We understand traumatic brain injury

Mild Traumatic Brain Injuries are defined as someone who is dazed, disoriented or confused after the trauma, but does not have a loss of consciousness of 30 minutes or greater, and has a Glasgow Coma Scale score of 13-15 (15 is the highest score possible.) Mild Traumatic Brain Injuries or "mTBI's" do not show visible bleeding on an MRI or CT. If a person has a brain injury with no loss of consciousness, and a Glasgow Coma Score of 13-15, but has positive imaging, it is called a “complex mild traumatic brain injury”; outcomes are similar to those of a person with a moderate traumatic brain injury.

In mTBI cases, there is "shearing" of the neurons and axons in the brain. Axons are the nerve structure that communicates messages along the nervous system both within the brain as well as within the spinal cord and peripheral nervous system. The brain itself has approximately 100 billion neurons, each one of which has approximately 10,000 connections. This results in approximately 100 trillion connections within the human brain.

Given that all of this sits inside your head, you can understand that the brain is incredibly densely packed with neurons and support structures like astrocytes. When microscopic damage occurs in this densely packed brain, it can create significant dysfunction in the brain and results in problems for the person who sustains that brain injury. As a point of comparison: even the highest resolution MRI machine can only resolve anatomy down to the size of a piece of rice. The structural damage of a mild traumatic brain injury is not that large, but still impacts potentially hundreds of thousands of connections within the brain. Damage the size of a grain of rice that can be imaged on an MRI is very significant; this is why people can have very impactful brain injuries without anything being seen on a brain MRI.

When axons sustain microscopic damage in the brain, this disrupts the ability of nerve pathways within the brain to communicate with each other, disrupting function. This structural damage (the primary injury in a TBI) is usually at the outside of the brain, or along the white/gray matter border.

As discussed above, there is a secondary neurochemical cascade change that occurs in traumatic brain injury. This disrupts the normal exchange of nutrients, ions and neuro-transmitters in the brain. This can create ongoing problems and does result in the onset of beta amyloid plaque being deposited in the brain, resulting in an increased risk of dementia and Alzheimer’s Disease. The chemical changes in the brain are even more problematic when the person experiences sleep disturbances and/or PTSD after the TBI because both of these will also cause neurochemical changes in the brain as well. Both sleep deprivation caused by TBI, and concurrent PTSD are common outcomes for people with traumatic brain injuries.

In the early 1990s, multiple medical societies created standardized definitions of mild traumatic brain injury, called a “consensus statement.” Consensus statements are arrived at in large committees, with appointed specialists on the topic, who then review the research and come to final agreements as to what set of criteria define an injury or disease. In the United States the two primary definitions of mild traumatic brain injury are the consensus statements of The American Congress of Rehabilitative Medicine (the organization of physiatrists, who often specialize in the field of traumatic brain injury) as well as the American Academy of Neurology (the organization of medical neurologists.)

Neither one of these consensus statements require a loss of consciousness, a head strike, a Glasgow Coma Scale score below 15 or positive MRI or CT. That is because it has been well known since the early 1990s that people can sustain a brain injury without any of these being positive. Despite this, insurance companies, insurance defense lawyers, and insurance defense doctors will regularly try to mislead jurors that one or all of these is required in order for an injured person to have a legitimate brain injury. The consensus statements are clear: a person only needs to have one of the required criteria in order to meet the definition of mild traumatic brain injury. In most cases, that will be feeling dazed, disoriented or confused after the incident.

Insurers, and the insurance doctors they hire, often falsely claim that everyone with a mild traumatic brain injury gets better. However, in a recent study of Level I trauma hospitals in the United States, in a one year follow up of people diagnosed with mild traumatic brain injury in the ER, 53% had ongoing symptoms. Of people with a Glasgow Coma Scale score of 15 and a negative CT scan, the rate of persistent symptoms was still 49%. The permanency rate grows larger with each additional concussion. Jury trials on behalf of people with a traumatic brain injury often hinge upon a trial lawyer’s knowledge of the medical literature. If you are looking for the best Colorado brain injury lawyer, make sure they understand the science about the permanency rate of mild traumatic brain injury. These are the most likely TBI cases to go to trial and so an experienced brain injury lawyer will know about medical research and how to use that in the direct examination of your treating doctors and expert witnesses, as well as how to cross examine the insurance company doctors who will testify that you are not injured, or that mild traumatic brain injuries are never permanent.

It is not realistic to expect an insurance company will do the right thing and make a reasonable offer to you. Mild traumatic brain injury cases are frequently undervalued by insurers and they often push these cases to trial because they are “invisible injuries.” Unless you have a lawyer willing to go to trial, you may find yourself accepting much less than you deserve simply because your lawyer doesn’t have the trial skills or understanding of your injuries to go to trial on a traumatic brain injury case. You don’t want to find that out when it is too late to change to a brain injury trial lawyer.

Moderate traumatic brain injuries are defined as someone who has a loss of consciousness of 30 minutes or greater after injury, and has a Glasgow Coma Scale score of 8-12 thirty minutes after injury (15 is the highest score possible.) Frank bleeding is more likely in moderate traumatic brain injury cases than in Mild Traumatic Brain Injuries, but you do not always see visible bleeding on an MRI or CT.

Symptomatically, the symptoms are the same, although they can be more profound and impactful on the TBI survivor. There is some research suggesting moderate traumatic brain injury symptoms have a higher rate of permanency than mild traumatic brain injuries.

Moderate traumatic brain injuries often involve additional legal issues including the need for vocational rehabilitation evaluation, a life care plan, and an economic loss evaluation if you are unable to work in the same way or at all. One thing that is seldom discussed is whether a lawyer is willing to pay up front for these expensive evaluations in order to ensure that your case is handled correctly. Often, large law firms who settle every case, minimize the amount they will spend to ensure your case is correctly substantiated. It is well known through research from Stanford Law professor Nora Engstrom into legal “settlement mills” that people with significant injuries are the worst served by high volume law firms. If you have a brain injury or other serious injury case, you need to hire a lawyer who will pay to thoroughly research the extent of your injuries and the costs of your future expenses and financial losses to arrive at a fair settlement, or be able to fully substantiate your injury case at trial.

Severe traumatic brain injuries are diagnosed when someone who has a loss of consciousness of 24 hours or greater after injury, and has a Glasgow Coma Scale score of 3-8 thirty minutes after injury (3 is the lowest score possible.) The Glasgow Coma Scale score looks at three issues only: verbal response, eye responsiveness and the ability to move arms or legs in response to a verbal request. It does not look at cognitive performance or any other symptoms caused by brain damage.

Frank bleeding is most likely in severe traumatic brain injury cases. These TBI cases are the ones where it is most likely to have positive CT and MRI.

Symptomatically, the symptoms are more profound and impactful on the TBI survivor. There is some research suggesting moderate traumatic brain injury symptoms have a higher rate of permanency than mild traumatic brain injuries.

Severe TBIs result in thousands of deaths every year. According to the United States Center for Disease Control, 22% of all people who sustain a severe traumatic brain injury die from the injury; 30% become worse over time; 22% stay the same symptomatically, and 26% achieve some improvements. One of the top facilities in the United States for the treatment of severe traumatic brain injuries is The Craig Hospital in Englewood Colorado. For those people who survive a severe traumatic brain injury, the severe TBI usually leads to permanent health problems and physical disability that will affect all aspects of a person’s life.

If you are a family member of someone with a severe traumatic brain injury, you need to look for the best Colorado brain injury lawyer. In these severe brain injury cases you really need an experienced brain injury lawyer who is willing and able to hire the best brain injury experts to evaluate the long term costs for care of your loved one. This will often include future medical care, rehabilitation, in home care, home alterations, or in-patient care.

While family members often think that they can handle the full-time care of their injured family member, research shows this is not a viable long term solution due to burnout, and the potential consequences of a lack of medical skills. You do not want to find that out after a settlement or trial, when there is never a second opportunity to get the full compensation necessary to care for a severely injured person. No one, no matter how motivated to do the right thing, can work 24 hours a day and often that will be required to adequately care for someone with a severe traumatic brain injury.

These cases require major financial expense — and an experienced Colorado brain injury lawyer with extensive trial skills. The law firm you hire must be willing to invest in fully evaluating cases and retaining the best expert witnesses to address the extent of the loss for a jury in the event a case does not settle.

Call our office at (303) 444 1505 for a free consultation to discuss the case. In severe brain injury and catastrophic injury cases where coming to our office is not possible for an in-person meeting, we will drive to the hospital or your home to meet the client in person so that we can best understand how to represent them.

Epidural Hematoma: An epidural hematoma is a collection of blood that occurs between the skull and the dura mater. This type of brain bleed is caused by head trauma, and is often associated with a skull fracture. Epidural hematomas produce a pocket of blood that compresses the brain against the rigid skull. An epidural hematoma can be life threatening and requires emergency neurosurgical intervention to drain the blood and decrease the pressure against the brain before neural damage occurs. Neurosurgery is frequently required.

Subdural Hematoma: A subdural hematoma occurs in the subdural space between the dura mater and the arachnoid mater due to the tearing of the small veins between those spaces. Subdural hematomas are more common than epidural hematomas but also can be life threatening. Subdural Hematomas require surgical evacuation. Depending on the severity of the condition, subdural hematoma brain bleeds carry a mortality rate of 50-90%. Neurosurgery is frequently required.

If discovered within three (3) days following an injury, these bleeds are considered an acute subdural hematoma (ASDH). If discovered after three (3) days and up to fourteen (14) days following an injury, it is considered a subacute subdural hematoma (SASDH). A chronic subdural hematoma (CSDH) is a brain bleed that is discovered more than two (2) weeks following an injury.

As a rule, anyone taking anticoagulant medication should have a CT after a traumatic injury if they have any symptoms of TBI. There have been cases of people having a moderate headache the day of a motor vehicle collision and then being dead a few days later when the anticoagulant therapy results in an unexpected brain bleed.

Subarachnoid Hemorrhage:A subarachnoid hemorrhage occurs when there is bleeding between arachnoid mater and the pia mater protective layers surrounding the brain. These hemorrhages usually are caused by ruptures of brain aneurysms (i.e., weak spots in a brain blood vessel), but also can occur due to a traumatic brain injury. Symptoms include a severe headache, rigidity of neck muscles, nausea, vomiting and an altered level of consciousness. Neurosurgery is frequently required.

Intracerebral Hemorrhage: An intracerebral hemorrhage (ICH) occurs inside the brain tissue. It is mainly caused by trauma, hypertension, rupture of an aneurysm, artery disease, coagulation disorders or brain tumor. Intracranial brain bleeds require emergency surgery. Neurosurgery is frequently required.

Intraventricular Hemorrhage: An intraventricular hemorrhage (IVH) occurs inside the ventricles of the brain. These are mainly caused by rupture of an aneurysm or traumatic brain injury. Intraventricular hemorrhages can block the circulation of cerebrospinal fluid (CSF) and can compress the brain against the hard skull. This condition usually requires brain surgery. Neurosurgery is frequently required.

The frontal lobes can be injured in mild, moderate and severe traumatic brain injuries.

The frontal lobe damage affects our emotional control center and home to our personality. There is no other area of the brain where damage causes such a wide variety of symptoms. The frontal lobes are involved in motor function (control of movement in the body), problem solving, memory, language, judgment, impulse control, and social and sexual behavior.

The frontal lobe includes the prefrontal cortex, which is considered the primary area of “executive function” in the brain. Executive functions controlled by the prefrontal cortex include basic cognitive processes such as attentional control, inhibitory control, working memory, and cognitive flexibility. People who sustain prefrontal cortex injuries have a problem with memory, organizing, planning, keeping their attention on one subject, and inhibiting their conduct.

Lack of inhibition can be particularly problematic with people saying things that most adults understand they shouldn’t, to spending money without appropriate restraint, to drinking excessively or using drugs, or engaging in illicit sexual or criminal behavior. This can result in the breakup of a family, bankruptcy, addiction, the loss of a job, or imprisonment.

The Prefrontal Cortex includes the following areas:

• The dorsolateral prefrontal cortex. This area (also referred to as the “DLPFC”) is involved with real time processing of information including the integration of cognition and behavior. This area is associated with problem-solving, planning, verbal fluency, working memory, organizational skills, reasoning, and other functions.
• The anterior cingulate cortex. This area (sometimes referred to by neurologists as the “ACC”) is involved in emotions, experience, inhibition of inappropriate responses, decision making and motivated behaviors. Brain damage in this area can lead to a loss of drive such as apathy, abulia (a lack of initiation for speech or thought) or akinetic mutism (indifference to pain, thirst or hunger) and may also result in decreased interest in social activities,career or vocational activities and sex.
• The orbitofrontal cortex. This area, (sometimes referred to by neurologists as the “OFC”) plays a critical role in impulse control, monitoring personal behavior and socially appropriate behaviors. Brain damage in the OFC cause a lack of normal inhibition, impulsivity, aggressive outbursts, sexual promiscuity and antisocial behavior. These are amongst the most destructive behaviors resulting from traumatic brain injury. While recent research suggests that more than 50% of people with mild traumatic brain injury have their cognitive deficits heal within one year, behavioral changes such as those caused by frontal lobe injury are less likely to heal than cognitive changes.

The frontal lobes are the most vulnerable area of the brain in a traumatic brain injury due to their location. The frontal lobes form the front of the brain and sit just behind the front part of the skull, and just in front of the sharp sphenoid wing on the base of the cranium. This means that in injuries where the head goes forward and back, the frontal lobes can be injured by the inside of the skull when the head goes forward, and the sphenoid ridge when the head goes back. Additionally shear injuries can occur between the gray and white matter border in the frontal region. MRI studies have shown that the frontal lobe is the most common region of injury following mild to moderate traumatic brain injury.

The temporal lobe is located behind the frontal lobe on both sides of the head above the ears. The functions of the temporal lobe include hearing, memory and speech. Temporal lobe injuries do occur, as a result of the brain being forced into the sharp sphenoid ridge of the cranium. Side impact collisions can also impact one temporal lobe more than the other, with the lateral surface of the temporal lobe striking the inside of the cranium.

Problems Caused by Temporal Lobe Injuries:

• disruption of auditory perception
• difficulties in attention to sound and vision
• disorders of visual perception
• impaired organization and categorization of verbal communications
• disturbance of language comprehension
• impaired long term memory
• altered personality behavior
• altered sexual behavior

• difficulty recognizing familiar faces (prosopagnosia) (right temporal lobe injury)
• aphasia (language disturbances)
• wernicke’s aphasia (difficulty understanding spoken works)
• impaired memory for verbal material (left temporal lobe injury)
• difficulty using words in the correct order
• problems recognizing words
• hearing deficits
• short term memory loss
• decreased musical abilities (right temporal lobe injury)
• impaired drawing ability (right temporal lobe injury)
• inability to categorize objects
• persistent talking (right temporal lobe injury)
• increased aggressive behavior
• hyperirritability
• increased anger

Temporal lobe injuries can also result in the onset of temporal lobe seizures. These seizures, often incorrectly referred to as “absence seizures,” involve the loss of periods of time for minutes to hours, followed by a period of confusion and difficulty speaking, the inability to recall what occurred during the seizure, unawareness of having had a seizure, and/or extreme sleepiness. These seizures, often missed because they do not include someone falling on the ground and convulsing (such as in grand mal seizures), can lead to increasing brain damage if not treated. While temporal lobe seizures are not present in most temporal lobe injury cases, they do occur in some TBI cases and should not be ignored. EEG can be used to evaluate these although this evaluation is only helpful if a person has a seizure while the EEG is monitoring their brain activity. A more advanced and sensitive technology for seizures is Magnetoecephalography or “MEG.” There are only a few radiology facilities in the United States with MEG machines, but they are very sensitive to a traumatic brain injury and seizure disorders.

The parietal lobe (top of the head near the back of the brain) processes sensory input to create a perception of one’s surroundings, and provides the spatial coordination to navigate our environment. The parietal lobe receives sensory information from skin, musculoskeletal system, taste buds and internal organs.

Injuries to the parietal lobe can cause:

• inability to multitask
• inability to name an object
• disorders of language (aphasia)
• inability to remember words while writing
• difficulty reading
• difficulty writing and drawing objects
• difficulty distinguishing right from left
• difficulty with mathematics
• lack of awareness of the location of parts of body and surrounding space
• inability to focus visual attention
• difficulty identifying the location of a sensation
• difficulties with hand-eye coordination
• impairment of self-care skills
• denial of deficits

The occipital lobe is at the back of the head. It is injured regularly in traumatic brain injury cases as the back of the occipital lobe can be forcefully thrown into the back of the cranial bones. Occipital lobe function can also be affected by damage to the neurons and axons in the occipital lobe as well as those that run through the brain to the occipital lobe. As discussed earlier, physical damage in the occipital lobe can also occur to the axons crossing the border between white matter and gray matter when a force accelerates the white matter more quickly than the gray matter.

The occipital lobe is the primary area of the brain for processing visual information – visual reception and interpretation. Signs of injury to the occipital lobe can include a bright flash of light at the time of injury, or floating in the person's vision immediately following the injury.

The neurological structures involved in vision take a long path from the eyes at the front of the head, through the brain in the optic chiasma, and to the back of the head in the occipital lobe. The occipital lobe receives stimuli from the eyes and processes that information.

Occipital lobe injuries frequently cause:

• visual deficits (visual field cuts or cortical blindness)
• difficulty locating objects in the environment
• difficulty identifying colors (color agnosia)
• hallucinations or illusions
• inability to recognize words, i.e., word blindness
• inability to recognize familiar faces or objects
• difficulties reading and writing

There are many more difficulties to vision that occur after TBI that are not processed within the occipital lobes. This includes problems with visual coordination, which is controlled by cranial nerves II (Optic), III (Oculomotor), IV (Trochlear) and VI (Abducens).

The brainstem is the transition between the brain and the spinal cord. The brain stem itself exits the hole in the skull called the foramen magnum, making it vulnerable to damage during trauma. This is particularly true in motor vehicle collision or truck crash cases where large forces axially extend the neck, pulling the fragile cerebellum and brainstem down into the rigid bony hole of the skull. This action itself can cause a condition known as cerebellar tonsillar ectopia, a traumatic type of a Chiari Malformation that can lead to extensive neurological problems throughout the body.

The brain stem serves to provide the individual with basic attention, arousal and consciousness. The brainstem connects the brain to the body and performs basic survival functions such as breathing and heart rate.

When trauma causes brain swelling, fluid pushes up against the skull and can cause the brain to push down on the brain stem. This compression of the brain stem can damage the part of the brain that is responsible for consciousness.

Signs and symptoms associated with a brain stem injury include:

• altered heart rate
• loss of consciousness
• abnormal breathing patterns
• inability to control movement
• inability to cough or gag
• abnormal sleeping patterns

In addition, all twelve of the cranial nerves exit from the brain stem. These very small and fragile nerves control everything from breathing to eye movements to smell and taste, to facial movements and sensation. Cranial nerve injuries are somewhat common in brain injury cases.

The cerebellum is located at the bottom back part of the skull (under the occipital lobe) near the opening to the spinal cord. It is connected to the midbrain and near the brain stem. The Cerebellum is divided into two hemispheres by the central vermis.

The cerebellum coordinates movement, planning, motor activities, physical skills and some cognitive abilities. It collects sensory nerve inputs, such as vision, balance information and limb position (called proprioception), and synthesizes them to control movement.

Cerebellar memory stores information from trial and error of physical tasks such as riding a bike. The primary function of the cerebellum is to coordinate the timing and force of muscular contractions so that body movements are appropriate for the intended task.

Symptoms associated with damage to the cerebellum include:

• dysdiadochokinesia (difficulty in performing rapid alternating movements)
• ataxia (difficulty coordinating timing, force, range and direction of movements)
• tremors
• loss of balance and central vertigo (resulting in shuffling walk and a wide stance)
• loss of muscle or posture tone, or muscle weakness
• dysarthria (loss of coordination of the muscles controlling speech)
• deficit in verbal working memory
• slow or slurred speech