Thingomometer Central

I call them thingomometers, this alphabet soup of shiny metal tubes, because they are believed to be the technological breakthrough which guides us out of the dark ages of diagnosis. Too often we turn to the radiologist, the lords of the thingomometers, to give us the answer: Brain damage, yes or no? We want the objective answer and we believe these computer based machines will show us the truth.

But the thing to understand about brain imaging is that normal studies do not rule out brain injury. There is only one way to conclusively “see” brain pathology: autopsy. Brain cells are microscopic. Autopsy studies, which utilize the microscope, can see brain damage. Even our best imaging studies would need to improve their resolution thousandfold, to see dead brain cells. What our imaging studies are getting better at doing is seeing conditions which will cause cell death: hemorrhage and hematoma, or the effect of these gross phenomenon – large clusters of dead cells. But when the primary cause of brain damage has been diffuse damage (meaning spread widely throughout the brain) to brain cells, there is a great likelihood of normal scans. Scans can even be normal for conditions that result in coma and death. That is why it is so important to understand the four element approach to diagnosing non-coma brain injury, which makes up the cornerstone of this page. Click here for a treatment of those elements.

The second concept to understand about imaging is that where it is not possible to see individual cell damage and death in a living brain, it is possible to see the footprint of such pathology. Even if the ophthalmologist cannot see the damage to the eye, or optic nerve, he or she can emphatically diagnose that damage occurred if you can no longer see. Likewise, with the neuro-otologist, if you can no longer hear, or stand on your feet. Would one question the objectivity of such a diagnosis? Yet, in such cases, the MD is not seeing the pathology, but basing the diagnosis upon the footprint that the pathology leaves (i.e., blindness, deafness). Such a footprint of pathology approach is the fundamental premise behind the field of neuropsychology. It has been well established that properly administered batteries of neuropscyhological tests will show a footprint of pathology that can be correlated to the nature of the trauma suffered and the clinical change in the person. Such findings are as objective as the ophthalmalogists’ and neuro-otologists’ findings of blindness and deafness.

So do we need to understand neuroimaging studies? Obviously, in the treatment of acute injuries, the CT scan has saved countless lives because of its ability to identify life threatening conditions and guide the neurosurgeon’s intervention. But after the acute stage, the value of neuroimaging studies is the subject of fair debate. See Emergency Room Critical Step in Diagnosing TBI for an example of such a debate. We lawyers always hold out hope that some of what the defense bar calls “objective evidence of injury” might develop so that we can “show” the jury the actual pathology. But in most non-coma cases, we aren’t there yet and screening cases based upon such criteria would exclude many significant cases. So is there any point in post acute imaging studies in non-coma cases? Of course.

We believe that countless cases exist where the pathology might have been identified by thingomometers, if the technology had been properly understood and prescribed at the appropriate time. Each thingomometer has its merit, each has its particular temporal niche when it is the preferred tool, and each has particular pathology for which it is most sensitive. The undertaking of this section is to help with the differential selection of thingomometers for the appropriate time and symptomotology pattern. And also, to help understand why a particular test may have been normal, despite a clear diagnosis of brain injury.

NEXT: CT or Cat Scan.

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.

View Our Video Series on Concussions