Symptoms of concussions often disappear within 7-10 days of an injury–prompting medical release back to sports play. However, preliminary results of a new imaging study presented at a recent American Academy of Neurology conference showed that brain changes caused by “temporary” concussions may last six months or more after the injury. The study, which is ongoing, used diffusion tensor imaging (DTI) to exam connective brain tissue or “white matter” in eighteen students with concussions. White matter brain changes are also associated with stroke and Alzheimer’s.
A study by doctors at Montefiore Medical Center and Albert Einstein College of Medicine provides additional support that use of Diffusion Tensor Imaging (DTI) may be clinically helpful to patients with mild Traumatic Brain Injuries (TBI) because it shows possible evidence of brain repair in post-injury patients. Scans conducted one year post-injury show that patients who exhibited abnormally high fractional anisotropy shortly after injury were “significantly associated” with better overall health outcomes.
The DTI scans were performed on a control group and on 39 injured subjects within 16 days of injury and one year later on 26 returning patients. According to the study, the patients were also tested for changes in cognition and symptomology. The results showed that DTI may be a “marker of compensatory neural mechanisms and an indicator of favorable outcome.” This is supportive data to an earlier study showing positive results from DTI use in pediatric patients, and an important study that used DTI to check the movement of water molecules in the brain of NFL players. In the NFL study the scans showed that those with marked deviations in fluid movement also demonstrated “abnormalities in attention and concentration, executive function, learning/memory and spatial/perceptual function.”
The ability to identify areas of damage and potential for repair are expected to inspire development of new effective treatments for patients with TBIs. Cognitive and physical effects of even mild TBIs may require extensive and long-term treatment from various healthcare providers including doctors, physical therapists, occupational therapists, and psychologists. If you or someone you know has suffered a TBI you should consult an experienced attorney to find out if you can seek reparation to get assistance with medical bills—consultations are usually free and services are often offered on a contingency basis.
Brent Masel, M.D., the medical director of the Brain Injury Association-America published a paper which called traumatic brain injury a chronic disease. In that paper, Dr. Masel outlined a list of medical conditions associated with traumatic brain injury and encouraged that a TBI be looked at, “not as an event, not as the final outcome, but rather as the beginning of a disease process.”
More recently, Charles Wilkinson, Ph.D. and Elizabeth A. Colasurdo, researchers with the Veterans Affairs Puget Sound Health Care System in Seattle issued a press release stating: “Although studies and civilians indicate a 25%-50% prevalence of hormonal deficiencies resulted from brain injury, surprisingly there is limited data on the prevalence and symptoms in military veterans.”
A new study from the University of Adelaide in Australia found that in the medium- to long-term pediatric traumatic brain injury (TBI), the fractional anisotropy (FA) values for numerous large white matter tracks in comparison to the whole brain were related to cognition. This study, published online in Developmental Neuropsychology, specifically examined the relationship between diffusion tensor imaging (DTI) findings and cognition following pediatric traumatic brain injury.
Francis X. Conidi, M.D. from the Florida Center for Headache and Sports Neurology has issued a new study which examined retired NFL players for signs of traumatic brain injuries using Diffusion Tensor Imaging (DTI), and the results were fairly damning. The study found that over 40% of the retired NFL players had sustained a traumatic brain injury. Approximately 40 retired NFL players underwent the exam, which included a Compressive Neurological/Headache history, neurological examination, neurophysiological evaluation, Clinical Dementia Rating Scale, physiological evaluation and DTI MRI were performed. According to Dr. Conidi, this represents “one of the largest studies to date in living retired NFL players.”
The North America Brain Injury Society (NABIS) held its 29th Medical Legal Traumatic Brain Injury Seminar to educate attorneys and assist them in better representing their clients. Medical and legal experts from around the United States presented at this three day conference held in Tampa, Florida.
As one of the programs co-chairs, along with Ken Kolpan, Stewart Casper, and Simon Forgette, we put together what many considered to be the premier medical legal traumatic brain injury conference in the United States. I had the pleasure of presenting on the topic of the admissibility of diffusion tensor imaging, which is a sophistic neuroimaging technique that can detect traumatic brain injury where conventional MRI and CT cannot.
I look forward to seeing everyone next year (March 29-April 1, 2017) in New Orleans when NABIS will be hosting the 30th Medical Legal Traumatic Brain Injury Seminar in conjunction with the International Brain Injury Association’s 12th World Congress that will be held at the same time.
Brent Masel, M.D., medical director of the Brain Injury Association of America, authored a paper entitled “Brain Injury as a Chronic Disease” in which he presented the strong argument that traumatic brain injury should be thought of as a chronic disease. In the white paper he laid out the long term consequences of TBI, including increased mortality and the increased incidence of sequelae from TBI. Nevertheless, defense courtroom doctors continue to argue that mild traumatic injury is self limiting and does not result in long term problems.
A new study from the University of Toronto, titled “Risk of Suicide after a Concussion,” assessed the long-term risk of suicide after concussion. Dr. Michael Fralick and his colleagues performed a longitudinal cohort analysis of adults with the diagnosis of a concussion in Ontario, Canada from April 1, 1992 to March 31, 2012, a 20 year period. Severe cases that resulted in hospitalization were excluded.
A federal judge has once again upheld the introduction of diffusion tensor imagining (DTI) in an mTBI case, rejecting defendant’s motion to exclude the DTI findings. In White v. Deere and Co., plaintiff filed a product liability action arising out of an incident that occurred while plaintiff was operating her Deere Model 4600 compact utility tractor and Model 460 loader. Plaintiff asserted that she sustained a traumatic brain injury as a result of a hay bale falling onto her head while she was operating the tractor.
Plaintiff retained Randall Benson, M.D. a board-certified neurologist as one of her medical experts. According to the opinion, Dr. Benson opined plaintiff sustained a traumatic brain injury, basing his opinion, in part, on the results derived from a DTI. Defendants moved to exclude Dr. Benson’s DTI findings, arguing that the DTI finding was unreliable.
The court, after discussing the admissibility standard established by the US Supreme Court in Daubert, Joiner and Kumho Tire, performed an analysis to determine whether Dr. Benson’s use and reliance on DTI was permissible.
A Nevada District Court trial judge recently ruled that Michael Freeman, Ph.D., an epidemiologist, was qualified to testify in a medical malpractice case. Karosy v. Summerlin Hospital Medical Center, et al., Case No. A-12-660815-C (Clark County, Nevada D.C.). In this case, 16-month-old infant plaintiff was admitted to Summerlin Hospital with a diagnosis of pneumonia. When her condition worsened, she was ultimately intubated. During the course of care, plaintiff sustained severe brain damage. The defendants, through their experts, claimed that plaintiff’s severe brain damage was likely caused by plaintiff’s medical condition and not medical negligence.
Plaintiff retained Michael Freeman, Ph.D., an epidemiologist, who performed an expert analysis of defendants’ alternative theories of causation. Epidemiology is a particular branch of medicine which studies the patterns, causes, and effects of diseases and other factors relating to the health of the body. Dr. Freeman offered opinions in epidemiology and rebutted defendants’ expert’s opinions that the child’s brain damage was caused by plaintiff’s medical condition individually and/or in combination, rather than defendants’ alleged negligence.
Defendants filed a motion in limine to strike Dr. Freeman and argued that because Dr. Freeman was not a medical doctor, he was not qualified to give opinions as to breaches in the standard of care, medical causation, and life expectancy.
Researchers at the University of Pittsburgh Medical Center recently utilized Shannon entropy, which is a mathematical information theory model that looks at areas of entropy or disorder in the brain, to determine which concussion patients would go on to suffer migraine headaches following a traumatic brain injury.
Researchers have been using Diffusion Tensor Imaging to assess concussion-related damage to the brain’s signal-transmitting white matter to look for symptoms like headaches. Fractional anistropy (FA), which measures how easily water moves through the brain, represents an average. As a result, someone with a higher FA to begin with may lose white matter integrity from trauma, but still might average out to have a normal mean FA, according to the study’s author Lea M. Alhilali, M.D.