Presenting cases of mild traumatic brain injury (TBI) has
always been more of a challenge than more severe brain injuries that may
include open skull fractures, large areas of intracranial hemorrhage or visible
cerebral contusions. Of course this is because of the lack of clear physical
evidence of injury in the various types of radiological studies. A case with a
massive depressed skull fracture, a huge subdural hematoma or large areas of
bruising in the brain have pathologies that are clear in the CT or MRI films,
even to a lay audience. Closed head injury or concussion cases most likely do
not have such clear and obvious physical manifestations.
The injuries in a mild TBI case that lead to long term or
permanent neurological deficits and symptoms in the patient occur on the
microscopic level affecting individual brain cells and the connections between
these cells. The impact forces that occur when the brain impacts the inner wall
of the skull can displace or shear these connections leading to injury and
death to the affected nerve cells. Traditionally, this mechanism had to be
discussed theoretically since these microscopic injuries could not be seen in
the post-accident radiological studies. This discussion was often a challenge
since it had to involve a description of the neurons, the connecting axons, the
gelatinous nature of the brain tissue, the shearing forces and the final
disruption and death of the affected cells.
Thankfully, MRI technology has improved dramatically over
the years. Modern MRI studies have a resolution so fine that the small lesions
created by a shear injury can often be demonstrated. These lesions primarily
result from petechial (pinpoint) hemorrhages or the small regions of scarring
that develops after this bleeding has resolved. The following image is a good
example of the type of lesion that I often see in these cases.
Certainly a legal case argued before an average jury can
be more effectively presented when there is physical evidence of the injury.
These small microscopic injuries may not be as dramatic or clear to the
uneducated viewer as other larger pathologies, but at least the attorney
presenting this evidence does not have to rely solely on a discussion of a
theoretical process in a brain that remains completely normal in appearance.
Who knows what the future may hold. I believe that the technology will only
continue to improve and that soon we will have routine studies that can show
these injuries in even greater and greater detail.
