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Closed Head Injuries/Brain Injuries

The number one cause of head injuries is road accidents. Drivers, passengers, pedestrians, and cyclists are the victims. Other causes include assaults, injuries incurred in sporting events, and falls resulting in a blow to the head.

1.5 million people each year incur a closed head injury, 75% of which are classified as mild. However, each year approximately 50,000 individuals die from head injuries and more than 100,000 suffer permanent disability. The severity of the injury is initially judged by assessing the so-called Glasgow Coma Scale (GCS) which assesses eye, motor, and verbal abilities. A score of 13-15 indicates a mild injury, a score of 9-12 indicates moderate injury, and a score of 8 or less indicates severe injury. Concussion, where there is no loss of consciousness, is considered a mild injury.

There have been great advances recently in the understanding of the pathologic process that results from a closed head injury. Depending on the severity of the blow the following structural findings may be present as noted clinically or by imaging: linear or depressed skull fractures, subgaleal hematomas ("goose eggs"), intracranial hemorrhage, cerebral edema, diffuse axonal injury (DAI), or no findings at all. Intracranial hemorrhages may include Sudbury hematoma, epidermal hematomas, intracerebral hemorrhage, or subarachnoid hemorrhage. The recent use of amyloid precursor protein staining has enabled clinicians to identify axonal injury which is often responsible for memory and cognitive impairment, and sometimes vegetative states associated with coma.

Neurochemical changes occur after traumatic brain injury. There is a release of free radicals as cell membranes break down. Together with free lipids and other chemical mediators such as prostaglandins and thromboxane, these substances produce severe inflammation which leads to swelling and ultimate cell and neuron death.

It is most important to ascertain whether or not you have lost consciousness during a traumatic incident. Generally, the prognosis is worse if you lost consciousness since there is a greater risk that the mediators of brain inflammation are produced in this setting. It is also important to elicit the type and mechanism of injury, as these also have some prognostic importance. Someone who is injured by assault or from a falling object has a much greater risk than patients sustaining acceleration/deceleration injuries that occur in motor vehicle accidents, because the former mechanism is associated with greater axonal damage. Also, if you are taking anticoagulant medication, you must immediately advise your physician, because you are at much greater risk for internal bleeding.

If you have sustained an injury to your head, a complete neurologic exam should be performed. External examination should rule out several telltale signs of serious internal head injury, namely: battle's sign and raccoon eyes (to rule out a basilar skull fracture), hemotympanum (blood behind the ear drum), oto- or rhinorrhea (cerebrospinal fluid coming from the ear or nose), or abnormal pupil size or reactivity (indicative of a space occupying bleed causing impending brain herniation). Focal motor abnormalities such as weakness of the extremities, impaired reflexes, or posturing are indicators of severe brain injury. Finally, a thorough mental status exam must be performed to assess memory (vs. amnesia), cognition and judgment.

Low serum sodium levels (hyponatremia) occurs in up to 50% of moderately and severely head injured patients because of SIADH (syndrome of inappropriate antidiuretic hormone). Also, low serum magnesium levels are noted in all degrees of head injury including mild forms. Elevated serum neuron- specific enolase and protein S-100 B are excellent prognostic markers and correlate with persistent cognitive impairment after 6-12 months in patients with both minor and severe head injuries.

Computerized tomography (CT) is the main imaging technique used in the immediate acute setting. This study is sometimes followed up with an MRI (magnetic resonance imaging) if the CT is equivocal or if there is a need to rule out axonal injury (DAI). All accident victims with loss of consciousness or focal neurologic findings should undergo CT. Behavioral disorders, memory and other cognitive dysfunction correlates with abnormalities of the cingulate gyrus metabolism that can be picked up by PET scanning (positive emission tomography). Also, mild head injury can produce elevated choline/creatine ratios that can be picked up on proton magnetic resonance spectroscopy (the MRI in these patients is normal).

Long term management of moderate and severe head injury is complex and often frustrating. Medications are necessary to control spasticity or dystonia. Cognitive impairment may improve with some experimental treatments including levodopa and methylphenidate.

Typically, these injuries are associated with mild symptoms and mild cognitive impairments and resolve within 3 months of injury. Symptoms include headache, numbness, tingling, ringing in the ears, neck soreness, dizziness, a dissociative feeling, forgetfulness, confusion, irritability, emotional lability, and an inability to concentrate. Some studies show that following mild head injury, only 54-79% of patients are able to return to their jobs. One study showed that after one year, 26% had moderate disability and 3% had severe disability. The most commonly reported persistent symptoms were irritability, fatigue, attention and memory disorders, and neuropsychologic dysfunction, including depression.

Post-traumatic headaches are also of special concern because they tend to be disabling. The mechanism involves the production of substances seen in migraine conditions: catecholamines and excitatory amino acids.

All head injured patients are potential litigants because of the persistent and disabling nature of the condition. Make sure your physicians document your case meticulously and substantiate the mechanism of your injury, the extent of your injury, the physical, emotional and cognitive consequences of your injury, delineate the treatment, and discuss your prognosis.

If you have suffered this type of injury, due to the negligence of another person or entity, you may be entitled to monetary compensation. These types of accidents require expert analysis and the resources of an experienced, board certified civil trial attorney. The Law Office of Steven S. Farbman, P.A., specializes in cases involving this type of injury and will make sure the negligent parties are held accountable for their actions. The Law Office of Steven S. Farbman, P.A. is committed to helping people who have been involved in an accident. We understand that being injured in an accident is a difficult time for you. Our office will be there for you in your time of despair. You are more than a file number at the Law Office of Steven S. Farbman, P.A.. You are family. We will protect your rights and aggressively pursue all legal remedies available to you under the law.

Call now for a FREE initial consultation 1(866) FLA-ATTY or click here for a FREE on-line evaluation. These types of cases are subject to a Statute of Limitations. Therefore, it is extremely important you act immediately to ensure your claim is preserved and you do not waive your rights to the compensation you deserve. Our firm works on a contingency fee basis. This means we get paid for our services only if, and when, there is a money recovery for you. You deserve the best possible legal representation, so call us now 1(866) FLA-ATTY.


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