Autopsy is such a morbid concept, such a horrible invasion of privacy at a time when loved ones are dealing with the shock waves of grieving. Yet, ironically it is the one good thing that can come out of death, especially the death of a young person. The remarkable findings announced this week of former NFL player Chris Henry’s autopsy will contribute immeasurably to our understanding of brain injury and the risks of playing football. Out of the tragedy of Chris Henry’s life and death, the lasting contribution he may make to our world is illuminating the connection between abnormal behavior and brain damage.
Mild Traumatic Brain Injury (MTBI) is one of the single most difficult things to diagnose and research in medicine. Its critical symptomotology, that momentary loss of consciousness or awareness, is almost never witnessed by the medical team. The pathology is far too small to be seen on CT scan, and only in the most serious cases are conventional MRI’s showing clear cut evidence. While it has a clear cut pattern of symptoms, other illnesses and conditions come with similar symptoms, making differentiating the condition harder. This issue confounds the long thought gold standard for MTBI diagnosis, neuropsychology. While in severe brain injury cases neuropsychology will demonstrate unequivocal patterns of cognitive deficits, in MTBI or (Post Concussion Syndrome – PCS, a term used interchangeably) the deficits are subtle and could be dismissed as being caused by a myriad of other problems, including depression and poor motivation. Adding to this problem is that depression and poor motivation are the symptoms of MTBI or PCS. Further complicating the diagnostic puzzle is that those with premorbid histories of depression, anxiety, PTSD, or prior MTBI are far more likely to be disabled by MTBI. Finally, as many as half of the neuropsychologists practicing today are “non-believers” in PCS.
Now contrast an in vivo (during life) diagnosis of MTBI with an autopsy. In autopsy there is no ambiguity. The microscopic damage can be seen under a microscope. The axonal tracts that may have been compromised, can be examined with the naked eye. Actual residual blood stains can be seen on neural tissue. The diagnosis can be made with a high certainty. What value does it have to diagnose a non-life threatening condition after a person is already dead? It moves the science of brain injury forward by leaps and bounds. Were autopsy an integral part of mild traumatic brain injury research, the skeptics would have to play their sophistic (plausible but fallacious) games elsewhere.
But here is the problem with making autopsy a more integral part of MTBI research: Since MTBI is a non-fatal condition, it may be decades between the onset of the condition and the autopsy. The movement to enlist NFL players to contribute their brains to a long term autopsy study is a true breakthrough, yet the research it will reveal will not become available for decades. (As a side note, those autopsy’s done in the future generations, will be most illuminative if good records are kept of behavioral issues the players had after their careers ended and accurate records are kept of the concussions they suffered.)
Occasionally, medical science gets lucky on the misfortune of someone who dies young. That is what happened with Chris Henry. It is also what happened in the important case reported by Erin Bigler, Ph.D. in the article Neuropsychological results and neuropathological findings at autopsy in a case of mild traumatic brain injury. J Int Neuropsychol Soc. 2004 Sep;10(5):794-806. See http://www.ncbi.nlm.nih.gov/pubmed/15327725 This research was possible because someone with a documented MTBI, died seven months later from an unrelated cause. Again, tragedy becomes fortuitous for medical science. The autopsy revealed:
Gross inspection of the brain at autopsy was normal; however, microscopic analysis demonstrated what were considered trauma findings of hemosiderin-laden macrophages in the perivascular space and macrophages in the white matter, particularly the section taken from the frontal lobe.
All of the foregoing is important because this patient’s PCS was clearly documented.
The patient had partially returned to work at the time of death, but had encountered problems with diminished cognitive performance in his work as an appraiser. Neuropsychological studies were generally within normal limits although several tests of either speed of processing or short-term memory showed lower than expected performance. This case demonstrates the presence of subtle neuropathological changes in the brain of a patient who sustained a mild TBI and was still symptomatic for the residual effects of the injury 7 months post injury when he unexpectedly died.
As discussed above, neuropsychological testing showed issues, but nothing that a skeptic couldn’t dismiss as unrelated or feigned. But you can’t fake the autopsy.
I have a narrow perspective on the neurosciences, devoting all of my time to representing those with traumatic brain injury. So take this with that bias in mind.
Nothing is more important to our medical science than to reach a greater understanding about the cause and nature of brain abnormalities, particularly those relating to trauma.
The U.S. government is now spending billions of dollars on TBI treatment for returning soldiers from Iraq and Afghanistan. This hopefully will give us a tremendous data base to understand the nature of the forces, the acute period symptoms, the chronic problems that occur and neurobehavior abnormalities and disability that persist from TBI. Some great data surveillance information could be available, with force sensors in helmets, pre-deployment and post-injury neuropsychological documentation, and long term treatment issues. But as far as I can tell, there is one huge missing element in that focus: autopsy.
It would be a horrible invasion of privacy and treading on the grieving process to make it autopsy mandatory, but all efforts and no expense should be spared to autopsy the brains of all American soldiers who die in combat. This is imperative if the soldier suffered any head trauma or PTSD prior to death. One of the wonders of autopsy is that it can sort out the chronic brain damage that existed prior to the fatal event from the brain damage which caused death, such as in Chris Henry’s case.
The fortuitous breakthrough from tragedy of a death from other causes with a documented prior TBI – such as what happened in Dr. Bigler’s study – does not need to be a once in a generation opportunity. Unfortunately, nearly every day an American soldier is being killed who had some previous MTBI. Make those deaths mean something. Hundreds of such autopsies will advance our understanding not just about TBI in general. Those autopsies could be of immeasurable value in treating other veterans who come home with TBI.
I give the NFL highest marks for its support of the give the brain to science program for its former players. (A number of ex-NFL players have agreed to donate their brains to the Boston School of Medicine, which is creating a bank of brains to examine as part of its research on head injury and future brain disease.) See http://www.tbilaw.com/blog/tag/nfl-and-brain-injury If veteran organizations, the VA, Congress or the Pentagon would show the same leadership, the dark cloud that shrouds the Post Concussion Syndrome could be lifted not in my lifetime, but in the next decade. Let some good come out of war.
Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
firstname.lastname@example.org :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.