Brain Damage Blog

A new study introduced at the Alzheimer’s Association’s International Conference in July, suggest a strong link between head injuries in veterans and dementia. Soldiers who had suffered brain injury were two times more likely to develop the brain disorder. http://today.msnbc.msn.com/id/43797462 Another study indicates an even more ominous prognosis for another group of veterans: retired football players. The research shows that by almost three times the normal rate, 35% of former NFL gridiron warriors studied had signs of dementia, compared to 13% in the general population. Other detailed studies done by research scientists at various universities including Loyola University in Chicago, UCLA and at the University of Pennsylvania, research indicates a Traumatic Brain Injury (TBI) and the development of ‘brain clogging plaque and tangles’ that are known to cause Alzheimer’s and dementia. The new research on combat veterans is especially worrisome to Dr. Douglas Smith, of the Penn Center for Brain Injury and Repair. He suggested that these injuries and long term effects to the brain may make the “Agent Orange” concerns of a generation ago “pale by comparison”.

One of the absolute cornerstone’s to my belief system as a brain injury advocate, is that brain damage is not an immediate occurrence but part of a complex and multi-factorial process that occurs not just over minutes, but as much as 24-72 hours after the trauma. This is an issue I can almost always get defense experts to admit, but not always within the type of trauma I represent people, concussions from fall and car wrecks. Last week I was blogging on the good and the bad of the huge influx of new brain injury research coming out of Iraq, but today’s new release is clearly all positive.

In research summarized at http://www.jhu.edu/~jhumag/0208web/wholly.html#apl researchers at Johns Hopkins are saying that “Blast exposure, especially repeated exposure, can cause brain damage so subtle that soldiers may not realize they’ve been wounded. Ibolja Cernak, director of the Biomedicine Business Area at the Applied Physics Laboratory, says that these mild brain injuries can lead to gradual neurodegeneration, similar to Alzheimer’s disease.

The main researcher on this work is Ibolja Cernak, director of the Biomedicine Business Area at the Applied Physics Laboratory, at Johns Hopkins.

While there has been little controversy that blasts can cause brain damage, even without a direct blow to the head, presumably from the rapid jostling of the brain matter, inside of the skull. The Johns Hopkins story explains:

“The prevailing argument has been that waves of compressed air emanating from the blast shake the skull with enough force to strain or stretch the brain, not unlike what happens in a bad car crash. ‘It’s like a turbo-charged whiplash,” says Ross Bullock, a professor in the Department of Neurological Surgery at the University of Miami.”

But Cernak’s research posits that the blast energy is transferred in waves to the large blood vessels, which bring blood to the brain. She claims that the drastic pressure changes and rushes of blood thru these vessels from the blast, then damage the small vessels within the brain and the adjacent tissue. While not clearly more complex, analogize this to getting a bloody nose, following a series of violent sneezes.

There clearly is historical evidence to support this as an additive theory as to how the brain gets injured in combat. One of the frustrating things about modern brain injury research, is that it is done with so little historical perspective on what was known about brain damage from what I would call the “collective common sense” of centuries of working with people who were “quite right in the head” after combat. The whole concept of shell shock evolved not just because soldiers were injured by the enemies shells, but also were exposed to brain damage, from being on the sending end of shelling. Sailors on British ships of the line, were known to be at risk of getting funny, if allowed to work below deck for too long.

I once started a lecture with this joke: the most important thing to being a brain injury lawyer, is learning how to type neuro.

It sometimes feels to me, and I am sure as often to the readers of my various web pages, that there are just too many specialities with the word neuro in them. I sometimes have a hard time sorting out the neuro this’s from the neuro thats. Sometimes the specialities can’t even agree on how to spell their speciality. Take for example, the neurootologists, who are specialists in the vestibular system. The same peer reviewed literature will spell the word: neuro-otologist, neurootologist (my preferred spelling) and neurotologists.

Any way, here is my “frontal lobe test” for myself: Name all of the neuro docs I can type in 30 seconds:

neurologist
neuropsychologist
neurootologist
neuroradiologist

If you gave me extra time, I would add… neurosurgeon, neuropsychiatrist, neurobehavioral scientist, and neurolawyer. But I am not sure that the last two are in the actual book (if there were one.)

Neurologist. Most people understand what a neurologist is – a medical doctor who specializes in the neurological system. Most people interested in brain injury don’t understand that the study of neurology is so broad that brain injury only makes up about 1% of what these doctors do. To improve your odds, try to find a “behavioral neurologist.”

Neuropsychologists – these are not medical doctors, but psychologists, who at their best are neurobehaviorists, and at their worst, are test administers, who will take the concept of lieing with statistics to obscene proportions. Neuropsychology is fundamentally based upon the theory that brain pathologies, even though they cannot be directly seen in live subjects, leave behind patterns of behavior that can pinpoint where the pathology is. In its most basic form, it is based on written tests, which will show a pattern of results, where the areas of the brain affected by the pathology, will cause the test subject to do abnormally worse on the test. But any neuropsychologist worth your time, will clearly realize that the role of neuropsychology is not to administer and interpret tests, but to do a full “neuropsychological assessement” that is not a statistical process, but an analysis of all of the “footprints of pathology”, that the written test patterns, are only a small proportion of. In the coming days, I will devote an entire blog (or perhaps series of blogs) to neuropsychology, the hope of my youth as a plaintiff’s lawyer, and the bain of my maturity as one. For more on my theory of the “footprints of pathology”, click here.

Neurootologists are doctors who specialize in the vestibular system, the remarkable and complex way in which your inner ear provides the body with a gyroscope. For more on the vestibular system, click here. Some of the best neurootologists are the ones that started as neurologists, and became more specialized in the disorders of balance and vertigo, but EMT doctors who did a fellowship in the vestibular system qualify as neurootologists as well.

Neuroradiologists are radiologists who specialize in the brain and spine. Radiologists are doctors who specialize in reading diagnostic tests such as XRay, CT scans and MRI. Most of the work of the modern neuroradiologist is in CT and especially high field strength MRI. For more on neuroradiology, click here.

Neurosurgeons are surgeons who do brain and spinal surgery.

Neuropsychiatrists are psychiatrists who cross over into the field of neurology and neurobehavior, where there is an interplay between emotional/psychiatric disease and organic processes within the brain. The irony of course in that definition is that it should apply to all brain specialties, as it is “all in the head”. Again, a topic for a blog of its own, more properly a book of its own.

Neurobehavioral scientist is somewhat my own term. I think it is the role that neuropsychologists should play, on an increasing level. The most important “footprint of pathology” is the change in a person’s behavior, and particularly that change in behavior in the real world. The problem with neurobehavioral science, is that it doesn’t reduce itself to statistical analysis, doesn’t make for definitive research studies and requires subjective analysis. Well, the reason these doctors went to school for all these years, is that they could use subjective judgment to make complicated diagnosis. The human mind is far too complex to diagnose the interplay between organic pathology and emotions, without subjective judgments of trained and experienced professionals. If you doctor is not a neurobehavioral scientist, you have the wrong doctor.

Neurolawyer? There is no such specialization, at least not a recognized one. I consider myself to be a neurobehavioral expert, but not a medical expert, nor a psychological one. I work almost exclusively in the field of brain damage, and have learned from and challenged the best medical/psychological minds in the country with my inquiries, questions and depositions. But most of what I have learned has been from you – the survivors of brain injury and the family members of those survivors. I keep learning, I keep writing, I keep asking the tough questions, the questions that because I cannot be pigeon holed into any of the above specialities, often are questions that require thought, and hopefully research to answer.