Traumatic Brain Injury Attorneys - TBI
Common Testing: Will it Help With TBI Diagnosis?
Diagnostic workup of individuals sustaining
traumatic brain injury has evolved dramatically in certain areas
(neuro-radiology being the foremost) and yet has remained extremely
static in other areas (standard neurological examination).
Family members, as well as victims, often learn of
various tests purportedly administered following traumatic brain
injury. Whether the tests were administered in a given case, and
whether positive results were found, may not conclusively establish,
nor rule out, the existence of brain injury. Nonetheless, brief
description of common tests follows:
the clinical neurological examination is the least effective test for
all but the most severe cases of traumatic brain injury. The usual
clinical approach to the study of brain function is the neurological
examination. This includes a study of an individual´s "behavior" which
comprises responses and motor patterns.
The neurologist examines an individual´s reactivity,
his/her strength, the appropriateness of the individual´s reaction to
commands, questions, and other inquiries, and challenges to muscle
groups. The neurologist examines the body, in general, looking for
evidence of brain dysfunction that maybe evidenced through atrophied
muscles, or due eye or retina deformation. When looking at behavior,
the neurologist looks at patterns in gross terms. In short, if the
neurologist can´t "see it", or "feel it", the conclusion is often
reached that "it does not exist".
One need not be an expert in traumatic brain injury
to understand the extremely limited benefit of a standard neurological
examination in cases involving mild to moderate traumatic brain injury.
In fact, most individuals sustaining mild to moderate traumatic brain
injury have virtually normal findings on clinical neurological exam.
The Glasgow Coma Scale is also used to rate coma victims, and an
individual´s response, or lack thereof, may correlate, especially in
severe cases, to cognitive deficits. Where the patient´s consciousness
has been compromised, the Glasgow coma scale has proved effective for
determining severity of injury. As indicated earlier, however, problems
can arise where the victim is found to be under the influence of either
pain medication or alcohol at the time of administration of the test.
Glasgow Coma Scale Response Chart
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Opens eyes normally
Opens to loud voice command
Opens eyes to pain
Does not open eyes
Best Motor Response
Follows simple commands
Pulls examiners hand away on painful stimuli (localizes source)
Pulls a part of body away on painful stimuli (withdraws)
Flexes body inappropriately to pain(abnormal flexion)
When evaluating injury severity, a GCS range of 3 to
8 is considered severe, 9 to 12 is moderate and 13 to 15 is mild. Coma
has been defined as occurring when the GCS is equal to or less than 8.
Severity Classification GCS
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13 or above
less than 20 min.
9 - 12
within 6 hours
8 or less
greater than 6 hours
As indicated above, the GCS creates a score on a
continuum ranging from a minimum of three to a maximum of 15 points.
Presumably, an individual can have a mild traumatic brain injury and
yet still score 15 on the GCS. This is why the American Congress of
Rehabilitative Medicines definition of mild traumatic brain injury
allows for a GCS of 13 to 15. The GCS has been criticized by many,
therefore, is having much more efficacy in the diagnosis of moderate to
severe traumatic brain injury then in the diagnosis of mild traumatic
Studies show that patients with a lower GCS score
show poorer prospects for recovery. This is another important use of
the GCS. Not only is the GCS used to evaluate severity, but it is also
used as a predicting tool to determine outcome. Moreover, it can be
used repeatedly over time as a prognosticating tool.
A complement to the GCS is the Glasgow Outcome Scale
(GOS). The GOS provides five levels for evaluating outcome. The first
is that of death due to brain damage. Generally speaking this will happen 48 hours after injury. The second is persistent vegetative state (PVS). The third is described as severe disability, which implies consciousness though individuals are dependent for daily support. The fourth state is described as moderate disability, which implies that the patient is disabled but is independent. The fifth state is described as good recovery,
which implies a resumption of normal life. Note that the fifth state
does not prognosis a return to the competitive workplace, however.
Criticism of the GOS primarily emanates from its
simplicity. Individuals often cannot be categorized within the five
listed categories. Discussion has occurred over time within the health
care profession of expanding the five categories to eight, but even
with eight listed categories, criticism exists.
While the GCS has been universally accepted as a
standard measure for determining severity of injury in patients whose
consciousness is comprised, it also has some inherent problems.
Mentioned above are problems where the patient has been sedated or
where the patient has been anesthetized or were intubated as a result
of injury. Where any type of medical treatment results in the patient
being unable to talk (such as a tracheotomy), or where the patient is
unable to move limbs as a response to pain, the GCS will obviously be
This scale describes levels of function and is used to evaluate the
progress of a patient and rehabilitative development. Most often, the
"Rancho scale" is used to track improvement, for evaluating potential,
for planning and placement purposes, and to measure outcome and
In essence, the Rancho scale measures eight levels
of cognitive function. The scale was primarily developed for use by
rehabilitation staff, and contemplates a course of improvement
following head trauma. The eight levels of cognitive functioning of the
Rancho scale are as follows:
No response: (such as where the patient is in a deep coma).
Generalized response: (inconsistent reaction and non-purposeful response to stimuli).
Localized Response: inconsistent though specific reaction to stimuli or even following simple commands).
Confused-Agitated: (patient has decreased ability to process information but is in a heightened state of activity).
Confused, Inappropriate, Non-agitated:(patient is able to
respond fairly consistently to simple commands and appears alert,
though with increased complex city of commands a fragmented response is
Confused-Appropriate: (goal-directed behavior is evident but the patient is dependent on assistance).
Automatic-Appropriate: (within the hospital and home
settings the patient is oriented and able to follow a daily routine
with minimal confusion but has shadow recall of activity).
Purposeful and Appropriate: (patient is alert, oriented, recall is intact, and patient is aware of responsive to environment).
Criticism of the Rancho scale is that the scale is not sensitive to
differences in levels of vocational potential and, as above, this scale
implies a similar rate of improvement for different kinds of functions
which may, or may not, be the case in each individual´s recovery.
Clinicians most often use the GOAT to assess more severely or
moderately impaired patients. In essence, this test is a short mental
status examination. It can be repeated as with the GCS. The vast
majority of the questions on this test involve whether the patient is
oriented as to time, place, and person. Two questions deal with
anterograde and retrograde amnesia. The GOAT is used to predict
ultimate recovery in a patient and is also used as an indicator of
level of responsivity.
The measurements obtained using the GOAT questions
dealing with anterograde and retrograde amnesia establishes the
relationship between severity of injury (GCS), and a patient´s
long-term outcome (GOS).
This test was designed for measuring the duration of post traumatic
amnesia and tests memory, demographics, and orientation. Each day, the
patient is tested as to his/her memory and ability to recall and
recollect. When the patient is able to score a perfect score 3 days in
a row, the test is concluded.
Different scales have evolved out of the Oxford Test. Different
scales can be used to determine recovery and duration, thereby charting
improvement on different components of orientation and memory.
Neuropsychological testing is the sine qua non for modern diagnostics
of brain injury. It is proven reliable, accurate, and unlike other
testing and evaluative mechanisms which compare patients with the
so-called "normal person", neuropsychological testing evaluates whether
a particular patient has himself/herself changed.
The rationale for this distinction is easily
enunciated: As an individual grows and matures, s/he develops and
utilizes the most efficient pathways in the brain. When traumatic brain
injury occurs, many times those pathways are severed or unable to
properly transmit or receive information. Methods of learning and
behaving are altered. While this individual may still be within the
normal population range, s/he would surely be outside their individual
Neuropsychological testing allows competent
professionals to reach the conclusion, to a reasonable degree of
scientific probability, that organic brain injury has occurred. It
further allows the professionals to pinpoint areas of deficit, be they
visual/spacial, memory, recall or other. Simply put, neuropsychological
testing is the most important testing most "mild" to "moderate"
traumatic brain injury patients will undergo.
Neuropsychological assessment is a method of
validation, which measures the ability of the nervous system to perform
cognitive functions we minimally need to exist. It measures compromise
of functions against pre-morbid capabilities. Neuropsychologists are
psychologists with specialized training. Neuropsychological assessment
is an interface between science and practice.
A current debate in the field of Neuropsychology
focuses primarily on approach. Many neuropsychologists advocate the
quantitative approach utilizing the so-called "non-flex"
Halstead-Reitan battery of testing. Still others advocate the "flexible
battery" approach. Statistical accuracy is the issue. In a 2000 survey,
it was found that only 15% of the neuropsychologists surveyed used a
fixed battery (the Halstead Reitan or Lurie-Nebraska batteries).
Clearly, there are advantages and disadvantages to
use of either a fixed battery or a flexible battery approach.
Utilization of a non-flex battery can reveal objective data in as much
as it is gathered without subjective influence and all scores are
subjected to the same variables. However a fixed battery does not allow
the clinician the freedom to address specific diagnostic problems. The
flexible battery does give the clinician the opportunity to
individually test and assess for certain problems which may be present
though missed under the non-flex approach.
Irrespective of approach, neuropsychological
assessment is essential to the proper diagnoses and treatment of most
victims of traumatic brain injury. Neuropsychological assessment
batteries are utilized in order to obtain an accurate diagnoses of the
individual (though with the improvement of neuro- imaging, discussed
below, utilization of assessment batteries for diagnostic purposes is
not as important today as it was in the past). Primarily then,
neuropsychological assessment batteries are utilized in order to obtain
and determined a functional assessment of the particular patient.
Numerous formalized batteries have been developed for general use while
others were "personalized" to assess a specific need. There are
literally thousands of tests available to the neuropsychologist
depending upon the issues faced. In essence, it is the incumbent upon
the neuropsychologist to derive a battery that provides for an
examination appropriate to the given patient. Tests that may be
utilized by a neuropsychologist may include, among others, the
Halstead Russell Neuropsychological Evaluation;
Repeatable Cognitive-Perceptual-Motor Battery (Lafayette Clinic Repeatable Neuropsychological Test Battery);
Luri-Nebraska Neuropsychological Battery;
Neuropsychological Assessment Battery;
Kaplan-Baycrest Neurocognitive Assessment;
Wechsler Intelligence Scales;
Peabody Individual Achievement Test;
The Kaufman Brief Intelligence Test;
Wide Range Achievement Test;
Woodcock Johnston Tasks of Cognitive Ability;
Stanford-Binet Intelligence Scale;
Iowa Screening Battery for Mental Decline;
Assessment of Individuals with Cognitive Impairment;
San Diego Neuropsychological Test Battery;
Repeatable Battery for the Assessment of Neuropsychological Status;
Obviously, there are hundreds of additional tests
which may, under the circumstances of an individual case, be utilized
by an appropriate neuropsychologist. Counsel representing individuals
with traumatic brain injury must be familiar with the general tests
given, the test purpose, the test parameters, and the methodology
employed in grading any such test.
Clearly the most exciting area of advancement in the diagnosis of
traumatic brain injury involves neuro imaging. At its most basic, neuro
imaging covers two broad categories: (1) brain structure; and (2) brain
Analyzing brain structure is very different
from analyzing brain function. When looking at brain structure, it is
the anatomy of the brain that is analyzed. In order this point be
understood, were an individual who immediately died be placed in a
scanning device which looks only at brain structure, and lest
significant deterioration of the brain immediately occurred, one could
expect the scan to be read as "normal". (This to be compared to a
devise scanning for brain function which obviously would demonstrate
"no function", thus extremely abnormal).
However, were there to be a trauma to the brain
itself, which trauma caused bleeding within the skull, or contusions to
the brain, or bleeding within the skull cavity, then a devise measuring
brain structure could be expected to show the abnormality, depending on
amount of damage.
Tests analyzing brain function are not nearly as
concerned with the actual structural environment of the brain as much
as they are concerned with brain function it self. We first discuss
those devices or tests which analyze brain structure:
Some of the imaging tests which analyze brain structure include the following:
Computed Tomography (CT);
Magnetic Resonance Imaging (MRI);
Diffusion Tensor Imaging (DTI);
Magnetization Transfer Imaging (MTI);
Magnetic Resonance Spectroscopy (MRS);
Magnetic Source Imaging (MSI);
Given that most individuals are familiar with basic x-ray, discussion herein is limited to the other scanning methods.
introduction in approximately 1973, computed tomography (CAT, or CAT computed axial tomography) has developed quickly. A series of
collimated x-ray beams through the tested body and measurement of the
extent of tissue absorption is made. CT is demonstrative of collections
of blood (hematomas), cerebral contusions (bruises), edema (swelling),
as well as basal skull fractures.
MRI is a diagnostic procedure which examines body tissue by subjecting the
atomic nuclei of the tissues to a magnetic field. The atomic nuclei of
the tissues are stimulated by the field. Bad tissue responds
differently than good.
In recent years, huge advances have occurred with
respect to MRI. Up until approximately 2000, most neuro imaging centers
maintained MRI machines with Tesla field strength 1 to 1.5 magnets. As
of recent, the FDA has approved Tesla field strength 3 magnets for
human use. With the use of Tesla field strength 3 magnets, lesions are
now being seen on MRI that were impossible to detect on the earlier MRI
scanners using lesser field strength magnets. Advancements in software
utilized by the MRI scanners have likewise improved their diagnostic
Where head injury is concerned, Gradient Echo
software has proved extremely valuable. Many teaching institutions are
now experimenting with field strength magnets as high as Tesla 10. It
is expected that with the advances in MRI technology, even extremely
mild traumatic brain injury patients will have demonstratively viewable
abnormality on MRI.
An example of this was capitalized on by the Scarlett Law Group during the case of Rasmussen versus Shade.
Mr. Rasmussen had been rear ended while in stopped traffic in Northern
California. There was less than $500 damage to the rear bumper of Mr.
Rasmussen´s vehicle. Nonetheless, Mr. Rasmussen sustained a traumatic
Following the accident, imaging was done on a T-1
magnet strength MRI scanner in the Sacramento area. The MRI scanner was
read as "normal". Several months later, imaging was again done on the
T-1 scanner. It too was read as "normal".
After contacting the Scarlett Law Group, treating
physicians ordered a repeat MRI, but this time utilizing a T-3 scanner.
Two focal lesions in the anterior and posterior frontal lobes were
immediately seen. Given the coup/contra coup pattern of the lesions,
and further given their presence at the juncture of the grey/white
matter of the brain, diagnoses of traumatic brain injury was
What is unique about this is that in utilizing the
lesser strength scanner, the lesions were not read on the film.
However, after looking at the T-3 film, and comparing it to the film
derived from the lesser strength MRI scanner, the abnormalities of the
lesions could be vaguely made out. In other words, no one could have
been critical of the earlier readings of the film from the lesser
strength scanners as the lesions were not readily apparent. However,
with the benefit of the T-3 film, the abnormalities could be seen on
the earlier scans though not with the absolute clarity of the T-3 film.
Where head injury is concerned, it is thought that the admission of the T-3 film into evidence in the Rasmussen versus Shade
case is the first time a California court (and jury), has had the
benefit of said technology. It is expected to be the norm in years to
tensor imaging is an MRI application that utilizes the diffusion of
water model molecules for imaging the brain. DTI not only measures the
diffusion of water molecules in a particular direction, but can analyze
by imaging diffusion in as many as six or more directions. This allows
for a three dimensional matrix or calculation of "tensor". Structural
integrity in the white matter of the brain can be measured as water
diffusion is higher along fiber tracks then across them.
Magnetization transfer imaging (MTI) is another technique that
increases the contrast between tissues by exploiting the exchange of
protons between water and macromolecules. A radio frequency pulse
selectively saturates protons that are bound to macromolecules in the
brain. MTI provides information about tissue changes not detected by T1
or T2 MRI. MTI has yet to be extensively used in the area of traumatic
Magnetic Resonance Spectroscopy detects signals from individual solutes
in body tissues thereby offering neuro chemical information about the
brain. MRS is generally used to assess metabolic irregularities
following brain injury. It is based on measuring magnetic signals from
certain nuclei in response to radiofrequency pulses. MRS correlates
well with neuropsychological functioning and functional outcome tests.
source imaging (MSI) utilizes magnetoencephalographic technology to
acquire electrophysiological data from the brain and combine it with
structural data from conventional MRI technology. MSI technology is
new. It holds hope in the diagnoses of mild TBI patients with
Generally speaking, structural imaging is extremely
helpful in cases involving skull fractures as well as hematomas, or
hemorrhages which may occur at a variety of locations in the brain.
Common hematomas include:
Epidural Hematomas - This injury forms
when the brain´s outer covering, or dura, is stripped away from the
skull by blood from lacerated blood vessels or bleeding from a
fracture. The injury generally occurs over the temporoparietal area but
can also occur in the frontal lobes as well as the other areas of the
Subdermal Hematomas - This injury forms
in the space between the dura and brain, often produced by torn veins
on the brain surface and the inside edge of the dura matter. This
injury may develop within the first 24 hours of insult, but and develop
up to two weeks are after insult.
Intracerebral Hematomas - This injury
forms within the substance of the brain and often results from a
laceration. Often occurring in the frontal and temporal lobes, the
injury has also been found in the basal ganglia and cerebellum.
Extradural Hematomas - This injury involves a collection of blood outside the dura between the inter-table of the skull and the dura.
Note that even more damage to the patient can
occur as a result of secondary damage due to the continuous process of
the initial insult. Intracranial pressure caused by ongoing hematomas
can be more damaging than the initial insult to the brain itself. Where
cerebral blood flow is cut off, without relief, death results.
As contrasted with the devices/tests which analyze
brain structure, discussed above, the following are utilized in order
to quantify and measure brain function:
Functional MRI (fMRI);
Positron Emission Tomography (PET);
Single Photon Emission Computed Tomography (SPECT)
Functional MRI is
gaining wide use as a neuro imaging technique for measuring brain
function. The test operates under the assumption that an increase in
neuronal activity results in an increase in local blood flow leading to
reduced concentrations of deoxy- hemoglobin, a product of oxygen
consumption. This concept is widely known as
blood-oxygen-level-dependent (BOLD). fMRI is particularly effective in
moderate to severe TBI as studies of working memory on these patients
suggest bloodflow abnormalities relative to comparison subjects,
particularly in the frontal lobes.
emission tomography uses very short-lived radioactive isotopes of
elements commonly used in brain metabolism (glucose), and then shows an
image which represents not only brain structure but also brain function
(i.e., how the glucose is used). Positron emission tomography shows
that language happens in a parallel array, and that the brain
simultaneously processes in several areas at once as opposed to
serially. In essence, PET is a diagnostic imaging technique for
measuring regional brain metabolism. The clinical uses of PET scanning
include brain injury evaluation; organic brain dysfunction; Parkinson´s
disease; epilepsy lesion location in pre-surgical evaluation;
cerebrovascular disease (stroke) and assessment of recovery;
differential diagnosis of Alzheimer´s disease and other memory
disorder; and differential diagnosis of brain tumor and radiation
treatment. Even where there is no abnormality found on MRI or CT scan,
PET scans have shown abnormality consistent with postconcussive
syndrome and mild TBI. In most jurisdictions, however, the abnormality
found on PET must be correlated with neuropsychological testing before
it becomes admissible in court.
Single photon emission tomography is another generation of cerebral
nuclear scans. It is commonly used for the study of circulation and
perfusion of the brain. It is a computer-an enhanced version of a brain
scan. It produces regional maps of the distribution of
radioactively-labeled tracers in the brain with more resolution than
traditional brain scans but without the cost of PET.
While not conclusive, these tests have provided
validation for neuropsychological assessments and in the setting of the
courtroom may provide the jurors with a picture of the invisible injury.
If you or someone you know has been injured
or suffered Traumatic Brain Injury or TBI,
you need the assistance of The Scarlett Law Group.
today to speak with a California Personal Injury Attorney.
The Scarlett Law Group: Traumatic Brain Injury Lawyers
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