Moderate to Severe Traumatic Brain Injury
Our San Francisco Traumatic Brain Injury Attorneys Can Defend You
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. Injuries of 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.
Common Effects of Moderate and Severe Brain Injuries
The resulting impairments suffered by the “moderate” to “severe” traumatic brain injury victim can generally be related to the original insult. However, 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:
- Sensory losses
- Decreased muscle control
- Sleep disorders
- Speech disorders
- Eating disorders
- Memory and recall difficulties
Comatose Brain Injury Victims
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 brain injury.
Specifics on 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 injuries occurring.
Various tests 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 being moderate.
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 brain injury.)
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 outcome.
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, for 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 least 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 vocation.
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. 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.
Specifics on 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 life:
Motor Function Problems
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
- Increased reaction time
- Decreased range of motion
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.
Frontal Lobe Syndrome and Executive Dysfunction
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 determination.
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
- Quickness to anger
- Tendency to irritability and excitability
- Erratic carelessness
- 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.
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 been settled.
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.
Meta-cognition, or 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 they become.
Attention and Memory Deficits
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 brain injury.
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.
Speech and Language Difficulties
“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.
SMELL and TASTE DIFFICULTIES
“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 many conflicts around the world. 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 itself.
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 epilepsy.
Emotional and Psychiatric Overlay
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 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 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.
Other Physical Injury
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.
If you or a loved one has sustained a moderate to severe brain injury, you are in need of immediate assistance. Contact our San Francisco brain injury lawyers at Scarlett Law Grouptoday!