An Examination of Axonal Function and Damage

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Posted on 7th October 2011 by Gordon Johnson in Brain Injury

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CircuitAxonCells are Like Electrical Connections:

The diagram  demonstrates the similarity (although of course on a much different scale) of the structure and purpose of a brain cell and that of an electrical connection. The cell body is similar to the switch. The axon is similar to the wires that connect the switch to the light socket and the terminal end of the axon (the spot where the nerve impulse leaves one cell and enters another), is similar to the end of the wire that connects to the light socket.

 

 

NeuronWiresAxons are Similar to Electrical Wires:

The axon is the part of the nerve cell that transmits the nerve impulse from one nerve cell to another, in a similar way that electrical impulse are transferred down a wire. Like a wire, if the axon is torn or broken, the nerve impulse will not be transmitted. And like a wire, axons may have insulation, which when it becomes damaged as a result of forces placed against the axon, may cause serious problems to the nerve cell, even if the axon is not actually torn.

 

For more information please see http://www.subtlebraininjury.com

The Structure of the Neuron

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Posted on 4th October 2011 by Gordon Johnson in Brain Injury

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The neuron is made up of several different components, but the portion of it which is most exposed to injury in a shear mechanism is the axon, the long thin protrusion which can extend substantial distances across different layers of the brain.

The primary role of a neuron is for information transfer, both from one end of the individual neuron to the other and from one cell to another. Transfer of information within a cell is called intracellular signaling and between cells, intercellular signaling. The intracellular signal begins at the cell body, runs down the axon, to the synaptic terminal end. The intercellular transfer is across the synapse, where the signal jumps from one cell to another.

The Role of the Axon: The role that the axon plays is roughly equivalent to the wire that connects a light switch to a light fixture. Like the wires in your wall, it may run substantial distances, as long as a full meter. Like a wire, it is thin. And like a wire, it transfers its signal by use of electrical impulses.

Axons are vulnerable. The axon is particularly vulnerable to injury when the brain mass begins to move as a result of rotational forces placed upon it, because it typically will stretch across layers of different density within the brain. When rapid acceleration/deceleration forces are placed upon the brain, the different layers, at progressively further distances from the fulcrum of the rotation will move at different speeds, creating a sliding effect of these different layers across themselves.

The effect of this sliding is that the axon is rapidly stressed beyond its tolerance, which may result in the axon being torn or stretched. Even if the axon is not entirely severed as a result of such force, it may be significantly damaged.. Again like the electrical wire, to protect the axon from damage and to assure that its electrical impulse does not stray from the appropriate channel, the axon is protected by insulation, called the myelin sheath.

NeuronUnlike electrical insulation, the myelin sheath is not a continuous covering, but is made up of a series of glial cells, laid end to end over the length of the axon. The glial cells resemble rolls of paper towels, with the glial material wrapped many times around the core tube of the axon. And just as if you were to line up a row of paper towels across a room, at each juncture between one glial cell and another, there is a small gap in the insulation.

These gaps, called the Nodes of Ranvier, also serve an important purpose, allowing energy to enter the axon to boost the electrical signal as it traverses the length of the cell.

The potential harm to the neuron and the brain when this insulation is damaged, is discussed at The Neuron, at page 27:

“This multiple membrane layer, which also happens to be unusually rich in lipid, insulates the axonal cytoplasm (the axoplasm) from the extracellular fluid. This means that the electrical current can flow across the axonal plasma membrane only at the nodes, and as we shall see in Part II, this has profound implications for the speed of transmission of electrical signals along the axon.”

In other words, when the the axons insulation is disrupted, the speed of information processing within the brain can be profoundly effected.

Source: Levitan & Kaczmarek, The Neuron, ©1997, Oxford University Press

For more information see http://www.subtlebraininjury.com

 

Emergency Room Misdiagnosis

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Posted on 2nd September 2011 by Gordon Johnson in Brain Injury

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Emergency Room Misdiagnosis

I have become increasingly frustrated by the prevalence of missed diagnosis of brain injuries. Seemingly several times a month, I come into contact with another client whose brain injury was not diagnosed in the emergency room. Despite significant symptoms of a brain injury, survivors are discharged with no more detailed diagnosis of brain injury than an analysis of the Glasgow Coma Scale. Yet the Glasgow Coma scale was not intended to apply to concussion injuries. Dr. Bryan Jennett, the author of the Glasgow Coma Scale had this to say about it use in these cases:

“The widespread adoption of the Glasgow Coma Scale has made it easier to classify severe injuries, but it was not intended as a means of distinguishing among different types of milder injury. Many of these patients are oriented by the time they are assessed and therefore score at the top of the Glasgow scale. Yet some of these patients have had a period of altered consciousness, either witnessed or evidenced by their being amnesic for events immediately following injury. Impairment of consciousness is indicative of diffuse brain damage, but there can also be marked local damage without either alteration in consciousness or amnesia;” Mild Head Injury, ©Oxford, 1989, page 24.

The extent of neurological examinations in the emergency room are poorly suited to diagnosing the subtle brain injury, even though such injuries can have devastating consequences. The patient is typically the primary source for what is perceived to be the most significant question: Did you lose consciousness. How reliable of a source is a person with a potential brain injury, to answer such a question? Certainly not without significant examination of the persons recollection of events. More significantly, loss of consciousness is not the litmus test for brain injury. Any change in mental state can be significant. Further, headache, lack of consistency in reported symptomatology, nausea and the need for oxygen could tip off the emergency team. Even a Polaroid photo of the accident scene and cars could point towards a head injury.

Delayed Loss of Consciousness.

A Loss of Consciousness may actually occur after discharge from the hospital. In cases of hematoma, or swelling, the LOC may occur later as a result of the increased pressure. It may occur when the patient has been discharged and gone to bed. Did relatives have difficulty waking the patient? Keep in mind the standard head injury instructions, these are aimed at just such a problem.

The Case of Other Serious Injuries.

There is also a high probability of misdiagnosis of brain injury in severe accidents, when there have been other serious or obvious injuries. The more severe the other injuries, the more likely that there will be a brain injury. There is a direct relationship between the existence of other severe injuries and the probability of brain injury. If there is enough force to break a bone, lacerate a forehead, damage the spinal cord, there is enough force to injure the brain. Yet, there tends to be an inverse relationship between the severity of other injuries, and the diagnosis of brain injury. If a person is bleeding or has some other obvious trauma, the careful analysis needed to identify a brain injury may be ignored.

Mandatory Followup.

I believe that the only way to efficiently increase the acute diagnosis of brain injury, is to schedule anyone who has evidence of concussional symptoms, for a followup the next day at the same ER. Actually give the a specific appointment time before they are discharged and discuss the importance of a followup with the person they are discharged to. Under no circumstances, should someone suffering from concussional symptoms be discharged alone. If this particular brain injury is more significant than was suspected at the initial triage, this will likely become apparent by the next day. If not, the followup exam can be brief, at little cost. But if the person and the person they were discharged into the care of, come back in the next day with a familiar pattern of symptomatology, such as excessive sleepiness, confusion, amnesia, then further analysis should immediately be done. Consideration at that time of a CT scan, vestibular workup and neuropsych screening would be warranted.

Another side benefit of requiring this type of followup, is that over a period of time, the ER personnel would become far more sensitized to what they should be looking for on this initial triage, from the stories they hear on the second day followup.

Kidney Transplant Patient Gets More Than He Bargained For: Brain Injury And A $6 Million Settlement

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Posted on 8th September 2010 by Gordon Johnson in Brain Injury

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A transplant patient who went into the hospital to get a kidney and wound up with brain damage will receive a $6 million settlement from Rush University Medical Center in Chicago, the Sun-Times reported Wednesday. 

http://www.suntimes.com/lifestyles/health/2684436,CST-NWS-KIDNEY08.article

The case involved diabetic Lauro Ortiz, who had been born with one kidney and sought to get another kidney so that he wouldn’t need dialysis. On Dec. 17, 2005, when Ortiz was 39, he learned that there was a kidney available for him and he received the transplant.

He was released from the hospital five days after his operation, but unbeknownest to him and his doctors, his new kidney had a fungal infection.  On Dec. 26 the organization that had supplied the kidney, Gift of Hope, both phoned and faxed Rush to warn the hospital that the kidney was infected, according to the Sun-Times. The hospital’s own test the next day confirmed that finding. 

But in an unfortunate mistake, Rush never contacted Ortiz to tell him there was a problem with the kidney. He was not feeling well, and was dizzy, so he returned to the hospital Jan. 13. It took Rush until almost a week later, until Jan. 19, to diagnose that Ortiz’s kidney infection had traveled to his brain.

So the kidney infection went untreated from Dec. 26 to Jan. 19, allowing it to spread to Ortiz’s brain.  

His attorney blamed the screw-up on the lack of communication at Rush. 

Ortiz had been a machinist before he sustained his brain injury. Now he lives with his mother in Chicago and has cognitive issues, including memory loss, according to the Sun-Times.

Suggested TV Viewing: ‘Secrets of Your Mind: Why We Do What We Do’

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Posted on 20th August 2010 by Gordon Johnson in Brain Injury

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The  Brain Injury Association of America recommends that you tune in to ABC’s “Nightline Prime,” and its series  ”Secrets of Your Mind: Why We Do What We Do,” which debuted Thursday night.

The four-part series tackles topics such as  the brain in love, brain and violence and the brain and food.

For times and listings and to learn more visit http://abcnews.go.com/Nightline/Prime/nightline-prime-secrets-mind/story?id=11394776.

For the “Brain in Love” installment, the BIAA helped ABC identify the couple featured in this segment.

‘As you may remember a few months ago a producer from ABC contacted the BIAA in search of a story about TBI and love,” said Wendy Leedy, the BIAA’s director of affiliate services.

“BIAA then put out a call to you to assist us in finding a survivor willing to share their story about sustaining a TBI and how that injury impacted their relationship,” Leedy said. “After numerous inquiries from survivors and professionals interested in sharing their story and experience, a couple, Anna and Derrick Gaines and their children, reached out and expressed their interest in sharing their story. This story chronicles Derrick’s injury and the impact it had on his marriage including the birth of their children following Derrick’s injury and where they are today – happily married while still learning and working towards overcoming obstacles.” 

NHL May Soon Ban Blind-Side Head Checks

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Posted on 19th March 2010 by Gordon Johnson in Brain Injury

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The National Hockey League isn’t dragging its feet on the concussion issue. It is looking to adopt a rule that would ban blind-side checks to the head this season, according to several published reports Thursday.

NHL general managers met in Boca Raton, Fla., last week to essentially craft a ban on what are often called head shots. The group initially wanted to prohibit blind-side checks for next season, but then some of them pushed to have the process fast-tracked, so officials can impose penalties on those who engage in blind-side head checks this season. http://www.nytimes.com/2010/03/18/sports/hockey/18hits.html?ref=sports

The general managers moved for the quick action in the wake of a March 7 incident involving Boston Bruin Marc Savard, who may be out the rest of the season. He suffered a concussion after the Penguins Marr Cooke gave him a blind-side hit. http://articles.latimes.com/2010/mar/17/sports/la-sp-nhl-head-hit-20100318

Under the proposed NHL rule, such a hit would result in a two-minute or five-minute penalty. Cooke wasn’t penalized for his hit on Savard because currently blind-side hits to the head are legal in pro hockey.

The New York Times reported that on Wednesday the NFL office in Toronto started handing out a video that depicted what will and will not be permitted under the blind-side head check ban.

The proposed ban on the blind-side checks will have to be approved by the NHL competition committee, and which is comprised of five general managers and five players.

The Times says that the committee is expected to approve the ban, which has been advocated by the NHL players’ union. Then the ban would have to be approved unanimously by the NHL board of directors.

A Fall of Concussions

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Posted on 18th December 2009 by Gordon Johnson in Brain Injury

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While I have been away from writing this blog, there has been more concussion news than I can remember. And as always, the real story usually gets lost in the headlines.

Tiger Woods is a perfect example. From all bystander and news accounts, he was undoubtedly knocked out when his SUV hit a tree. Much speculation swirled before the infidelity took over the story, but no one said it quite this clearly:

Tiger Woods must have had a brain injury and his reluctance to speak in public may have been for medical reasons in addition to his reluctance to discuss his marriage. He might have cancelled his next golf tournament because of injuries he suffered. I am not naive to the more likely motivations for his disappearance from the public stage, but concussion is an issue that should not be forgotten.

The good news on the concussion front is that awareness seems to be growing daily. The NFL has gotten headlines for its new concussion policies, which don’t read any different to me than what should have always been its policy, but something clearly has changed. Players who would have been medically cleared to play, have been told they couldn’t. That includes starting quarterbacks on what were playoff caliber teams at the time, the Phoenix Cardinals and the Pittsburg Steelers. Yet the same week, I saw Jermichael Finley take a horrendous hit to his jaw from another players helmet, yet not even be taken out for one play. They stopped the play for the penalty and by the time they had marked off the yardage, he was lined up again.
How could anyone have known what lingering effects he had of a ding everyone clearly saw, if he didn’t even come to the sidelines?

One of the continuing problems with sideline concussion evaluations is the presumption that anyone noticed the initial concussion. That is an organic problem that can’t really be avoided, but if a player isn’t pulled out of a game to talk to the trainer, there is no chance to avoid the catastrophic second impact syndrome that turns a concussion into a severe and even life threatening injury.

The story of concussion in sport and its relevancy to the non-fan in us, will be a focus of the blogs to come.

Brain Injury – Confusion and Amnesia – Not the Same Thing

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Posted on 9th September 2009 by Gordon Johnson in Brain Injury

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I began both of my last two speeches holding a nerf football, asking the question of those in the audience, what it was an NFL quarterback did before he snapped the football. It took a couple of minutes each time, but among the answers were the following:

  • Listened for the play;
  • Remembered the play;
  • Communicated the play to his teammates;
  • Assessed the defense;
  • Made a rapid decision, based upon that assessment to use the called play or to audible to another play;
  • Snapped the ball; and
  • Executed the play, requiring instant judgment and reaction in the face of extreme stress of large bodies trying to dismember him.
To complete the play from start to finish requires an immense ability to process, remember and use information. Clearly, someone cannot be confused and do all of those things, and particularly, do them in a series of plays, a game.

Yet, there is really no question that a quarterback can do all of those things, win the game, yet be amnestic for all or a portion of the game. The anecdotal evidence of such occurrences are numerous and undisputed.

How could this be true? Amnesia and confusion are not the same.

More on this in our next few blogs.

RNC chairman attacks Obama on health care

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Posted on 20th July 2009 by Gordon Johnson in Brain Injury

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Could this be a sign of real progress on meaningful healthcare reform, that the Republican’s are now attacking the plan and that the Democrats seem to be willing to go ahead for what is in the best interest of the people, without bi-partisan support? The Democrats have the votes, if they can close ranks. It would be a great sign of Obama’s leadership if he can get a public option plan thru Congress.

Attorney Gordon Johnson
http://tbilaw.com
http://fishtail.tv
http://waiting.com

Date: 7/20/2009 9:29 AM

DAVID ESPO,AP Special Correspondent


WASHINGTON (AP) — The chairman of the Republican Party is accusing President Barack Obama of conducting “risky experimentation” with his health care proposals, saying they will hurt the economy and force millions to drop their current coverage.

Michael Steele, in remarks prepared for delivery at the National Press Club, also said the president, House Speaker Nancy Pelosi and key congressional committee chairmen are part of a “cabal” that wants to implement government-run health care.

“Obama-Pelosi want to start building a colossal, closed health care system where Washington decides. Republicans want and support an open health care system where patients and doctors make the decisions,” Steele said in excerpts of his speech made available in advance.

Obama has repeatedly said he does not favor a government-run health care system. Legislation taking shape in the House envisions private insurance companies selling coverage in competition with the government.

Even so, numerous Republicans in Congress continue to level the accusation at Obama and congressional Democrats, and Steele did so in sharply critical terms.

“Many Democrats outside of the Obama-Pelosi-Reid-Waxman cabal know that voters won’t stand for these kinds of foolish prescriptions for our health care. We do too. That’s why Republicans will stop at nothing to remind voters about the risky experimentation going on in Washington,” the party chairman said in advance excerpts. Harry Reid, D-Nev., is Senate majority leader; Rep. Henry Waxman, D-Calif., is chairman of the House Energy and Commerce Committee.

Republican officials said they were supplementing Steele’s speech with a round of television advertising designed to oppose government-run health care. The 30-second spot, titled “Grand Experiment,” criticizes recent government aid to the auto industry and banks as “the biggest spending spree in our history” and warns of “a risky experiment with our health care.”

In his speech, Steele broadened his attack beyond health care to question Obama’s truthfulness.

The president “tells us he doesn’t want to spend more than we have, he doesn’t want the deficit to go up, he doesn’t want to live off borrowed money. But he also told us he didn’t want to run an auto company. President Obama justifies this spending by saying the devil made him do it. He doesn’t want to spend trillions we can’t afford, but he says he just can’t help it,” Steele said in the prepared excerpts.

The Republican chairman is making his speech at a time when Obama is struggling to advance his trademark health care proposal after a period of evident progress. Two of three House committees have approved their portions of the bill, while one of two Senate panels have acted.

But conservative Democrats have raised objections to some elements of the legislation, and efforts in the Senate to reach a bipartisan agreement have yet to bear fruit. Obama’s attempt to impose an early August deadline on both the House and Senate for passage of legislation is in jeopardy.

On Sunday, Obama’s advisers urged critics of their health care overhaul to wait for Congress to finish writing legislation before issuing verdicts. They also signaled they are willing to wait longer than their White House-imposed August deadline for action if it means they can sway wary lawmakers.

The White House spent the day defending Obama’s health care proposals and stressing that Congress has not yet written the final draft of legislation that would dramatically reshape how Americans receive health care. Instead, they said, Republicans — and even some Democrats — should wait until a final bill takes form.

“There are basically five different plans in Congress right now and there are a variety of ways,” Health and Human Services Secretary Kathleen Sebelius said, trying to calm nervous lawmakers whose re-elections could hinge on the legislation.

“More will be done,” she said. “The House and the Senate are committed to working with the president to get this done.”

Getting it done by August, though, appeared to be pushed back. Administration officials said they still have a goal for the Senate and the House to pass separate bills before an August recess, leaving reconciliation of their differences for September or later. But they slid away from a once-firm do-it-this-summer demand.

“We think we can make that. We’re working towards that,” White House budget director Peter Orszag said. “And we have to remember, there are some who are advocating the delay simply because they don’t have anything to put on the table. … There are those who are advocating delay just as a desperation move to try to kill this.”

Time would appear to be on the Republicans’ side, however. A Washington Post-ABC News survey released Monday shows approval of Obama’s handling of health care reform slipping below 50 percent for the first time. The poll had a margin of sampling error of plus or minus 3 percentage points.

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Associated Press Writer Philip Elliott contributed to this report.

HBO series details Alzheimer’s pain, progress

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Posted on 9th May 2009 by Gordon Johnson in Brain Injury

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Date: 5/9/2009 4:23 PM

LYNN ELBER
AP Television Writer


LOS ANGELES (AP) — Maria Shriver said her role in a major HBO documentary series on Alzheimer’s stems from the professional and the intensely personal.

“I approached this project as a child of Alzheimer’s,” she said, a reference to her father, Sargent Shriver, who was diagnosed in 2003 with the fearsome disease that causes deepening, irreversible dementia.

Her work on the four-part “The Alzheimer’s Project” also reflects her vantage point as a journalist and a citizen who wants others to get involved in overcoming Alzheimer’s, she said.

“It’s going to take all of us as a nation to get involved in finding a cure for this,” said Shriver, a series executive producer and host of one of the programs.

There’s reason for hope, according to the documentary. In fact, “The Alzheimer’s Project” was a result of the progress being made toward treating and possibly preventing the brain disorder, said series producer John Hoffman.

After HBO’s similarly ambitious project “Addiction,” produced in cooperation with the National Institutes of Health, the cable channel wanted to continue its relationship with the agency, Hoffman said.

The search for the next topic focused on “where science has advanced and the public is unaware of these gains in knowledge,” said Hoffman.

Alzheimer’s fit that profile, he said. The disease also is among the most-feared in the nation, affecting at least 5 million Americans and expected to hit millions more as the population ages, Hoffman said.

But scientists are beginning to crack the disease’s code, according to the HBO project, which carefully — and without hype — documents advances against the disease.

The series, beginning Sunday and airing over three nights, also focuses on the emotional toll Alzheimer’s takes on its sufferers and those close to them.

It open with “The Memory Loss Tapes,” an intimate look at seven people living with Alzheimer’s. The two-part “Momentum in Science,” airing Monday and Tuesday, explores research advances with the scientists and physicians leading the way.

Also airing Monday is “Grandpa, Do You Know Who I Am?” with Shriver, which gives voice to the children and grandchildren of Alzheimer’s patients. Tuesday’s “Caregivers” details the hard work and rewards of those in the disease’s inner circle.

Besides being featured on all HBO channels and HBO On Demand, the series will stream free on hbo.com. There’s also a companion book, “The Alzheimer’s Project: Momentum in Science,” and a Web site.

Executive producer Sheila Nevins recognizes that some viewers might be more interested in the science while others are drawn to the personal accounts.

“We don’t want people to see one part and think that’s the whole story. Every part in contingent on the other,” Nevins said. “The hope is that each show answers questions and raises others answered in the multiple programs.”

Shriver, formerly with NBC News, a member of the Kennedy political dynasty and wife of California Gov. Arnold Schwarzenegger, said the call to action must include but go beyond government support for Alzheimer’s research and caregivers.

“It’s up to our generation to help find a cure,” Shriver said. “A cure is not just going to happen unless we stand up and say, ‘There are millions and millions of use, and we’re dying in a different way alongside the person who has Alzheimer’s.’”

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On the Net:

http://www.hbo.com/alzheimers

Copyright 2009 The Associated Press.
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