike moderate or severe TBI, milder TBI may not involve obvious signs of damage (hematomas, skull fracture, or contusion) that can be identified with current neuroimaging. Instead, much of what is believed to occur to the brain following mild TBI happens at the cellular level. Significant advances have been made in the last decade to image milder TBI damage. For example, diffusion tensor imaging (DTI) can image white matter tracts, more sensitive tests like fluid-attenuated inversion recovery (FLAIR) can detect small areas of damage, and susceptibility-weighted imaging very sensitively identifies bleeding.[35]
Successful treatment of TBI requires an interdisciplinary team approach involving numerous professionals, including: a Physiatrist, a doctor trained in physical medicine and rehabilitation, an Occupational therapist, a Physical therapist, a Speech and language pathologist, a Neuropsychologist, a Social worker or case manager, a Rehabilitation nurse, a Traumatic brain injury nurse specialist, Recreational therapist, who assists with time management and leisure activities, and a Vocational counselor.[36]
So, who pays for all this costly medical care? You do, unless you have health insurance, and even then your ability to optimize your treatment may be limited by HMO, PPO and other insurer restrictions and reluctance to pay for medical services. Government funded services are inadequate and unless you are independently wealthy, a traumatic brain injury not only threatens your personal existence, it threatens your financial existence as well. California law provides that everyone is responsible for injury caused by their failure to use ordinary care (negligence) and further provides, “a system under which liability for damage will be borne by those whose negligence caused it in direct proportion to their respective fault.” Li v. Yellow Cab Co. (1975) 13 Cal.3d 804, 813. Thus each person, corporation or other “entity” can be made to pay damages for your injuries even if they are only 1 percent at fault and even if you are also partially to blame.
Thus, in the event your traumatic brain injury is due to the carelessness or fault of another person or corporation, you will need to add an experienced trial lawyer knowledgeable and experienced in traumatic brain injury litigation to your recovery team. As the medical issues are extremely complex and the damages and potential recovery large, defendants, their insurance companies, attorneys and cooperative experts will invest what ever it takes to escape responsibility. Thus, you will need not only a knowledgeable and experienced attorney, you will need an attorney with the financial ability to successfully pursue your claim through trial if necessary. Be thoughtful and wise in your choice.
Thomas Cecil is a personal injury lawyer with over 30 years’ experience.
Additional Resources:
National Institute of Neurological Disorders and Stroke
NINDS Traumatic Brain Injury Information Page
https://www.ninds.nih.gov/Disorders/All-Disorders/Traumatic-Brain-Injury-Information-Page
Centers for Disease Control and Prevention (CDC)
U.S. Department of Health and Human Services
Basic Information about Traumatic Brain Injury and Concussion
http://www.cdc.gov/traumaticbraininjury/basics.html
Resources for Health Care Providers
http://www.cdc.gov/traumaticbraininjury/providers.html
Heads Up
http://www.cdc.gov/headsup/index.html
Concussion Danger Signs
http://www.cdc.gov/headsup/basics/concussion_danger_signs.html
Injury Prevention & Control: Traumatic Brain Injury
http://www.cdc.gov/traumaticbraininjury/
Brain Injury Association of California
Resources
http://biacal.org/brain-injury-resources-california.htm
UCLA Steve Tisch BrainSPORT Program
https://www.uclahealth.org/brainsport/
UCLA Steve Tisch Concussion Clinic
https://www.uclahealth.org/brainsport/treatment
Casa Colina
Brain Injury Rehabilitation Center in Southern California
http://www.casacolina.org/A-Center-of-Excellence/Signature-Programs/Brain-Injury.aspx
Centre for Neuro Skills
Mayo Clinic
Traumatic Brain Injury
http://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/basics/treatment/con-20029302
Endnotes:
[1] Will You Ever Be Able to Upload Your Brain? By Kenneth D. Miller, New York Times, Opinion, Oct. 10, 2015 https://www.nytimes.com/2015/10/11/opinion/sunday/will-you-ever-be-able-to-upload-your-brain.html
[2] Sebastian Seung’s Quest to Map the Human Brain, By Gareth Cook, New York Times Magazine, Jan. 8, 2015 https://www.nytimes.com/2015/01/11/magazine/sebastian-seungs-quest-to-map-the-human-brain.html
[3] Centers for Disease Control and Prevention (2019). Surveillance Report of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths—United States, 2014. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. https://www.cdc.gov/traumaticbraininjury/pdf/TBI-Surveillance-Report-FINAL_508.pdf
[4] Traumatic Brain Injury: Hope Through Research National Institute of Neurological Disorders and Stroke, National Institute of Neurological Disorders and Stroke, website at https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Traumatic-Brain-Injury-Hope-Through
[5] Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA, p. 19 https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Report_to_Congress_Epi_and_Rehab-a.pdf
[6] American Association of Neurological Surgeons, Patient Information, Traumatic Brain Injury page, Http://www.aans.org/patient percent20information/conditions percent20and percent20treatments/traumatic percent20brain percent20injury.aspx
[7] Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA. p. 15 https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Report_to_Congress_Epi_and_Rehab-a.pdf
[8] Id.
[9] Traumatic Brain Injury: Hope Through Research, National Institute of Neurological Disorders and Stroke website, https://www.ninds.nih.gov/disorders/patient-caregiver-education/hope-through-research/traumatic-brain-injury-hope-through
[10] Id.
[11] Centers for Disease Control and Prevention. (2014). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA. https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Report_to_Congress_Epi_and_Rehab-a.pdf
[12] Maas AIR, Menon DK, et al., Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017 Dec;16(12):987-1048. doi: 10.1016/S1474-4422(17)30371-X. Epub 2017 Nov 6. PMID: 29122524. P. 989 https://pubmed.ncbi.nlm.nih.gov/29122524/
[13] Centers for Disease Control and Prevention website, Heads Up, What is a Concussion? https://www.cdc.gov/headsup/basics/concussion_whatis.html
[14] Seabury SA, Gaudette É, Goldman DP, et al., Assessment of Follow-up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion: Results From the TRACK-TBI Study. JAMA Netw Open. 2018;1(1):e180210. Published 2018 May 18. doi:10.1001/jamanetworkopen.2018.0210 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324305/
[15] Morissette MP, Prior HJ, et al., Associations between concussion and risk of diagnosis of psychological and neurological disorders: a retrospective population-based cohort study, Family Medicine and Community Health 2020;8:e000390. doi: 10.1136/fmch-2020-000390. https://fmch.bmj.com/content/8/3/e000390
[16] Maas AIR, Menon DK, et al., Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017 Dec;16(12):987-1048. doi: 10.1016/S1474-4422(17)30371-X. Epub 2017 Nov 6. PMID: 29122524. P. 989 https://pubmed.ncbi.nlm.nih.gov/29122524/
[17] Traumatic Brain Injury Also called: Acquired brain injury, TBI, U. S. National Library of Medicine, MedlinePlus, Summary Page, https://www.nlm.nih.gov/medlineplus/traumaticbraininjury.html#cat5
[18] Brain Neurotrauma: Molecular, Neuropsychological, and Rehabilitation Aspects, Kobeissy FH, editor, Boca Raton (FL): CRC Press; 2015, Chapter 4, Pathophysiology of Mild TBI, Implications for Altered Signaling Pathways, Robert A Laskowski, Jennifer A Creed, and Ramesh Raghupathi, http://www.ncbi.nlm.nih.gov/books/NBK299186/
[19] Id.
[20] Shafi R, Crawley AP, Tartaglia MC, et al. Sex-specific differences in resting-state functional connectivity of large-scale networks in postconcussion syndrome. Sci Rep. 2020;10(1):21982. Published 2020 Dec 15. doi:10.1038/s41598-020-77137-4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738671/
[21] Nelson LD, Temkin NR, Dikmen S, et al. Recovery After Mild Traumatic Brain Injury in Patients Presenting to US Level I Trauma Centers: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study [published online ahead of print, 2019 Jun 3] [published correction appears in JAMA Neurol. 2019 Oct 21;:]. JAMA Neurol. 2019;76(9):1049-1059. doi:10.1001/jamaneurol.2019.1313 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6547159/
[22] McCorkle TA, Barson JR, Raghupathi R. A Role for the Amygdala in Impairments of Affective Behaviors Following Mild Traumatic Brain Injury. Front Behav Neurosci. 2021;15:601275. Published 2021 Mar 4. doi:10.3389/fnbeh.2021.601275 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969709/
[23] Bazarian JJ, Blyth B, Mookerjee S, He H, McDermott MP. Sex differences in outcome after mild traumatic brain injury. J Neurotrauma. 2010;27(3):527-539. doi:10.1089/neu.2009.1068 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2867588/
[24] Mayo Clinic website, Persistent post-concussive symptoms (Post-concussion syndrome), https://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/symptoms-causes/syc-20353352
[25] Hiploylee, Carmen et al. “Longitudinal Study of Postconcussion Syndrome: Not Everyone Recovers.” Journal of neurotrauma vol. 34,8 (2017): 1511-1523. doi:10.1089/neu.2016.4677 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5397249/
[26] Tenovuo O, Diaz-Arrastia R, Goldstein LE, Sharp DJ, van der Naalt J, Zasler ND. Assessing the Severity of Traumatic Brain Injury-Time for a Change?. J Clin Med. 2021;10(1):148. Published 2021 Jan 4. doi:10.3390/jcm10010148 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7795933/
[27] Shenton ME, Hamoda HM, Schneiderman JS, et al. A review of magnetic resonance imaging and diffusion tensor imaging findings in mild traumatic brain injury. Brain Imaging Behav. 2012;6(2):137-192. doi:10.1007/s11682-012-9156-5 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3803157/
[28] Hiploylee, Carmen et al. “Longitudinal Study of Postconcussion Syndrome: Not Everyone Recovers.” Journal of neurotrauma vol. 34,8 (2017): 1511-1523. doi:10.1089/neu.2016.4677 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5397249/
[29] McMahon P, Hricik A, Yue JK, et al. Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI study. J Neurotrauma. 2014;31(1):26-33. doi:10.1089/neu.2013.2984 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880097/
[30] Centers for Disease Control and Prevention website, Injury and Prevention Control: Traumatic Brain Injury, What are the Potential Effects of TBI? http://www.cdc.gov/TraumaticBrainInjury/outcomes.html
[31] Verboon LN, Patel HC, Greenhalgh AD. The Immune System’s Role in the Consequences of Mild Traumatic Brain Injury (Concussion). Front Immunol. 2021;12:620698. Published 2021 Feb 15. doi:10.3389/fimmu.2021.620698 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928307/
[32] Centers for Disease Control and Prevention website, Injury and Prevention Control: Traumatic Brain Injury, What are the Potential Effects of TBI? http://www.cdc.gov/TraumaticBrainInjury/outcomes.html
[33] Traumatic Brain Injury: Hope Through Research, National Institute of Neurological Disorders and Stroke, https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Traumatic-Brain-Injury-Hope-Through#:~:text=top-,How%20is%20TBI%20diagnosed%3F,or%20behavior%2C%20among%20other%20abilities
[34] Ganti L, Stead T, Daneshvar Y, et al. GCS 15: when mild TBI isn’t so mild. Neurol Res Pract. 2019;1:6. Published 2019 Feb 28. doi:10.1186/s42466-018-0001-1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7650085/
[35] Nadel J, McNally JS, DiGiorgio A, Grandhi R. Emerging Utility of Applied Magnetic Resonance Imaging in the Management of Traumatic Brain Injury. Med Sci (Basel). 2021;9(1):10. Published 2021 Feb 14. doi:10.3390/medsci9010010 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930990/
[36] Mayo Clinic, Diseases and Conditions, Traumatic Brain Injury, Treatments and Drugs, http://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/basics/treatment/con-20029302