Neuropathology

• Graham and Lantos, Greenfield's Neuropathology, 6th Edition, ©Arnold, 1997.
• Narayan, Wilberger & Povlishock, Neurotrauma, ©McGraw-Hill, 1996.

A. Brain Injury is a Process not an Event.

This is a category that many would argue you should skip, especially with the quality of authority cited above. This is unquestionably the most difficult field to a absorb. However, my fascination for this field has largely revolved around the natural jury skepticism, that an injury which is insignificant at the scene of the crash, could be so disabling. The problem with the authority cited herein that LOC is not required, is that it does not attempt to explain why. The why is that brain injury is a process, not an event, which often escalates in severity after the period of time that our clients are being examined by the medical community.

1. Greenfield's Neuropathology. Greenfield's says at page 197:

The delayed consequences of the primary injury have only recently begun to be understood. These are various events that have been triggered by the primary injury and include neurobiological processes involving cellular dysfunction such as free radical formation, receptor mediated mechanisms, calcium and inflammation mediated damage. In various combinations, and in various severities, the resultant cellular dysfunction defines the nature and extend of the primary injury, the outcome of which may not become apparent for several days or even weeks after the injury.

Greenfield'sis the most expensive book I own, but for me, it is the consummate learned treatise. It is in its 6th Edition; the chapter cited above is co-authored by Thomas Gennarelli, the man credited for the term "diffuse axonal injury"; it is a book published in England, distributed in the U.S. by Oxford University Press and includes a cast of international contributors without peer in the field. What is more, it looks and smells authoritative, yet it is a dynamic work, not reluctant to admit that: "Since the 5th edition of Greenfield's Neuropathology there have been considerable advances in the understanding of the nature and time course of axonal injury after TBI. "

B. Neurotrauma. This book is unique in that it incorporates the fields of head injury, spinal injury, and basic neurotrauma research into one source.

B. Risk Factors for Poor Outcomes.

My approach to proving the subtle brain injury case is to first get over the threshold acute symptomotology to convince the fact finder that there was a brain injury/concussion and then to suggest the explanations as to why this particular person may have had a poor outcome. The three most likely explanations are age over 40; history of prior brain trauma; and/or extraordinary demands upon the injured brain. On all three of these issues, the Chapter in Mild Head Injuryby Wrightson and Gronwall, is strong authority. In addition, the postscript in the book Injured Brains of Medical Minds, discussed on our page on Advocacy, has a provocative discussion about these risk factors and research needed.

Understanding Subtle Brain Injury

The concussions that disable, are almost always more symptomatic at 24 hours, than at the 2-4 hour time frame when injured persons are evaluated in the emergency room. Brain injury symptoms escalate over the first 24 hours, because brain injury involves a cascade of events. It is critical that if you are still symptomatic the day after your injury, go back to the same Emergency Room, don’t wait for a doctors appointment. It is critical that the Emergency Room personnel see that the symptoms still persist or have gotten worse.

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