Snellings Law PLLC Attorneys are Personal Injury Trial Lawyers
Traumatic Brain Injury Lawyers
How are traumatic brain injuries diagnosed?
Having an injury diagnosed is never fun. I was with a friend one afternoon when he got a text from his wife – “Ella broke her arm, I need you to meet us at the hospital.” His husbandly response – “Are you sure its broken?” The responding text was a photo of a clearly broken arm. The x-rays at the hospital confirmed it, the doctors determined no surgery was necessary, and they casted it. There was no discussion as to whether the arm was broken or not, they did not have to run multiple tests to determine if it was broken, and there were no arguments as to whether she needed to take numerous other tests to determine whether her arm was broken. Anyone could look at the photo and determine she broke her arm. The biggest discussion point in the whole ordeal was what color cast she should get.
Brain injuries are different. As we discussed in What is a Traumatic Brain Injury (TBI), the medical field does not have a uniform definition of a traumatic brain injury (TBI). The definitions that are out there rely on very general phrases like “disrupts normal function of the brain” and “impairment of cognitive, physical and psychosocial functions.” Obviously, relying on very vague general phrases means that really smart people can disagree on whether someone meets the definition.
So when someone suffers a potential brain injury, what do providers look at and how do they diagnose a TBI?
Initial Tests For TBI
Most potential traumatic brain injury patients will go through some series of testing. Usually, the first “test” someone will go through will be one to determine their Glasgow Coma Score.1 This is what first responders are using when they ask your name, if you know where you are, what year it is, etc. This test measures your consciousness level by looking at your ability to open your eyes, your verbal responses to questions (like those noted above), and motor response (obeying commands, moving specific body parts).
Each of these areas are measured on a scale specific to each. For instance, the eye opening scale goes up to a 4 while the verbal response score goes to a 5. The highest score you can get is a 15. It is often measured numerous times as the patient is being observed, and her care is transitioning to another provider.
First responders or doctors will also look at the eyes to determine whether there has been a potential brain injury. A head injury can affect how your pupils (the black part of your eyes) react to light. Ordinarily, if we shine a light into someone’s eyes their pupils will shrink, and they will dilate in darker lighting. If the victim’s pupils are dilated, even in a well-lit area, and they remain unreactive to light, that is another indication of a potential brain injury.
First responders may also ask those that saw the event occur what happened. More specifically, they are trying to determine whether the person lost consciousness, for how long, was the head struck, was the body whipped around or jarred, and other similar types of questions. This will help them to determine if there is a potential head injury that they can report to the emergency physician.
Additional standardized tests a provider may rely upon to diagnose a traumatic brain injury include the Acute Concussion Evaluation (ACE), which was created by the Centers for Disease Control2 or the Sport Concussion Assessment Tool 3.3 In these tests, the reviewer collects information about the characteristics of the injury, whether there was any memory loss/seizures, and the presence of any other symptoms related to physical, mental, emotional, and sleep issues.
Imaging for TBI
Doctors will typically order imaging to look inside the head for any obvious trauma or conditions related to a traumatic brain injury. The first scan an emergency room doctor will usually order is a computerized tomography (CT) scan. This scan uses a series of detailed X-rays to create an image of the brain. These are used to look for fractures as well as any evidence of bleeding in the brain, blood clots, and bruised or swollen brain tissue.4 If the symptoms do not improve, many times another scan will be ordered. This is typically magnetic resonance imaging (MRI). This scan uses radio waves and magnets to create a detailed view of the brain on many different levels and from many different viewpoints. MRIs are typically more effective once a person’s condition has stabilized. There are different algorithms and settings that can be run within an MRI scan to focus on more detailed aspects of brain function, which will be the subject of another blog post.
Neuropsychological TBI Tests
Neuropsychological Tests (often shortened to “neuropsych”) are given to determine how someone’s brain is functioning. Most of the time these tests will assess things such as memory, concentration, speech, speed at which the brain processes information, ability to control behavior, reaction time, and problem solving. These tests are helpful in determining the severity of damage done to the brain as well as developing rehabilitation plans for the victim.
Levels of Traumatic Brain Injury
Healthcare providers can use any combination of tests and imaging to collect the necessary data to diagnose an individual with a traumatic brain injury. Oftentimes, they will then label the traumatic brain injury as mild, moderate, or severe. As with the definition of TBI in general, there is no consensus on what specifically constitutes each level of TBI.
Mild: One of the most commonly used definitions for mild traumatic brain injury comes from a committee out of the American Congress of Rehabilitation Medicine:5
• A patient with a mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following:
o Any period of loss of consciousness;
o Any loss of memory for events immediately before or after the accident;
o Any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused); and
o Focal neurological deficit(s) (eg, arm or leg weakness, paralysis, tingling) that may or may not be transient (lasting for a short time).
o But where the severity of the injury does not exceed the following:
Loss of consciousness of approximately 30 minutes or less;
After 30 minutes, an initial Glasgow Coma Scale of 13-15; and
Post-traumatic amnesia not greater than 24 hours.
Another commonly used definition comes from the National Center for Biotechnology Information:
• Normal structural imaging;
• Loss of consciousness between 0-30 minutes;
• Alteration of consciousness/mental state from a moment up to 24 hours;
• Post-traumatic amnesia from 0-1 day;
• Glasgow Coma Scale (best score within first 24 hours) is 13-15
Moderate: The National Center for Biotechnology Information defines a moderate TBI as:
• Normal or abnormal structural imaging;
• Loss of consciousness for greater than 30 minutes but less than 24 hours;
• Alteration of consciousness/mental state for greater than 24 hours;
• Post-traumatic amnesia for greater than 1 day but less than 7 days; and
• Glasgow Coma Scale (best score within first 24 hours) is 9-126
Severe: The National Center for Biotechnology Information defines a severe TBI as:
• Normal or abnormal structural imaging;
• Loss of consciousness for greater than 24 hours;
• Post-traumatic amnesia for greater than 7 days; and
• Glasgow Coma Scale (best score within first 24 hours) is less than 9
Unlike broken bones, diagnosing a traumatic brain injury is much more complicated, especially when you start attempting to further classify them into different categories of TBI. Throw in the fact that many of the classifying factors depend on the brain injured patient or provider to accurately report symptoms and how long they last, and it becomes that much more difficult.
We are always surprised by how many of our potential clients come meet with us during our initial meeting, and they display several signs and symptoms of a traumatic brain injury; however, it never occurs to them that they have suffered one. Our next article will focus on how to recognize a potential TBI by going through those common signs and symptoms.