The Role of Neurology Neuropsychology and Radiology in the Diagnosis and Treatment of Traumatic Brain Injury

*1.5-2 million people a year sustain brain injuries from motor vehicle and motorcycle accidents–falls–sport injuries–and acts of violence. 500,000 severe enough to require hospitalization.

*50,000 die from complications of head injury. 5.3 million are living with head injury related disability.

*Head injuries are most common among males 15-24 and people older than 75.

These alarming statistics affect all communities. Since the advances of medical technology–health care has become more and more specialized. However–who does one see to help diagnose and treat a suspected head injury? A Family Doctor? A Neurologist? A Psychologist? A Radiologist? What about a Neuropsychologist? So many to choose from–but which one would be most helpful? The answer is that they all offer an important piece to the puzzle. For example–Sevan (a fictitious name of a patient) was 21 years old–when he was involved in a motorcycle accident on Christmas day. An intoxicated truck driver collided with his motorcycle while making a left turn on a green light. Sevan was ejected from the seat of his motorcycle and subsequently landed in the middle of the street. While he had no memory of the accident–eyewitnesses notified paramedics and reported the accident. The paramedics rushed him to the emergency room. He regained consciousness after 5 hours in a coma. While he did not sustain any major physical injuries–his family noticed a drastic change in his behavior and way of thinking. He lost his ability to read words–experienced difficulty with attention–concentration–memory–and behavior (i.e.–he was more short-tempered–aggressive–irritable–and impulsive). According to his mother–"his son had changed since the accident and she was desperate to find someone who could help him. Therefore–his mother took Sevan to his family doctor who ordered some brain imaging diagnostic tests (CT and MRI scans) and referred him to a long list of specialists such as a neurologist and psychiatrist to clarify his condition.

WHAT IS A NEUROLOGIST?

A neurologist is a physician (MD or DO) who specializes in diseases of the brain and nervous system. Although they overlap a bit with psychiatrists because they share the same organ (brain)–they tend to concentrate on physical manifestations of neurological problems–or problems related to abnormalities in structure or function of specific regions of the nervous system. They deal with brain–spinal cord–nerve roots–nerves–and muscles. Psychiatrists (also MD) deal with emotional and cognitive disorders–such as schizophrenia–depression–panic disorders–etc. A neurological examination provides crucial information about the nervous system. It is a non-invasive way to find out what might be wrong. It typically includes an examination of the 12 nerves of the head and neck–reflexes–balance and coordination–muscle strength and movement–and mental status (awareness and responsiveness to the environment)–appearance and general behavior–orientation–attention and memory. Neurologists also perform diagnostic tests–such as lumbar puncture–electroencephalograph (EEG)–electromyography/nerve conduction velocity (EMG/NCV).

Based on the results of the neurological exam and the diagnostic tests (EEG–EMG–CT–MRI)–a neurologist is likely to refer a patient with head injury to a Neuropsychologist to get an understanding of which brain functions are impaired and which remain intact. A neuropsychological evaluation can show exactly how the injury affected thinking and behavior.

WHAT IS NEUROPSYCHOLOGY?

Neuropsychology comes from the Greek word "neuron" meaning "nerve," the Greek word "psyche" meaning "mind," and the Greek word "logos" meaning "the study of." When you put the words together you get: the scientific study of brain-behavior relationships and the clinical application of that knowledge to human problems. In simpler terms–Neuropsychology is the study of how different disorders of the brain (i.e.–traumatic brain injury–concussion–aneurysm–stroke–dementia–tumor–etc) affect a person’s thinking–emotions–and behavior.

WHAT IS A NEUROPSYCHOLOGIST?

A Neuropsychologist typically holds a doctoral degree (PhD) in Clinical Psychology/Neuropsychology from an accredited university or professional graduate school. A Neuropsychologist may have also completed additional graduate level coursework in Neuroscience–such as Neurology–Neuroanatomy–Neuropathology–Neuropsychological Assessment–Neuroradiology–etc.

He/she must be a licensed psychologist with specialized training and experience in the field–which includes predoctoral supervised Internship in psychology and Neuropsychology–followed by 1-2 years of Postdoctoral Fellowship in Neuropsychology.

WHAT IS A NEUROPSYCHOLOGICAL EVALUATION?

A neuropsychological evaluation is a comprehensive evaluation of cognitive–behavioral–and emotional functioning performed using standardized tests and procedures. A Neuropsychologist uses a wide variety of paper/pencil and computerized tests that are very sensitive to even mild brain dysfunction. Typically the evaluation includes 60-90 minutes of clinical interview about your problems and background (childhood–education–occupation–family–medical and psychiatric history)–followed by 4-6 hours of formal testing. The evaluation can be scheduled for a single day or divided into several days–depending on the fatigue level and time. After testing–the results are reviewed–scored–and interpreted to generate a report. This could add an additional 4-6 hours. At the completion of the report–the Neuropsychologist reviews the results of he evaluation with the patient and his/her family and makes treatment recommendations. A copy of the report is also forwarded to the referring physician and other health care providers.

WHICH MENTAL FUNCTIONS ARE GENERALLY TESTED?

A Neuropsychologist typically evaluates how the brain functions in the following areas:

Intellectual abilities

Attention/Concentration

Learning and Memory

Language

Problem solving–planning–and organizational skills

Reasoning and Judgment

Perceptual and Motor Skills

Visual-spatial skills

Academic Skills

Emotion–Behavior–and Personality

HOW CAN THE RESULTS HELP ME?

The results of a neuropsychological evaluation can help your doctor clarify weaknesses–differentiate among illnesses (Traumatic Brain Injury vs. Stroke vs. Alzheimer’s vs. Depression)–establish a "baseline" before surgery or before problems are seen–plan treatment that uses strengths to compensate for weaknesses. The results can also help the Social Security office determine if you qualify for Disability benefits. Following is a sample of some of the many questions that can be answered by a neuropsychological evaluation:

* Do I actually have brain injury?

What is the cause of my problems? Is it medical–emotional–neurological or stress?

** All neurological–physical–and imaging (CT & MRI scans) tests are normal–why do I still have difficulties doing everyday things?

Will I be able to return to work/school–drive again–or play golf?

Am I getting better? How much? Is treatment helping me?

* This is especially true following "mild" brain injury–when effects of an injury may be subtle and easily confused with other factors–such as stress–medications–or depression.

**Just because a skull X-Ray or CT/MRI scans of the brain are negative (normal) does not mean everything is fine. You can still experience difficulties in thinking–behavior–and expressing emotion–that affect your quality of life. Because CT/MRI measure structure–not function or behavior–a Neuropsychological Evaluation is recommended especially when problems persist.

Stay Healthy,

Dr. Hayganoush Kalinian

Neuropsychologist

Authors

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