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

Detecting Brain Injury, especially in trauma cases, is difficult.  Usually emergency medical technicians and emergency room physicians focus on the most pressing and visible injuries: blood gushing wounds and the like.

When a person comes to the ER with a TBI, doctors must determine if there is any bleeding in the brain.  Bleeding can cause a pool of blood that puts pressure on the surrounding brain tissue, causing more damage. Subdural and epidural hematoma being most common.  Currently, the best, quick way to look for intracranial bleeding is with a CT scan.  Unfortunately this test provides little resolution to actually see anything other than big masses of blood.

 CT scans are used to detect a number of potential problems for ER patients. So the demand for the units is often high and the wait for a scan for a TBI patient can be long. In addition,  in 95 percent of patients with mild TBI, the CT scans are normal.  So CT is not the best detector of brain injury, it is simply practical in that it is least invasive to the injured patient, takes realtively less time then other tests such as MRI, EEG, DTI and PET.

 Researchers are looking at another way to detect potential brain damage from a TBI, using a blood test instead of an imaging technique. The blood test looks for a marker, called S-100B, a type of protein from a type of brain cell known as an astrocyte. Studies show this marker is elevated in patients with a brain bleeding after a TBI.

 The blood test takes about 20 minutes to perform. However, studies suggest that the test must be done within three hours to ensure accuracy. If the test is negative, it’s most likely the patient doesn’t need a CT scan.

 The S-100B test is approved for use in Europe, but it is still under study in the U.S. Researchers are still enrolling patients in the US trial. In the future, a portable screener may be developed so that rescue workers can administer the test before the patient gets to the hospital. That will save time in the emergency room and enable doctors to start appropriate treatment faster.

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Hospitals that make greater use of inpatient diagnostic imaging exams achieve lower in-hospital mortality rates with little or no impact on costs, according to a peer-reviewed study of more than 1 million patient outcomes in more than 100 hospitals nationwide published in the November issue of the Journal of the American College of Radiology (JACR).

"The results of our in-depth study would indicate that greater use of imaging does, in fact, lead to better patient outcomes in terms of lower in-hospital death rates with no significant impact on overall cost," said David W. Lee, Ph.D., lead author of the article and Senior Director, Health Economics and Outcome Research at GE Healthcare. "This study dealt only with imaging provided in hospitals, but would seem to confirm what many have long suspected - that medical imaging exams save lives."

Read the full article here.

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 The belief that healthy older brains are substantially smaller than younger brains may stem from studies that did not screen out people whose undetected, slowly developing brain disease was killing off cells in key areas, according to new research. As a result, previous findings may have overestimated atrophy and underestimated normal size for the older brain.
 

The seeming age-related atrophy in gray matter more likely reflected pathological changes in the brain that underlie significant cognitive decline than aging itself, the authors wrote. As long as people stay cognitively healthy, the researchers believe that the gray matter of areas supporting cognition might not shrink much at all.

"The Prevalence of Cortical Gray Matter Atrophy May Be Overestimated In the Healthy Aging Brain,"
Saartje Burgmans, PhD student, Martin P. J. van Boxtel, PhD, MD, Eric F. P. M. Vuurman, PhD, Floortje Smeets, PhD student, and Ed H. B. M. Gronenschild, PhD, Maastricht University; Harry B. M. Uylings, PhD, Maastricht University and VU University Medical Center Amsterdam; and Jelle Jolles, PhD, Maastricht University;
Neuropsychology, Vol. 23, No. 5.
 

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Advance in neuroimaging are always exciting as they assist doctors and clinicians in treating patients with traumatic brain injury. 

Functional magnetic resonance imaging (fMRI) is a technique widely used in studying the human brain. However, it has long been unclear exactly how fMRI signals are generated at brain cell level. This information is crucially important to interpreting these imaging signals. Scientists from the Academy of Finland's Neuroscience Research Programme (NEURO) have discovered that astrocytes, support cells in brain tissue, play a key role in the generation of fMRI signals.

Functional magnetic imaging has become a highly popular method in basic neurobiological research, psychology, medicine as well as in areas of study that interface with the social sciences and economics, such as neuroeconomics. fMRI imaging does not directly measure the activity of nerve cells or neural networks, but local changes in cerebrovascular circulation during the execution of certain functions. Interpretation of the measurement data obtained with this method therefore requires a close knowledge of the cell-level mechanisms that are responsible for these local changes in cerebrovascular circulation.
 

Read morehere.

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While I have seen the uses and acceptance of PET in traumatic brain injury cases in the court room, this is something worth sharing on other uses of PET:

PET scans are commonly used to investigate the following conditions:
Epilepsy - it can reveal which part of the patient's brain is being affected by epilepsy. This helps doctors decide on the most suitable treatments.MRI and/or CT scans are recommended for people after a first seizure, this study explains.

Alzheimer's disease - it is very useful in helping the doctor diagnose Alzheimer's disease. A PET scan that measures uptake of sugar in the brain significantly improves the accuracy of diagnosing a type of dementia often mistaken for Alzheimer's disease, a study revealed.

Interesting related articles:

What is MRI? How does MRI work?

What is a CT scan? What is a CAT scan?
Cancer - PET scans can show up a cancer, reveal the stage of the cancer, show whether the cancer has spread, help doctors decide on the most appropriate cancer treatment, and give doctors an indication on the effectiveness of ongoing chemotherapy. A PET scan several weeks after starting radiation treatment for lung cancer can indicate whether the tumor will respond to the treatment, a study showed. This article looks at whether PET scans are beneficial during cancer diagnosis, staging and monitoring.

Heart disease - a PET scan helps detect which specific parts of the heart have been damaged or scarred. Any faults in the working of the heart are more likely to be revealed with the help of a PET scan. A study revealed how comprehensive diagnosis of heart disease based on a single CT scan is possible.

Medical research - researchers, especially those involved in how the brain functions get a great deal of vital data from PET scans.

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I came across this brief explanantion of some of the topics I will be presenting with Dr. Joseph Wu of University of California, Irvine, in next week's Brain Injury Association of America Conference in Las Vegas.  Here CT, MRI,fMRI, Spect and PET are discussed.  These diagnostics show us the structure and metabolism of the brain.  EEG (not discussed below) reveals electrical activity of the brain.

Dr. Wu is the Director of the Brain Imaging Center and will be discussing advances in Positron Emission Tomography technology and use in brain injury detection.  This information was derived from Microsoft® Encarta® Online Encyclopedia 2007:

Brain Imaging

Several commonly used diagnostic methods give images of the brain without invading the skull. Some portray anatomy—that is, the structure of the brain—whereas others measure brain function. Two or more methods may be used to complement each other, together providing a more complete picture than would be possible by one method alone.

Magnetic resonance imaging (MRI), introduced in the early 1980s, beams high-frequency radio waves into the brain in a highly magnetized field that causes the protons that form the nuclei of hydrogen atoms in the brain to reemit the radio waves. The reemitted radio waves are analyzed by computer to create thin cross-sectional images of the brain. MRI provides the most detailed images of the brain and is safer than imaging methods that use X rays. However, MRI is a lengthy process and also cannot be used with people who have pacemakers or metal implants, both of which are adversely affected by the magnetic field.

Computed tomography (CT), also known as CT scans, developed in the early 1970s. This imaging method X-rays the brain from many different angles, feeding the information into a computer that produces a series of cross-sectional images. CT is particularly useful for diagnosing blood clots and brain tumors. It is a much quicker process than magnetic resonance imaging and is therefore advantageous in certain situations—for example, with people who are extremely ill.

Changes in brain function due to brain disorders can be visualized in several ways. Magnetic resonance spectroscopy measures the concentration of specific chemical compounds in the brain that may change during specific behaviors. Functional magnetic resonance imaging (fMRI) maps changes in oxygen concentration that correspond to nerve cell activity.

Positron emission tomography (PET), developed in the mid-1970s, uses computed tomography to visualize radioactive tracers (see Isotopic Tracer), radioactive substances introduced into the brain intravenously or by inhalation. PET can measure such brain functions as cerebral metabolism, blood flow and volume, oxygen use, and the formation of neurotransmitters. Single photon emission computed tomography (SPECT), developed in the 1950s and 1960s, uses radioactive tracers to visualize the circulation and volume of blood in the brain.

Brain-imaging studies have provided new insights into sensory, motor, language, and memory processes, as well as brain disorders such as epilepsy; cerebrovascular disease; Alzheimer's, Parkinson, and Huntington's diseases (see Chorea); and various mental disorders, such as schizophrenia.

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This information was derived from Microsoft® Encarta® Online Encyclopedia 2007:

Brain Imaging

Magnetic Resonance Imaging or MRI

Magnetic resonance imaging (MRI), introduced in the early 1980s, beams high-frequency radio waves into the brain in a highly magnetized field that causes the protons that form the nuclei of hydrogen atoms in the brain to reemit the radio waves. The reemitted radio waves are analyzed by computer to create thin cross-sectional images of the brain. MRI provides the most detailed images of the brain and is safer than imaging methods that use X rays. However, MRI is a lengthy process and also cannot be used with people who have pacemakers or metal implants, both of which are adversely affected by the magnetic field.

Computed Tomography or CT

Computed tomography, also known as CT scans, developed in the early 1970s. This imaging method X-rays the brain from many different angles, feeding the information into a computer that produces a series of cross-sectional images. CT is particularly useful for diagnosing blood clots and brain tumors. It is a much quicker process than magnetic resonance imaging and is therefore advantageous in certain situations—for example, with people who are extremely ill.

Functional Magnetic Resonance Imaging of fMRI

Changes in brain function due to brain disorders can be visualized in several ways. Magnetic resonance spectroscopy measures the concentration of specific chemical compounds in the brain that may change during specific behaviors. Functional magnetic resonance imaging (fMRI) maps changes in oxygen concentration that correspond to nerve cell activity.

Positron Emission Tomography or PET

Positron emission tomography (PET), developed in the mid-1970s, uses computed tomography to visualize radioactive tracers (see Isotopic Tracer), radioactive substances introduced into the brain intravenously or by inhalation. PET can measure such brain functions as cerebral metabolism, blood flow and volume, oxygen use, and the formation of neurotransmitters. Single photon emission computed tomography (SPECT), developed in the 1950s and 1960s, uses radioactive tracers to visualize the circulation and volume of blood in the brain.

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60 Minutes just aired an incredible piece on new findings for brain injured people in a minimally conscious state. 

The story describes fireman Don Herbert who was injured when a roof fell on him while making a rescue attempt.  Unconscious for 10 years, Don is shown waking up and being aware of the fact that he was "gone."

The next story is of George Menendez who also sustained brain injury and was minimally conscious.  His mother thought to give him Ambien for sleep one night when he was moaning.  George, for the first time, opened his eyes and was able to communicate with his family.

Experts believe there is a subset of brain injured people who may respond to Ambien.  PET scans were done before and after Ambien was ingested and the results were remarkable.  The brain showed distinctive functioning after Ambien.

This is an exciting discovery and I hope there is more to come.  To see the amazing 12 minute video click here.

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