Brain Injury Law Blog : Head Injury : Coma : Personal Injury : Las Vegas Nevada Lawyer & Attorney Tim Titolo

 A new study reveals that hypertension combined with at least one risk factor for developing Alzheimer's increases the chances of dementia.

"The identification of hypertension as an additional risk factor for amyloid plaque deposition is encouraging as we may be able to prevent, or at least slow, pathological aging in some individuals through lifestyle modification or pharmacological intervention," the study concludes. 

The study was conducted by Karen Rodrigue, PhD of the University of Texas at Dallas.

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Gulf War Illness and Traumatic Brain Injury.

New research confirms a link between physical changes and brain fibers that process pain. This new study concludes that veterans, compared to unaffected subjects, have significant axonal damage.

Medical symptoms have been reported by more than one-fourth of the 697,000 veterans deployed to the 1990-1991 Persian Gulf War. These symptoms, termed Gulf War Illness, range from mild to severe or debilitating and can include widespread pain, fatigue, and headache, as well as cognitive and gastrointestinal dysfunctions.

Gulf War Illness was most prevalent in veterans who served in forward areas of Iraq and Kuwait, where it was most strongly associated with use of a medication given to 1991 Gulf War troops.  Taking medications were designed to protect troops from effects of nerve agents. The study found that Gulf War Illness prevalence was nearly six times higher in veterans who served in Iraq or Kuwait, where all ground battles took place during the 1991 conflict, compared to veterans who remained on board ship during the war.

A potential biomarker for Gulf War Illness may be on the horizon as well as a possible target for therapy aimed at regenerating these neurons.

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The North American Brain Injury Society (NABIS) is having their 11th Annual Conference on Brain Injury at the Intercontinental Hotel in New Orleans, Louisiana.  The conference will be held on September 18-21, 2013.  NABIS is requesting Abstracts for the Conference.  To learn more click NABIS.

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Injured Areas of the Brain Draw on Other Areas for Function

A recent study supports the Brain's compensating for itself after injury.  I remember learning long ago that a blind person has a greater hearing ability than a person who is not blind.  Well now I have come across a study that seems to support that.

Scientists at Carnegie Mellon University's Center for Cognitive Brain Imaging (CCBI), using a combination of neural imaging methods, investigated how the human brain adapts to injury. The research is published in Cerebral Cortex, (R. A. Mason, C. S. Prat, M. A. Just. Neurocognitive Brain Response to Transient Impairment of Wernicke's Area. Cerebral Cortex, 2013; DOI: 10.1093/cercor/bhs423)  The findings show that when one brain area loses functionality, a "back-up" team of secondary brain areas immediately activates, replacing the unavailable area.

This has far reaching implications.  For instance, a situation I deal with frequently in my practice is a client who sustained a traumatic brain injury but was walking and talking afterward.  Such behavior raises significant questions from insurance companies and their lawyers as to whether a brain injury occurred.  But these new findings provide an answer.  Walking and Talking after an injury does NOT rule out traumatic brain injury.

Marcel Just, one of the scientists involved in the study, states:

"The human brain has a remarkable ability to adapt to various types of trauma, such as traumatic brain injury and stroke, making it possible for people to continue functioning after key brain areas have been damaged....It is now clear how the brain can naturally rebound from injuries and gives us indications of how individuals can train their brains to be prepared for easier recovery. The secret is to develop alternative thinking styles, the way a switch-hitter develops alternative batting styles. Then, if a muscle in one arm is injured, they can use the batting style that relies more on the uninjured arm."

Read more about the findings. 

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 Sleep Apnea

Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep.  This usually presents when someone is snoring.

Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.  The condition goes largely unnoticed by the person suffering from it since they normally fall back to sleep and are unaware of the interruption.  A sleeping partner usually notices.

Sleep apnea usually is a chronic (ongoing) condition that disrupts your sleep. When your breathing pauses or becomes shallow, you’ll often move out of deep sleep and into light sleep.

As a result, the quality of your sleep is poor, which makes you tired during the day. Sleep apnea is a leading cause of excessive daytime sleepiness.

Sleep Apnea Causes Damage

 Untreated sleep apnea can:

• Increase the risk of high blood pressure, heart attack, stroke, obesity, and diabetes
• Increase the risk of, or worsen, heart failure
• Make arrhythmias, or irregular heartbeats, more likely
• Increase the chance of having work-related or driving accidents

Women With Sleep Apnea Are More Susceptible To Brain Damage Than Are Men

 Approximately 10 years ago, this UCLA research team was the first to show that men with obstructive sleep apnea have damage to their brain cells.   Sleep Apnea causes the oxygen level in the blood to drop, eventually resulting in damage to many cells in the body.

The latest, multi-year study, "Sex Differences in White Matter Alterations Accompanying Obstructive Sleep Apnea,"  the researchers looked at patients who were diagnosed with obstructive sleep apnea at the UCLA Sleep Laboratory.

"This study revealed that, in fact, women are more affected by sleep apnea than are men and that women with obstructive sleep apnea have more severe brain damage than men suffering from a similar condition," says Paul Macey, assistant professor and associate dean of information technology and innovations at the UCLA School of Nursing.

To find out more go to the Journal Sleep VOLUME 35, ISSUE 12. 

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 Frontal Lobe

I am finishing this series of Breaking Down the Brain with an exploration of the Frontal Lobes.  The frontal lobes are considered our emotional control center and home to our personality. There is no other part of the brain where lesions can cause such a wide variety of symptoms (Kolb & Wishaw, 1990).

The frontal lobes regulate motor function, problem solving, spontaneity, memory, language, initiation, judgement, impulse control, and social and sexual behavior. The frontal lobes are extremely vulnerable to injury due to their location at the front of the cranium.  MRI studies show that the frontal area is the most common region of injury following mild to moderate traumatic brain injury (Levin et al., 1987).

Flat affect, loss of facial expression, is associated with frontal lobe damage.  

Another area often associated with frontal damage is that of behavioral spontaneity.  This was the case with the famous case of Phineas Gage.   In 1848,a twenty-five-year-old railroad construction foreman Phineas Gage was packing powder and sand into a hole in rock, and the powder detonated. A 13-pound iron rod was driven through Gage's cheek, out of the top of his head to land 30-some yards behind him. One of the more amazing anecdotes of this event was that Gage was brought to town–conscious–and he sat on his porch relating the details of the accident to his landlord while a doctor was summoned from the next town.  Although he suffered an infection soon after, and his family prepared a coffin for him, he soon recovered, even though the rod damaged one or both of his brain’s frontal lobes.

The frontal lobes are involved in several functions of the body including:

• Motor Functions
• Higher Order Functions
• Planning
• Reasoning
• Judgement
• Impulse Control
• Memory

 This is the most often damaged part of the brain when concussed in a motor vehicle crash, fall or assault.  The frontal lobes sit right on top of the cranium's bony structure near the eye sockets. Therefore, when concussed, the brain slides along those bony structures and gets damaged.

You can read more about Phineas Gage and the frontal lobes in my previous posts:

Phineas Gage and Yasser Lopez Offer Modern Brain Injury Research More Data 

Phineas Gage

Functions Associated with Lobes of the Brain

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 Temporal Lobe

We continue Breaking Down the Brain by looking at the Temporal Lobe.  The temporal lobes are one of the four main lobes or regions of the cerebral cortex. Structures of the limbic system, including the olfactory cortex, amygdala, and the hippocampus are located within the temporal lobes.

The temporal lobes play an important role in organizing sensory input, auditory perception, language and speech production, as well as memory association and formation.

• The limbic system supports a variety of functions including emotion, behavior, motivation, long-term memory, and olfaction.
• The Olfactory Cortex is the sensory system used for the sense of smell.
• The Amygdala performs a primary role in the processing of memory and emotional reactions.
• The Hippocampus plays an important role in the consolidation of information from short-term memory to long-term memory and spatial navigation.*

The Functions of the Temporal Lobe include:

• Auditory Perception
• Memory
• Speech
• Emotional Respones
• Visual Perception

Kolb & Wishaw (1990) have identified eight principle symptoms of temporal lobe damage:

1) disturbance of auditory sensation and perception,

2) disturbance of selective attention of auditory and visual input,

3) disorders of visual perception,

4) impaired organization and categorization of verbal material,

5) disturbance of language comprehension,

6) impaired long-term memory,

7) altered personality and affective behavior,

8) altered sexual behavior.

Again, damage to the temporal lobe from car crash, fall, assault or other event may not result in impairments of all these areas.  Often there is selective impairments to a few areas making it difficult for others to understand.  This can make relationships and socialization with others difficult. Neuropsychological testing helps medical providers identify impairments and propose treatment.

Seizures of the temporal lobe can have dramatic effects on an individual's personality. Temporal lobe epilepsy can cause perseverative speech, paranoia and aggressive rages (Blumer and Benson, 1975). Severe damage to the temporal lobes can also alter sexual behavior (e.g. increase in activity) (Blumer and Walker, 1975).

You can read more about the temporal lobes in my previous blog posts:

Changes Observed after Brain Injury

Functions Associated with Lobes of the Brain

Psychiatric Issues in Traumatic Brain Injury

Imaging and Diagnosis of Alzheimer's

* Definitions from Wikipedia

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 The Parietal Lobe

The Parietal Lobe is the upper middle lobe of each cerebral hemisphere, located above the temporal lobe. Complex sensory information from the body is processed in the parietal lobe, which also controls the ability to understand language.  The parietal lobe is a part of the brain positioned above (superior to) the occipital lobe and behind (posterior to) the frontal lobe.

The functions of the Parietal Lobe include:

• Cognition
• Information Processing
• Pain and Touch Sensation
• Spatial Orientation
• Speech
• Visual Perception

Damage to the left parietal lobe

can result in right-left confusion, difficulty with writing (agraphia) and difficulty with mathematics (acalculia). It can also produce disorders of language (aphasia) and the inability to perceive objects normally (agnosia).

• Agraphia is inability to write resulting from brain damage.
• Acalculia is a difficulty performing simple mathematical tasks, such as adding, subtracting, multiplying and even simply stating which of two numbers is larger.
• Aphasia is an impairment of language ability.
• Agnosia is a loss of ability to recognize objects, persons, sounds, shapes, or smells. It is usually associated with brain injury.*

Damage to the right parietal lobe

can result in neglecting part of the body or space which can impair many self-care skills such as dressing and washing. Right side damage can also cause difficulty in making things (constructional apraxia), denial of deficits and drawing ability.

• Constructional apraxia is characterized by an inability or difficulty to build, assemble, or draw objects.*

Damage to both the right and left parietal lobes

can cause a visual attention and motor syndrome. This is the inability to voluntarily control the gaze, inability to integrate components of a visual scene (simultanagnosia), and the inability to accurately reach for an object with visual guidance (optic ataxia). 

• Simultanagnosia is characterized by the inability of an individual to perceive more than a single object at a time.
• Optic Ataxia is a lack of voluntary coordination of muscle movements.*

Right parietal-temporal lesions can produce significant changes in personality.  Damage to the areas between the parietal lobes and the temporal lobes can also result in changes in personality and memory.

It is very important to understand that a traumatic brain injury from a fall, assault, car crash, or other event, which causes damage to the Parietal Lobe does NOT mean that all the impairments discussed above will definitely manifest.  So you can have some of the impairments and not others.  This where neuropsychological testing becomes vital for doctors in accessing injury and treatment protocol.  

Too many times the people who live, work, socialize or interact with a person, who has sustained parietal lobe damage, do not understand how the person is able to do many things appropriately but cannot do certain other things.  This problem can lead to overlay or manifestation of other problems like depression.

For additional information you can read my prior blog posts:

• Changes Observed After Brain Injury
• Functions Associated with Lobes of the Brain

* Definitions from Wikipedia.

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 This second installment of the series I am posting about the Anatomy of the Brain deals with the Occipital Lobe.  The occipital lobe is the visual processing center of the mammalian brain.

The primary visual cortex is Brodmann area 17, located in the interior portion of the occipital lobe. Although located at the back of the brain, the Occipital Lobe is responsible for vision which enters the brain through the eyes at the front of the brain.

The Occipital Lobes are positioned at the back region of the cerebral cortex and are the main centers for visual processing. In addition to the occipital lobes, posterior portions of the parietal lobes and temporal lobes are also involved in visual perception. Located within the occipital lobes is the primary visual cortex. This region of the brain receives visual input from the retina. These visual signals are interpreted in the occipital lobes.

The occipital lobes are involved in several functions of the body including:

• Visual Perception
• Color Recognition

 They are not particularly vulnerable to injury because of their location at the back of the brain, although any significant trauma to the brain could produce subtle changes to our visual-perceptual system.  Disorders of the occipital lobe can cause visual hallucinations and illusions. Visual hallucinations (visual images with no external stimuli) can be caused by lesions to the occipital region or temporal lobe seizures. Visual illusions (distorted perceptions) can take the form of objects appearing larger or smaller than they actually are, objects lacking color or objects having abnormal coloring. Lesions in the parietal-temporal-occipital association area can cause word blindness with writing impairments (alexia and agraphia).  (Kandel, E., Schwartz, J., & Jessell, T. Principles of Neural Science. 3rd edition. New York: NY. Elsevier, 1991.)

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Breaking Down the Brain Series: 1-Thalamus 

The next few posts will deal with the Anatomy of the Brain.  This is a general overview of the brain structure and function.  This is the first in a series I am posting about the Anatomy of the Brain.  This week we will look at the Thalamus.

The thalamus is a mid-line paired symmetrical structure within the brains of vertebrates, including humans. It is situated between the cerebral cortex and mid-brain, both in terms of location and neurological connections.

Anatomically, the thalamus is perched on top of the brain stem, near the center of the brain, in a position to send nerve fibers out to the cerebral cortex in all directions.

The Thalamus is involved in sensory perception and regulation of motor functions. It is involved in several functions of the body including:

• Motor Control
• Receiving Auditory, Somatosensory and Visual Sensory Signals
• Relaying Sensory Signals to the Cerebral Cortex
• Controling Sleep and Awake States

Both parts of this structure of the brain in the human are each about the size and shape of a walnut. These are about three centimeters in length, at the widest part 2.5 centimeters across and about 2 centimeters in height. 

The thalamus also plays an important role in regulating states of sleep and wakefulness.

To learn more see the Free Medical Dictionary.

Next week we will examine the Occiptal Lobe.

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Sports Concussions do NOT Differ as to Gender.

In the first study to control for type of sport played when looking a gender differences, the only significant gender-related difference researchers could identify was that female soccer players reported a greater number of post-concussion symptoms. There were no significant differences in post-concussion neurocognitive scores.

 As female participation in sports has grown rapidly, there is a popular notion that there are gender-related differences in athletes' responses to sports-related concussion, and prior research has supported these gender discrepancies.  One personal observation as to the reason why we have findings like that is boys/men engage in more concussion orientated sports like football and boxing.  But that too has changed in the last decade.

A Vanderbilt University Medical Center study, conducted to review symptoms and neurocognitive findings in male and female high school soccer players, shows no gender-related differences.

The researchers selected 40 male and 40 female concussed patients who were matched, as closely as possible, for age, medical/psychiatric history, years of education, lack of special education assistance, history of psychiatric treatment, number of prior concussions, timing of pre- and post-concussion testing, and sport (all engaged in soccer).

I was also pleased when discovering that high schools with athletic trainers have lower overall injury rates, according to a new study, "A Comparative Analysis of Injury Rates and Patterns Among Girls' Soccer and Basketball Players," presented Oct. 22 at the American Academy of Pediatrics (AAP) National Conference and Exhibition in New Orleans. In addition, athletes at schools with athletic trainers are more likely to be diagnosed with a concussion.

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  MRI Shows Promise in Treating Post Concussion Syndrome

New findings suggest MRI shows changes in the brains of people with post-concussion syndrome (PCS).  These findings are from a new study published online in the journal Radiology. Researchers hope the results point the way to improved detection and treatment for the disorder.

Concussion Defined

A concussion is a type of traumatic brain injury that alters the way your brain functions. Effects are usually temporary, but can include problems with headache, concentration, memory, judgment, balance and coordination, light sensitivity and more.

Many concussions are usually caused by a blow to the head.  But they can also occur when the head and upper body are violently shaken in a very short period of time - milliseconds. These injuries can cause a loss of consciousness, but most concussions do not. Because of this, some people have concussions and don't realize it.

Concussions are common, particularly if you play a contact sport, such as football. But every concussion injures your brain to some extent. This injury needs time and rest to heal properly. Luckily, most concussive traumatic brain injuries are mild, and people usually recover fully. However in making that statement one must acknowledge that there are a percentage - 15-25% - of concussions that do not fully recover.

 Post Concussion Syndrome affects approximately 20 percent to 30 percent of people who suffer mild traumatic brain injury (MTBI) -- defined by the World Health Organization as a traumatic event causing brief loss of consciousness and/or transient memory dysfunction or disorientation.

Conventional neuroimaging cannot distinguish which Mild Traumatic Brain Injury patients will develop Post Concussion Syndrome.  "Conventional imaging with CT or MRI is pretty much normal in Mild Traumatic Brain Injury patients, even though some go on to develop symptoms, including severe cognitive problems," said Yulin Ge, M.D., associate professor, Department of Radiology at the NYU School of Medicine in New York City.

In my years of practice, I have witnessed clear mild Traumatic Brain Injury in clients who have been in an accident.  Sometimes the person is markedly forgetful, lacks the ability to concentrate and communicate, stays isolated socially, or any other of a myriad of symptoms.  However the MRI of the brain is "normal."  People trying to disprove the Brain Injury love to cling to this finding.  It is objective and can get quite a bit of mileage for those defending a traumatic brain injury case.  They'll say the person is faking or lying about the injury.

• The Study

For the new study, Dr. Ge and colleagues used resting-state functional MRI to compare 23 MTBI patients who had post-traumatic symptoms within two months of the injury and 18 age-matched healthy controls. Resting state MRI detects distinct changes in baseline oxygen level fluctuations associated with brain functional networks between patients with MTBI and control patients.

The MRI results showed that communication and information integration in the brain were disrupted among key DMN structures after mild head injury, and that the brain tapped into different neural resources to compensate for the impaired function.

Findings like these will make it easier to detect, identify and treat people who fall into the mild traumatic brain injury category.  And it will make proving the injury and its affects easier.

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 Traumatic Brain Injury and Post Traumatic Stress Disorder Cause Vision Problems for Veterans

As the wars in Afghanistan and elsewhere rage on, scientists and medical providers have plenty of test subjects for Brain Injury and Post Traumatic Stress Disorder study.

 Many veterans of the United States armed forces with traumatic brain injury or/or post-traumatic stress disorder are also likely to have undiagnosed, chronic vision problems.  These findings were presented in two studies.  

The first at the 116th Annual Meeting of the American Academy of Ophthalmology, jointly conducted this year with the Asia-Pacific Academy of Ophthalmology.

• Vision Affected by Traumatic Brain Injury

Researchers found that vision problems in veterans with mild traumatic brain injury are much more common and persistent than previously recognized.  67 percent of the 31 patients studied reported chronic vision disorders. Though none of the affected veterans suffered direct eye wounds, their vision continued to be impaired more than a year after they endured the injuries that caused their traumatic brain injury.

Blast-related traumatic brain injury is the most frequent injury of the Iraq and Afghanistan wars. From 2000–2012, the Department of Defense reported 194,561 cases of mild traumatic brain injury, or about 76% of all traumatic brain injuries.

• Vision Affected by Post Traumatic Stress Disorder

A second study of war veterans, conducted at the Miami Veterans Affairs Medical Center and the Bascom Palmer Eye Institute at the University of Miami, found that veterans who have post-traumatic stress disorder (PTSD) or depression are much more likely to develop dry eye syndrome than veterans who do not have these psychological diagnoses.  Dry eye syndrome is when the eye is unable to maintain a healthy layer of tears to coat it. 

Generally, in U.S. population, the risk of dry eye syndrome increases with age, affecting about 3.2 million women age 50 and older and 1.68 million men age 50 and older.  The average age of the veterans with dry eye syndrome in this Veterans Affairs Medical Center study is younger than is typical for dry eye patients in the civilian population.

It is still unclear whether the dry eye syndrome is directly caused by the Post traumatic stress disorder, depression associated with it, or the medication used to treat it.

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