Neuroimaging: MRI 3.0 Teslar and Brain Injury
Although plain x rays will sometimes detect some skull fractures, they cannot help assess the brain and they delay more definitive brain imaging; thus, plain x rays are usually not done. CT is the best choice for initial imaging, because it can detect hematomas, contusions, skull fractures (thin cuts are obtained to reveal clinically suspected basilar skull fractures, which may otherwise not be visible), and sometimes DAI. On CT scan, contusions and acute bleeding appear opaque (dense) compared with brain tissue. Arterial epidural hematomas classically appear as lenticular shaped opacities over brain tissue, often in the territory of the middle meningeal artery. Subdural hematomas classically appear as crescent shaped opacities overlying brain tissue. A chronic subdural hematoma appears hypodense compared with brain tissue, whereas a subacute subdural hematoma may have a similar radiopacity as brain tissue (isodense). Isodense subdural hematoma, particularly if bilateral and symmetric, may appear only subtly abnormal. In patients with severe anemia, an acute subdural hematoma may appear isodense with brain tissue. Among individual patients, findings may differ from these classic appearances. Signs of mass effect include sulcal effacement, ventricular and cisternal compression, and midline shift. Absence of these findings does not exclude increased ICP, and mass effect may be present with normal ICP. A shift of > 5 mm from the midline is generally considered to be an indication for surgical evacuation of the hematoma.
MRI may be useful later in the clinical course to detect more subtle contusions and DAI. It is usually more sensitive than CT for the diagnosis of very small acute or isodense subacute and isodense chronic subdural hematomas. Preliminary, not yet confirmed evidence suggests that certain MRI findings predict prognosis. Angiography, CT angiography, and magnetic resonance angiography are all useful for the evaluation of vascular injury. For example, vascular injury is suspected when CT findings are inconsistent with the physical examination findings (eg, hemiparesis with a normal or nondiagnostic CT due to suspected evolving ischemia secondary to vascular thrombosis or embolism from a carotid artery dissection).Breakthrough: The most modern MRI techniques are now showing significant pathologies in Subtle Brain Injury cases.
Two major developments that may completely change the diagnostic process for those with subtle or mild brain injury.
The first is the development of higher resolution scanners, 3.0 Tesla strength magnets, as opposed to the last generation of 1.5 Tesla strength magnets. The second, perhaps more significant, is the ability to do 1 mm slices of particular parts of the brain, where pathology can be anticipated. While it is too early to determine whether the majority of those diagnosed with Post Concussion Syndrome will have abnormal scans (as opposed to the overwhelming majority who had normal scans previously) the chance of actually being able to see what has so long been called the "invisible injury" is vastly improved with this new technology.
The implications of this development, are shocking. In forensic cases, the issue of diagnosis has overwhelmed the more important questions of what impact the injury has had on behavior, function and emotions of the injured person. Injured and distressed people shouldn't be put through the agony of a diagnostic ordeal, but to overcome the skepticism and ignorance of so much of the medical community, it has been necessary.
However, with the improving MRI capabilities, at least for a significant proportion of individuals, the role of the doctors can now be understanding and documenting the problems the patient is having, not arguing about whether or not they were injured. Can you imagine asking that someone with a broken leg, run miles to prove the leg was broken? Yet, we routinely demand of the injured brain, a full day of tests, to prove it needs help.
The leading author in the field of neuropsychology, Muriel Lezak had this to say about the shift in the role of neuropsychologists:
Neuropsychological Assessment Fourth Edition, 2004, Oxford University Press,Muriel D. Lezak, Diane B. Howieson and David W. LoringWith H. Julia Hannay and Jill S. Fischer.
"Advances in diagnostic medicine, with the exception of certain cases with mild or questionable cognitive impairment,1 have changed the typical referral question to the neuropsychologist from one that attempts to determine if the patient has neurologic disease or not. In most cases, the presence of "brain damage" has been clinically established. However, the behavioral repercussions of brain damage vary with the nature, extent, location, and duration of the lesion; with the age, sex, physical condition, and psychosocial background and status of the patient; and with individual neuroanatomical and physiological differences (see Chapter 3, 7 and 8). Not only does the pattern of neuropsychological deficits differ with different lesions characteristics and locations, but two person with similar pathology and lesion sites may have distinctly different neuropsychological profiles." page 17.
What makes this development so exciting is that Lezak's words were written before the latest breakthrough technology was fully developed. Now in significantly greater proportion of "the certain case(s) of mild" brain injury, the MRI will establish that there was brain damage. For those cases, the defense position that the injured person is malingering or that the symptoms are due to a congruous interplay of emotional deficits, will ring as hollow as a politicians rhetoric.
At Sam Harding Law Firm, The Good Guy, we understand the problems suffered by people who have sustained "mild" Traumatic Brain Injuries. We know that insurance companies often try to take advantage of unrepresented clients. We work hard for our clients to get them the money they deserve without their having to go to court. We work to get medical bills, lost income and money for pain and suffering. However, should your case require us to litigate, we are prepared to take your case to court. We are an ABOTA and AV rated Martindale Hubbel law firm.
Las Vegas Personal Injury Lawyers