Traumatic Brain injuries, suffered by Florida car accident victims | Lake Worth personal injury Lawyer

Brain Injuries, a lecture on Traumatic Brain Injuries offered by Richard S. Bailyn, M.D.

Perhaps the best way to approach classification of brain injuries with regard to litigation is to divide them into two categories: 1) Obvious, and 2) Subtle. Obvious brain injuries include those that are supported by clear evidence of injury on imaging studies. These injuries may not be within the brain itself, or "intraparen­chymal" (injuries actually within the brain matter), but also include other "intracranial" injuries (typically areas of hemorrhage inside the skull, but not necessarily within the brain tissue).

Intraparenchymal injuries include injuries such as areas of hemorrhage, contusion, or edema within the brain matter. However, in some instances, specific areas of injury may not be seen. Instead, the pathol­ogy can be diffuse. Acute injuries can result in general swelling of the brain that may only be noted in radiology reports by references to decreases in the spaces around the brain (such as "decreased subarach­noid space," "decreased cisterns" and/or "decrease in the normal sulci."

Injuries within the skull, but not within the brain itself are generally areas of hemorrhage or hematoma. These areas of hemorrhage are characterized as being "epidural" (between the inner skull and dura), "subdural" (between the dura and arach­noid meningeal layer), "subarachnoid" (between the arachnoid layer and the brain), or "intraventricular" (within one of the ventricles of the brain).

Injuries in and around the brain are often described as being associated with "mass effect". This descriptor is significant in that it means that the particular injury is significant enough as to affect other adjacent areas ofthe brain. "Mass effect" is frequently evident in the form of decrease in the size of the ventricles adjacent to primary area of injury or "mid-line shift" (meaning that injuries on one side of the brain are so significant that they are compressing the opposite side of the brain.

Mass effect can become so severe that it may cause part of the brain to herniate through the "tentorium" (a tough membranous layer of tissue that is firmly attached to the skull and separates the cerebrum from the cerebellum). This hemiation is typically referred to as a "transtentorial" or "uncal" herniation. This type of herniation is particularly significant because the brain stem in this area is responsible for controlling heart rate and breathing. Compression of this area by the herniated brain tissue may result in death.

In contrast to obvious brain injuries, subtle brain injuries may be described as those that are barely visible or not visible on traditional imaging studies --or those that may be of question­able etiology (perhaps related to something other than the traumatic event in question). These types of injuries are gener­ally referred to as "shear" or "diffuse axonal injury" (although "traumatic" axonal injury is becoming more widely accepted as a better description of these injuries than "diffuse" axonal injury. These types of injuries can occur by simple acceleration and/or deceleration injuries -even without a blow to the head.

Shear injury occurs at the junction of the gray matter (cell bodies) with the white matter (axons). Because these two types of tis­sue are of different consistencies, they move differently during trauma. As a result, the axons are prone to injury in this area. Small blood vessels are also present in these areas. Sometimes, the trauma also results in rupture of one or more of these blood vessels. MRls are able to detect the resulting blood. Even though these areas may be tiny, the presence of even one area supports arguments that thousands ofaxons in the area were likely injured as well.

In some situations, axonal injuries can occur without evidence of lesions on MRls, because the blood vessels in this area are much larger and more resilient than the axons. Therefore, during trauma, multiple axons can become torn or injured without injury to a single blood vessel. Because no blood vessels are torn, there is no hemorrhage detectable on MRI. In instances like this, proof of brain injury must focus on the resulting neurological deficits. These deficits must be correlated with the area of the brain that controls those functions, as well as explaining how the forces of trauma affected that specific area of the brain.