California TBI - Traumatic Brain Injury Attorneys
Moderate to Severe Traumatic Brain Injury
Those who sustain concussion, hemorrhage,
significant loss of consciousness, coma, and/or skull fractures are
typically diagnosed as having sustained a "moderate" to "severe"
traumatic brain injury.
this nature are generally detectable on CT, MRI, and other imaging
devices. In many instances, the patient´s very survival is an issue.
Brain swelling, contusion and edema are likely complications. In
virtually all cases, quality of life is a premier end goal.
The resulting impairments suffered by the "moderate" to "severe"
traumatic brain injury victim can generally be related to the original
insult, although in case after case insurance companies and their
lawyers contest these relationships. Physical consequences of
"moderate" to "severe" traumatic brain injury are diverse and vary from
patient to patient. They may include: paralysis, sensory losses,
decreased muscle control, including hemipareses, weakness, seizures,
sleep disorders, speech and eating disorders, as well as memory and
Individuals, while in coma, represent the “severe” end of traumatic brain injury. This is not to infer that one need be comatose to be classified as having sustained a “severe” traumatic brain injury, but comatose individuals have clearly sustained a “severe” traumatic brain injury irrespective of its potential transient nature.
Family members of comatose patients are often times left with nothing
but hope, as health care professionals too, must wait as the human
recovery process begins. It is no less important for family members to
seek assistance from support groups during the recovery process.
A multi-disciplinary treatment and rehabilitative approach can be
justified in virtually all cases of “moderate” to “severe” traumatic
A. Moderate Traumatic Brain Injury
Statistically, between 8% - 10% of all traumatic
brain injuries are "moderate traumatic brain injuries". Certain
literature suggests that this percentage may be low, and that moderate
traumatic brain injury may be as high as 28% of all traumatic brain
can be utilized in order to determine and rate traumatic brain injury
severity. As indicated earlier when discussing mild traumatic brain
injury, estimates of severity of injury based on posttraumatic amnesia
duration (PTA), can be utilized. Where the posttraumatic amnesia lasts
between 1 hour and 24 hours, the injury rating is generally listed as
Neuro-imaging, including CT scan, MRI (functional as well as T-3 and other strength ratings, gradient echo and other software applications), SPECT scan and PET scans are often used as diagnostic tools for the purpose of rating moderate traumatic brain injury.
Another test commonly utilized to rate injury is that of the Glasgow Coma Scale (GCS).
While "coma" is listed in this test´s title, the test is actually used
to describe all post-traumatic states of altered consciousness from
mild to deep coma. In evaluating injury severity, a GCS range of 9 to
12 is moderate. (Note also that a GCS range of 3 to 8 is considered
severe, while a range of 13 to 15 is considered mild. Where a patient
is without ability to obey commands, without ability to spontaneously
open eyes, and without ability of comprehensible speech, with a GCS
equal to or less than eight, coma has been defined.)
The length of a coma or unconsciousness is yet
another indicator of injury severity. Length of unconsciousness greater
than 20 minutes, though no longer than six hours indicates a moderate
traumatic brain injury. (Less than 20 minutes coma duration would
therefore indicate a mild traumatic brain injury, while greater than
six hours of coma duration would generally indicate a severe traumatic
One of the prime benefits of the GCS is that it can
be used by emergency medical technicians in the field as well as by
doctors and other medical personnel in the emergency room. The GCS
actually includes three response dimensions which therefore allow
medical personnel to evaluate levels of consciousness when other
aspects (such as vision or speech) are compromised by factors other
than impaired consciousness. The GCS is also a good predictor of
The GCS is not without problems, however.
Intoxicated patients are known to produce unreliable GCS scores. Many
trauma patients initially remain lucid at the scene of the accident but
then become agitated, or which sedation is required. Sedation, as with
intoxication, may lower their GCS. As with other tests, the GCS is but
one test to be taken into account.
Statistics vary on the outcome of individuals
sustaining moderate traumatic brain injury. At lease one study
indicated that as many as 28% of those individuals seen in an emergency
room and in an intensive care unit diagnosed with a moderate traumatic
brain injury made a "good recovery" on the Glasgow Outcome Scale.
Changes in sleep patterns, fatigue, judgment, headache, multitasking,
memory, concentration, word selection, attention deficits, processing
speed problems, and problems with independent living were nonetheless
found to persist. Most individuals sustaining moderate traumatic brain
injury will find it extremely difficult to return to their pre-morbid
The specific area of the brain where damage occurs can likewise have an
extreme impact on outcome. For example, where the injury is localized
in the temporal lobes, seizure or temporal lobe epilepsy (TLE) can
develop. Where the injury is primarily localized in the frontal lobes,
frontal lobe syndrome can develop. (For a more detailed discussion of
seizure or frontal lobe syndrome, click here.)
Depending on whether the injury is focal or diffuse, and further
depending on the area of the brain affected, the outcome of individuals
sustaining moderate traumatic brain injury is difficult to predict, as are the clusters of symptoms likely to remain.
B. Severe Traumatic Brain Injury
Statistically, severe traumatic brain injury victims
comprise approximately 10% of all traumatic brain injuries. However,
because individuals sustaining severe traumatic brain injury are
unlikely to ever return to work or independent living, and because their rehabilitative
needs are so great and expensive, and because almost all are unable to
return to independent living, this group represents a growing problem
for society and for the health care profession. Families of individuals
sustaining severe traumatic brain injury are subjected to severe
financial and emotional burdens.
As indicated above, where a patient sustains a PTA
with duration from one day to seven days, their injury can be rated
"severe". (Note that where the PTA is between one to four weeks, the
traumatic brain injury can be rated "very severe", and where the PTA
duration is for more than four weeks, the traumatic brain injury can be
rated "extremely severe").
As further indicated above, where the Glasgow Coma
Scale score is found to be equal to or less than eight, or where coma
duration is found to be greater than six hours, a rating of "severe
traumatic brain injury" is appropriate.
Severe traumatic brain injury continues to have
significant effects on emotional, cognitive, vocational, psychosocial,
independent living, and family function decades after the injury. There
is a distinct interplay between emotional components and organic injury
that interplays and interacts cumulatively in effect.
Generally speaking, individuals sustaining severe
traumatic brain injury display dysfunction in virtually all areas of
cognition, and indeed display motor defects affecting physical
response. While there may be some unique characteristics demonstrated,
patient by patient, it is not uncommon for the following deficits to
persist in varying levels of severity over the course of the patient´s
While the profile of motor problems varies from
individual to individual, it is not uncommon to see problems in basic
motor functions such as equilibrium, range of motion, abnormal or
involuntary movements, primitive reflexes, and problems with sitting,
kneeling, standing, walking or running. These problems may be more
impaired during the early phase of the severe traumatic brain injury.
Of course, where the severity of brain injury or
other insult has been significant enough to impose paraplegia and/or
quadriplegia (with or without spasticity), entirely different motor
function problems arise.
Individuals sustaining severe traumatic brain injury
often experience decreased dexterity, decreased manual speed and
increased reaction time, tremors, hemiparesis, decreased range of
motion and contractures.
A wide variety of rehabilitative care is usually
employed over the course of the patient´s life in order to attempt to
improve motor function.
Without question, the most devastating permanent
disorder associated with severe traumatic brain injury is that of
executive dysfunction, which involves an individual´s capacity for self
control, regulation, self-direction, planning, organization, and self
Frontal lobe functions as "executive" abilities.
These can be summarized as capabilities necessary for goal formation,
planning and organization, decision-making, and monitoring and altering
behavior on the basis of performance. Where dysfunction occurs in
executive abilities, extreme problems result. Frontal lobe functions
include drive, mood, emotion, and personality. The frontal lobes are
crucial for monitoring behavior.
Deficits associated with frontal lobe injury are
often the most severe as they interfere with the ability to fluently
utilize knowledge, appropriately or adaptively. Many behavioral
problems seen in patients sustaining executive dysfunction are apparent
to all. Among them are signs of faulty capacity for self control or
self-direction, including emotional lability or flattening, a quickness
to anger, a tendency to irritability and excitability, impulsivity,
erratic carelessness, rigidity, and difficulty in making shifts in
attention and ongoing behavior. Deficits associated with frontal lobe
injury prohibit a person from engaging in independent behavior. Such
individuals must live in a structured environment, and often times need
24/7 attendant care.
Deficits in executive function, however, are often
much more insidious, and less apparent to the untrained individual. In
discussing these deficits, noted neuropsychologist, Muriel D. Lezak
states as follows:
Other defects in executive functions, however,
are not so obvious. The problems they occasion may be missed or not
recognized as neuropsychological by examiners who see patients only in
the well-structured in-patient and clinic settings in which psychiatry
and neurology patients are ordinarily observed. Perhaps the most
serious of these problems, from a psychosocial standpoint, are impaired
capacity to initiate activity, decreased or absent motivation
(anergia), and defects in planning and carrying out the activity
sequences that make up goal directed behaviors. Patients without
significant impairment of receptive or expressive functions who suffer
primarily from these kinds of control defects are often mistakenly
judged to be malingering, lazy or spoiled, psychiatrically disturbed,
or--if this kind of defect appears following a legally compensable
brain injury--exhibiting a "compensation neurosis" that some interested
persons may believe will disappear when the patient´s legal claim has
Individuals sustaining executive dysfunction through
severe traumatic brain injury are often inert. It is not that they are
physically incapable of performing certain tasks; it is instead the
nature of the brain injury that stops them from performing the task.
Perseveration is also a key and frequently
exhibited trait of executive dysfunction. One needs only think of a
horse with blinders on. The patient demonstrating perseveration will
not change course once the course has been "started". Thus, executive
dysfunction does include diminished cognitive abilities because even
though the patient may possess information needed to resolve a problem,
the patient´s perseveration will stop them from using such information
unless prodded or queued.
the awareness to be able to think about oneself is compromised through
frontal lobe injury. Insight and empathy are naturally compromised when
self-awareness dissipates. Think about it in its most simplistic sense, a
patient will likely not accept the need for rehabilitation without
maintaining a degree of self awareness.
Individuals sustaining executive dysfunction have
processing speed problems and difficulty dealing with competing sources
of information. They may be subject to "overload" in a stimuli bound
environment. The greater these problems, the more socially dependent
Deficits in attention and memory are virtually
always seen in individuals sustaining severe traumatic brain injury.
These problems generally consist of deficits in the retrieval and
acquisition of information. Short-term memory is more likely to be
affected than long-term memory. Name retrieval-both new names and old
names-is a common complaint of individuals sustaining severe traumatic
Deficits in the area of attention and memory are
especially problematic when dealing with the skill sets necessary in
both the social and vocational arenas. Simply put, where individuals
are unable to remember events occurring only an hour before, all the
compensatory tools in the world will not resolve the deficit. Work and
social interaction become impossible.
Working memory deficits are also apparent when
victims of severe traumatic brain injury attempt multitasking. While
most survivors of severe traumatic brain injury will never be cleared
to return to driving an automobile, working memory deficits would be
the primary consideration weighing against such a return. Operation of
an automobile requires clear processing of multiple stimuli under
considerable time pressure.
"Aphasia", or the lack of ability to understand
speech, is present in a small percentage of individuals sustaining
severe traumatic brain injury. These individuals have been estimated as
being approximately 2% of the severe traumatic brain injury population,
and generally consist of individuals having sustained focal lesions.
As indicated above, word finding problems are much
more common in patients having sustained a severe traumatic brain
injury. Communication is often slowed as the patient searches for an
appropriate word. A lack of logical content resulting from cognitive
deficits and executive dysfunction is likewise often seen.
Another problem commonly encountered in individuals
sustaining severe traumatic brain injury results where executive
dysfunction renders the individual "concrete". The patient, in essence,
is incapable of abstract thought, and can only think in extremely
concrete terms. Verbal fluency is best limited by capability of
thought. Obviously, where confusion, disorientation and distractibility
exist, verbal retrieval and communication will be limited.
"Anosmia", or a decrease in the sense of smell and
taste may also result from frontal lobe damage. Due to the fact that
the olfactory nerves are located on the bottom of the frontal lobes,
such nerves are susceptible to trauma even in mild cases of command
brain injury. Cranial nerve number one should be tested in individuals
sustaining severe traumatic brain injury.
In virtually every case of severe traumatic brain
injury, there is a risk of the patient developing post-traumatic
epilepsy. In fact, the risk of developing epilepsy following a
penetrating head wound has been reported in excess of 58%. Statistics
are expected to become even more refined as troops are examined
returning from the Gulf, the Iraqi, and the Afghanistan conflicts.
Post-traumatic epilepsy include seizures developing after TBI that
cannot be attributed to anything other than the traumatic brain injury.
In general, where there is a focal lesion, there is an increased risk
of post-traumatic epilepsy. Where severe traumatic brain injury occurs,
the risk of seizure will remain for decades. Where a seizure occurs
within days of insult, the risk of development of seizure disorder is
greater. However, seizure may not occur following severe traumatic
brain injury for 10 years or more.
Depending on the focal nature of the injury,
temporal lobe epilepsy may likewise develop. These are seen as unusual
electrical bursts emanating from the temporal lobes themselves.
Depression is reported frequently in patients with temporal lobe
epilepsy. In fact, personality disorders are much more common among
seizure patients and those specifically sustaining temporal lobe
epilepsy have been found to display excessive verbal output,
circumstantial thinking, and altered sexuality.
Some of the necessary life-saving surgery, including
craniectomy, involving decompression and evacuation, carry risks of
seizure. Clearly, however, the risk of seizure following such
life-saving procedure is outweighed by the benefit of the procedure
An ongoing controversy in epilepsy is whether a
progressive cognitive decline occurs as a result of the seizures
themselves. Suffice it to say, there are studies indicating that
seizures themselves cause such a decline.
Lastly, pseudo-seizures can, and often do, result in
individuals sustaining severe traumatic brain injury. Although not true
"seizures" (wherein abnormal electrical activity can be seen on EEG),
they are paroxysmal events which resemble seizures. Most occur with
depression, anxiety disorder, conversion disorder, or schizophrenia.
However, the literature would indicate that seizures and
pseudo-seizures can coexist in up to 20% of the cases. Pseudo-seizures
are extremely revealed to the individual experiencing same, and are not
capable of intentional invocation. Neuropsychological testing may be
helpful in differentiating pseudo-seizure patients from patients with
Though the civil defense bar would like to clearly
differentiate between organic brain injury and emotional or psychiatric
disorders, the fact remains that often times they can coexist. It makes
sense. Where an individual has sustained an organic brain injury, and
has enough self-awareness to recognize deficits, why wouldn´t that
individual become depressed?
Conversely, we must remember that traumatic brain injury injures the brain they that an individual already had.
If that individual was depressed prior to the resulting traumatic brain
injury, why wouldn´t that depression become exacerbated by the
recognition of organic brain injury and its resulting limitations?
The simple fact remains that many different kinds of
emotional alterations take place as a result of traumatic brain injury.
Depression, anxiety, quickness to anger, as well as apathetic behavior,
and non-initiating patterns of conduct are often seen. In severe brain
injury, more often than not there is an organic based etiology.
Increased rates of personality disorder involving sensitive-compulsive individuals are often times seen. Social isolation
is common. Many patients want nothing more than to sit in a dark room
staring at a TV for hours on end.
Where trauma is significant enough to result in a severe traumatic brain injury, most patients will have sustained injury (secondarily to other areas of their body) resulting either from the traumatic brain injury or the trauma itself. These injuries can be as broad and varied as the human body itself. Common injuries include vestibular problems as well as ophthalmic injuries.
Cases involving moderate traumatic brain injury and severe traumatic brain injury are complicated cases necessitating a need for immediate acute care, intermediate acute rehabilitative care, and long-term rehabilitative care.
If you or a loved one has sustained a moderate to
severe traumatic brain injury, you are in need of immediate assistance.
Make sure that the law firm you retain has the experience and knowledge
necessary to properly handle the case. We at the Scarlett Law Group
stand ready to assist you in your time of need.
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.