Insurance Company and Defense Tactics to Thwart Diagnosis of TBI (Traumatic Brain Injury

It is scientifically known from overwhelming peer review articles and legitimate scientific journals that both Diffusion Tensor Imaging (DTI) and Quantitative Electro-Encephalography (QEEG) can detect Traumatic Axonal Injury (TAI) where both MRIs and CTs can fail to do so.

Traumatic Axonal Injury (TAI) is an injury to the axons within the brain and is involved in most cases involving Traumatic Brain Injuries (TBI).

In my other comments, I have explained in further details what axons are and their functions within the brain. Simply put, axons are the part of the neuron which act as the communication pathways. 

Axons can be damaged when the brain is caused to suddenly move and stop/ accelerate and decelerate. This can occur even where there is no actual impact to the head. It is the sudden motion of the brain which causes different parts of the brain to move at different speeds. This is due to the various densities (weight) of parts of the brain as well as to the asymmetrical and lack of aero-dynamic design of the brain. Compare the half eaten mushroom like shape of the brain to that of a golf ball or baseball. Both of the latter are designed so that the weight and shape are optimal for traveling. Even these balls start to stretch at certain speeds (view in slow motion and the balls warp into egg/oval shapes). Now imagine how poorly designed the brain is to move.

As the brain is suddenly caused to move with various part of it moving at different speeds, it can shear and can damage the axons which are long and are but a tiny fraction of the diameter of capillaries of our bodies. The axons are coated with myelin sheaths which are basically white fatty tissue. Hence the term white matter of the brain. When the myelin sheaths are stretched and twisted, they can shear, tear or stretched too much. This is in essence Traumatic Axonal Injury (TAI).

While axons damage can occur due to other non-traumatic pathologies, they often occur globally within the brain.

Traumatic Axonal Injury (TAI) occurs at junctures of the brain that would be most stressed and move at different speeds. These are the common regions of interests (ROIs) that research have consistently found to be have axonal damage in cases involving Traumatic Axonal Injury (TAI).

As I stated earlier in this commentary, it is well known and accepted among legitimate scientific research that MRIs and CTs will most often fail to detect Traumatic Axonal Injury (TAI). But for the past two decades, both Diffusion Tensor Imaging (DTI) and Quantitative Electro-Encephalography (QEEG) have proven to be two of the most sensitive investigations into Traumatic Axonal Injury (TAI).

DTI can determine the structural integrity of the axons by investigating the water diffusion. And QEEG investigates the electrical connectivity of the brain to determine the functionality of the axons. This is akin to MRIs showing damage to a intervertebral disk in the neck or back and EMGs showing signal abnormalities of the corresponding nerves along the dermatomes. Quantitative Electro-Encephalography (QEEG) is a computerized Electro-Encephalography (EEG)- which has been employed for about a century. 

Yet, why is it that few doctors and virtually no lay person have ever heard of either technologies? Many patients afflicted with traumatic brain injuries face ignorant doctors who either shrug their shoulders or diagnose temporary post concussion syndrome telling their patient that their headaches and other cognitive symptoms will improve in time. It is hard to believe but most physicians including neurologists don't know what else to do once the brain MRIs and/or CTs come back normal. This allows the insurance companies and defense lawyers with the convenient diagnosis of malingering, secondary gain, somatoform disorder, and other psycho-somatic diagnosis leaving the patient to believe that they are crazy or just exaggerating their symptoms.

Both DTI and QEEG are expensive. Much more expensive than MRIs. As it is, the "insurance protocol" in treating patients before the doctor "should" send the patient for an MRI is to clinical assessment, medication and wait and see if the symptoms improve so that $1200-1500 (average cost of MRI in New York City area) doesn't have to be spent on an MRI. One can certainly see how expensive it will be when both DTI and QEEG become mainstream in the protocol of traumatic brain injury investigation.

In my last trial involving mild traumatic brain injury, the defense attorneys called as an expert a neuro-radiologist who happens to be one the heads at a very well respected teaching hospital, to argue against the DTI results of my client. A crucial part of analyzing a DTI study is that a quantitative assessment (QA) must be performed upon the image of the patient's brain water diffusion as compared to a normative database of other brain water diffusion. (The idea is that a computer is much more accurate and sensitive that the human eyes.) Yet this neuro-radiologist had never performed a quantitative analysis or even know how it is done. But due to his credentials, he has been used and called time and time again by the defense lawyers to refute the proof of Traumatic Axonal Injury (TAI) offered by DTI. Fortunately an intelligent jury found for and believed my client did suffer from TBI. However this defense expert who does not even know how to perform a crucial analysis as part of the DTI study has been successful in other trials.

With regard to Quantitative Electro-Encephalography (QEEG), the insurance industry and defense lawyers have recycled the same expert in numerous trials to convince the jury to reject Quantitative Electro-Encephalography (QEEG). Despite the fact that over the last fifteen years, not one peer review article (and I believe there has been over 1000 articles written in this period of time), has found anything other than that Quantitative Electro-Encephalography (QEEG) is both reliable and accurate in the treatment and diagnosis of mild traumatic brain injury, the insurance industry and their defense lawyers still try to argue that QEEG is unreliable in detecting TBI.

In arguing against both DTI and QEEG, the insurance companies and defense lawyers beckon status quo and ignorance to advances in medicine and technology. The KISS (Keep It Simple Stupid) strategy that often works too well before a jury of lay people and sometimes judges, is often used by the defense lawyers to keep in the hope that a lazy juror or judge will shut their minds. Trying to explain and in essence teach a jury of DTI and QEEG how they work can be extremely hyper-technical and complicated. It can turn them off to your case if not done right and with absolutely understanding of the nuts and bolts of each technology. 

I have witnessed disastrous results in trials due to a lawyer not fully understanding these neuro-imaging technologies. It results in not only being unable to satisfactorily explain the technology but also being unable to effectively expose the defense expert's lack of knowledge and deception.

NGUYEN LEFTT P.C. – Traumatic Brain Injury Attorneys / Lawyers
565 Fifth Avenue, 22nd Floor, New York, NY 10017
tel: 212-256-1755   •   fax: 212-256-1756 

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