THE USE/MISUSE OF SPECT TO DIAGNOSE MINOR BRAIN DAMAGE IN TRAUMA OR TOXIC EXPOSURE CASES

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1 THE USE/MISUSE OF SPECT TO DIAGNOSE MINOR BRAIN DAMAGE IN TRAUMA OR TOXIC EXPOSURE CASES PRESENTED BY: JOHN J. SOLTYS COZEN O CONNOR SEATTLE, WASHINGTON FDCC MID-WINTER MEETING HAWAII MARCH 8-13, 2004 REVISED: November 2003

2 THE USE/MISUSE OF SPECT TO DIAGNOSE MINOR BRAIN DAMAGE IN TRAUMA OR TOXIC EXPOSURE CASES By John J. Soltys Cozen O Connor Seattle, Washington I. INTRODUCTION The plaintiff s use/misuse of nuclear medicine to diagnose mild brain damage resultant from trauma or toxic exposure is exploding in spite of cautions published by the American Academy of Neurology warning that SPECT/PET is still primarily experimental and not yet available for clinical use. We see plaintiffs attempting to introduce SPECT (Single-Photon- Emission Computed Tomography) and PET (Positron Emission Tomography) at trial to diagnose alleged mild brain damage resultant from a trauma, or from environmental or toxic exposure to chemicals such as pesticides, glues and solvents, 1 or pharmaceutical or foreign body reactions such as to breast implants. While a limited number of articles and publications on the use of SPECT/PET for such clinical diagnosis of brain damage have been published, the technique has not been accepted by the medical community for clinical use. 2 Its use should be the subject of a Daubert Challenge. Daubert v. Merrell Dow Pharmaceuticals, 509 U.S.579, 113 S. Ct. 2786, 125 L.Ed. 2d. 469 (1993). Daubert held that Federal Rules of Evidence 702 provides the standard for admitting expert scientific testimony, not the Frye test which still seems to be the applicable rule for the admissibility of expert testimony in criminal cases. Daubert, 113 S. Ct. at ER 702, which is the same as Federal Rule of Evidence 702, states: If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education may testify thereto in the form of an opinion or otherwise. 1 Heuser G., Menard, Thomas C., Alamos F., Cerebral Blood Flow in Patients Exposed to Neurotoxic Chemicals [Abstract] J. Nucl. Med. 1994; 35 (Suppl. 210 P.). 2 Jchise M. Charg et al., Technetium-99- HMPAO SPECT, CT and MRI in the Evaluation of Patients with Chronic Traumatic Brain Injury: A Correlation With Neuropsychological Performance. J. Nucl. Med. 1994; 35: Gray B.G. et al., Technetium-99-HMPAO SPECT in the Evaluation of Patients with a Remote History of Traumatic Brain Injury: A Comparison with X-ray Computed Tomography, J. Nucl. Med. 1992; 33:

3 ER 702 requires the trial judge to ensure that all scientific material or testimony rests both on a reliable foundation and is relevant to the task at hand. Reliability depends on whether the scientific testimony qualifies as scientific knowledge of a known certainty. Relevancy depends on whether the expert s testimony will be helpful to the trier of fact. Helpfulness turns on whether the underlying reasoning or methodology is scientifically valid and can be applied to the facts at issue. This requires the plaintiffs to establish by a preponderance of the evidence that the reasoning and methodology underlying the testimony is scientifically valid and that the proper scientific principles and methodologies were used in deriving the scientific information. To assist in this analysis, the Daubert court set forth a non-exclusive list of issues to be considered. A. Courts should examine what methodology or technique was employed by the expert and whether that methodology or technique is capable of being classified as or actually employs a scientific method. Daubert, 113 S. Ct. at B. Courts should consider whether the particular methodology or technology employed by the expert was subjected to peer review and publication; its potential or known rate of error; and whether it has gained general acceptance within the scientific community. Id., at (Emphasis added). Virtually every jurisdiction has adopted Daubert into its own case law. Competent physicians, certified in Nuclear Medicine by the American Board of Nuclear Medicine, and aware of the work of the American College of Neurology and the National Society of Nuclear Medicine and its Brain Imaging Council will provide you with declarations which will advise the court of the lack of all of the requirements which the plaintiff must prove in order to defeat a Daubert challenge. Regardless of the lack of acceptance of SPECT/PET to diagnose minor brain damage, in the medical community, many plaintiff s attorneys utilize such testimony from various medical doctors who apparently believe in, and/or are willing to testify regarding, the efficacy of this untried methodology to diagnose minor brain damage. Just as we have encountered, met, and defeated the short lived use of thermography and computerized electroencephalographic brain mapping (BEAM) we must also prepare ourselves to understand and meet SPECT/PET when it is inappropriately used. A. Description of SPECT/PET. II. WHAT IS IT SPECT has been around since the early 1980s and is a process in which a computer evaluates cerebral perfusion (blood flow) after a radionuclide or a radioactive tracer is intravenously injected into a patient s blood stream. The radioactive tracer is built as a fat loving material capable of crossing from the blood into the brain where it becomes hydrophilic, which means that it is no longer fat loving. A hydrogen atom replaces an organic molecule and then becomes trapped in the neuron in the brain. The brain s neurons include various chemicals 2

4 including glutathione. This chemical is more prominent in the gray matter which is why the radiopharmaceutical sticks primarily in that matter. It accumulates in different areas of the brain depending on the rate of delivery of nutrients (blood flow) being supplied to that volume of brain tissue. 3 After the tracer sets in the brain, a rotating gamma camera using the techniques of CT is able to view the distribution of the radiopharmaceutical within the brain. (See Fig. A and B.) The camera essentially counts the photons for a computer to analyze. These radiopharmaceuticals concentrate primarily in the brain s gray matter in a ratio of FIGURE A Typical Multi-detector camera apparatus used in SPECT Figure B Multi-detector camera demonstrating the patient position during data acquisition approximately 4 to 1 when compared with the white matter. The cameras are able to identify the cerebral perfusion in a patient s brain such that it can then be compared with the expected patterns in a normal brain or even to the average cerebral activity in the same slide of the same brain. Computers are then able to examine and display the results in a convincing and colorful (even three dimensional) manner. (See Fig. C and D.) The SPECT picture which is presented at trial looks like a photograph but is actually a computer generated presentation. 3 Special Article. Assessment of brain SPECT. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology, Neurology 1996; 46:

5 FIGURE C A portion of a Brain SPECT Scan in Color (axial slices) FIGURE D A normal 3 dimensional SPECT Brain (Surface Rendered Study) Although this paper deals with SPECT, the concepts apply equally to PET which utilizes positron emitting radiopharmaceuticals which are incorporated into biologically active compounds which in turn are also injected into the blood stream. 4 Unlike SPECT, PET can measure regional cerebral metabolism. PET has been available since the 1970s and was traditionally believed to be complimentary of and superior to EEG. EEG provides information about events occurring only at the surface of the brain in proximity to the electrodes. PET measures the metabolism and substrate utilization of volumes of tissues in three dimensions throughout the complete volume of the brain tissue. Both PET and SPECT are safe procedures in that the radiation exposure in absorbed dose is generally approximately equal to that received in a routine radio diagnostic medical procedure. 5 It is not recommended that an independent defense SPECT or PET be obtained because to do so might suggest some credibility in the clinical use of the procedure in the first instance. Nonetheless, if you should decide that you do need such an independent study, the plaintiff should not be heard to refuse due to the alleged risk of being over-exposed to radiation. A. Some Accepted Uses of SPECT. III. CLINICAL USE OF SPECT Before exploring what SPECT cannot be used for, it is important to recognize the importance of and the accepted clinical uses of the procedure in nuclear medicine. Essentially SPECT maps the distribution of brain perfusion or blood flow. Any disease process which alters cerebral perfusion will show a deviation from normal on SPECT. There are various conditions and diseases which display distinctive patterns of abnormal cerebral metabolism which can be 4 Mazziotta, J.C., Phelps, M.C.; Positron Emission Tomography Studies of the Brain, etc., New York: Raven Press 1986; Freeman, L. M.; Freeman and Johnson s Clinical Radionuclide Imaging (3d. ed.), Vol. II, Orlando, Florida: Grunet & Stratton 1984:

6 demonstrated and therefore diagnosed with SPECT. In such instances, SPECT is clinically useful in making a diagnosis. After significant peer review SPECT has become accepted in the medical community for clinical use in the diagnosis of Alzheimer s Disease (see Fig. E and F), Parkinson s Disease, Huntington's Chorea, Pick s disease, stroke (see Fig. G), epilepsy (both for diagnosis and to locate the focal origin thereof), in grading brain tumors (both to evaluate tumor growth patterns and to differentiate between recurrent high FIGURE E. Color SPECT of typical Alzheimer s patient FIGURE F 3-D SPECT demonstrating a typical severe Alzheimer s pattern. FIGURE G SPECT demonstrating major asymmetry resultant from a left side infarct (stroke). 5

7 FIGURE H Black and white SPECT demonstrating marked asymmetry resultant from an infarct (stroke). The CT on this patient was normal. FIGURE I 3-D SPECT showing a significant infarct (stroke)on the right side 6

8 FIGURE J 3-D view of a subject with a small left posterior parietal region of brain ischemia in which no large region of brain death occurred as evidenced by a normal 4-hour delayed image. (This is an old technique.) grade tumors and chemotherapy induced necrosis), HIV encephalopathy, and in the determination of brain death. 6 B. Unacceptable Uses of SPECT. In other areas, the use of SPECT is still experimental. Criminal lawyers have improperly attempted to use SPECT as objective evidence in support of a criminal defendant s claim that his crime was the result of organically based poor judgment, lack of insight, uncontrolled aggression or impulsivity, or due to an organic brain dysfunction. There are limited functional brain imaging studies of subjects with criminal behaviors. 7 These studies are seriously flawed in protocol design and often lead to erroneous conclusions. Likewise in civil cases, the role of SPECT in the evaluation of brain damage from head trauma or toxic exposure remains experimental. 8, 9 6 Assessment of Brain SECT. Report on the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 1996; 46: Functional Brain Imaging in Forensic Psychiatry: In Clinical Perspective SNM 1994, Helen Mayberg, M.D. 8 American Academy of Neurology, Assessment Positron Emission Tomography (PET) Report of the Therapeutics and Technology Subcommittee. 9 Waxman Chapter on Functional Brain Imaging in the Assessment of Multiple Chemical Sensitivities in Multiple Chemical Sensitivity/Idiopathic Environmental Intolerance, Occupational Medicine, State of the Art Review, Editor: Patricia J. Sparks, M.D. 7

9 IV. REVIEWING THE PLAINTIFFS EXPERTS THEORIES There are several ways in which the results of SPECT may be intentionally or unintentionally manipulated. When confronted with SPECT testimony, defense counsel must question not only the physician s interpretation of the results but also the use of improper or untested acquisition and processing protocols, the use of improper norms, and other factors of a technical or reporting nature. Although most courts will sustain a Daubert challenge to the plaintiff s use of SPECT in making a clinical diagnosis, some will allow the introduction of that evidence. In such an instance, defense counsel must be prepared to question all the variables associated with the procedure. A. Protocol. It is imperative that SPECT Brain Studies be administered in a proper manner. The American Academy of Neurology is in the process of establishing a proper protocol and is expected to publish same in the near future. Until the publication of such protocol, one must use the methodology accepted by the Nuclear Medicine Community when administering SPECT Radiopharmaceutical Preparation. The FDA has approved radiopharmaceuticals Tc-99mHMPAO and Tc-99mECD for evaluating brain perfusion in stroke cases. Three others have been FDA approved for other uses. No other applications have currently been approved by the FDA. This does not mean that other radiopharmaceuticals are necessarily inappropriate. 11 HMPAO must be injected within 10 to 30 minutes following its preparation. Imaging should start 90 minutes following injection. ECD must be injected within four hours of its preparation and imaging started 60 minutes after injection. 2. Patient Preparation. Patients should be prepared in a separate quiet, dimly lit room in a comfortable reclining position with eyes open and with soothing background noise. A hepacath or IV is to be inserted in the patient at least 15 minutes prior to the injection of the radiopharmaceutical. This allows the patient to calmly get used to the IV. Some physicians, who frequently testify as SPECT experts for the plaintiffs, have developed their own procedure which is at variance with accepted protocol. They often utilize unique protocols which have not been peer reviewed or accepted in the medical community. By way of example, some physicians will ask that their patients conjure an image of themselves at a beach. Although such an image might be restful to a large percentage of patients, that same mental imagery might trigger or stimulate other patient s brains. The visual cortex of the brain might not react the same way in the patient who enjoys Caribbean vacations as it would in a different patient who may have recently lost a loved one through a drowning, or a shark attack. (On a normal SPECT Brain Scan, the cerebellum will most often appear brightest and closely related in intensity to the primary visual cortex in the 10 Juni J, Taking Brain SECT Seriously: Reflections on Recent Clinical Reports in The Journal of Nuclear Medicine. J. Nucl. Med. 1994; Waxman, A., A Practical Approach to Brain Image SPECT. 8

10 occipital lobes. A schizophrenic who is having visual hallucinations may have a brighter visual cortex than cerebellum). It is generally accepted amongst nuclear medicine physicians that external stimulus during injection should be avoided. 12 Some physicians have developed their own protocols including flow studies which require them to inject the radiopharmaceutical in a patient while the patient is lying in the machinery while the data is being acquired. Inappropriate and unproven activation protocols have been attempted. These unproven activation protocols may result in variable protocols including results between subjects and may result in different patterns in the same individual if tested at different times (reproducibility problem) (see Figure K.) which demonstrate the effect of activation on the human brain. Protocol demands that the patient be placed in a separate room without distractions. If the patient is being injected while reclining within the confines of the gamma camera (which resembles CT equipment) (see Fig. A), he is receiving external visual and auditory stimuli. The camera is rotating about the head (see Fig. B) and making noises which could cause confusion, tension, claustrophobia, fright, or other cognitive processes. Such activation studies using mental conjuring have not yet been peer reviewed and are not accepted in the medical community. FIGURE K The same slices of normal subject demonstrating the effect of language and/or music activation on the brain s metabolism. 3. Radiopharmaceutical Intake. After a patient has been injected, brain uptake is rapid and reaches its maximum in about 10 minutes. The radiopharmaceutical crosses from the blood into the brain where it has been taken up and becomes hydrophilic. (See Fig. L.) 12 American Academy of Neurology, Assessment: Positron Emission Tomograph (PET) Report of the Therapeutics and Technology Subcommittee. 9

11 FIGURE L. How it works The hydrogen atom which replaces the organic molecule is then unable to escape from the brain tissue where it is trapped in the neuron. The patient needs only be quiet for minutes while the radiopharmaceutical is being injected. The injection should be done slowly taking about 3 minutes. Patient movement during this minute period may affect the readings. After the 10 minute quiet period, and after the injection period has passed, an additional 60 to 90 minutes must elapse before the study is conducted. The patient may be active during this minute period and may move about freely. During this period, any of the blood that surrounds the brain will clear away leaving only the pharmaceutical that has been trapped in the brain. Background ratio improves with time. Immediately after the injection, the radiopharmaceutical has also been taken up by the head s soft tissues including the salivary glands, the parotid glands, the submandibular glands, nose and the sinuses (especially if the patient has a cold). The soft tissue blood pool initially is also elevated and the pharmaceutical needs the minute opportunity to clear. The test should only measure the radiopharmaceutical which has become hydrophilic in the nerve cells of the brain. Once the radiopharmaceutical is taken up in the brain, it remains frozen for two to four hours. 4. Image Acquisition. Multi-detector cameras (see Fig. A) and ring-type systems are the most desirable for use in that they generate higher resolution images in a reasonable time frame. Single detector systems may still be used but require more time and produce a suboptimal (fuzzy) image which some physicians feel is inadequate to produce valid results. (See Fig. M.) The cost of this equipment is still high and the number of qualified facilities remains low. While a single detector head system costs around $250,000, a multi detector system can cost considerably more. Patients must remain still in the equipment while data is being acquired. Motion artifact should be evaluated in all subjects by reviewing the raw data (cine images) following 10

12 FIGURE M Cloudy result from a single detector system acquisition. Adequate time should be allowed to acquire sufficient information (counts) for data processing to be effective. Twenty to thirty minutes of data acquisition is usually sufficient for a three detector system. A single detector system may require one hour of acquisition time for adequate results. 5. Image Processing. The result and studies should be processed in all three dimensions. The raw data obtained is processed through digital filters prior to interpretation. The type of filter used is critical. It is important to ensure that one uses a filter which eliminates artifacts but still allows the passage of data without distorting image contrast or magnifying minimal irregularities. Noncontrast enhancing or spatially enhancing filters, or low pass filters such as the Butterworth filter or combined low pass/ramp filters are recommended by the Brain Imaging Council of the Society of Nuclear Medicine. Spatially varying filters or resolution recovery filters such as the Metz or Weiner filters are often undesirable because they may distort the shape of images. They may also increase the image contrast and produce artifacts. One can see that if an inappropriate filter is used it can eliminate certain levels of emissions from the SPECT while magnifying other insignificant elements. With incorrect filtering, one might inappropriately conclude that there was inadequate blood flow to the area of the brain where the filter had eliminated emissions of a certain level when in fact the filter was the actual cause of the irregularity. (See Fig. N.) 11

13 FIGURE N. The same normal brain using 4 different filters and the same threshold of 60. FIGURE O. The same normal brain as shown in Figure N, but using a higher threshold of 65. The cutoffs or upper and lower window settings (cutoffs) input to the computer are also critical. Readings above or below the cutoffs will not be recorded at all. The background cutoffs chosen for the display are also important. When high background cutoffs (above 20%) are used, subtle or minor acceptable irregularities are emphasized. (See Fig. O.) It is important that the entire brain be reconstructed from vertex through cerebellum. Although one might not suspect injury or damage to a certain portion of the brain, its SPECT comparison with other portions of the brain is useful. SPECT data should be reconstructed at one pixel thickness with attenuation correction. The data is then reformatted into transaxial, coronal, and sagittal views. 6. Data Display Volume and surface displays should be generated when possible along with the axial, coronal and sagittal views. The gamma camera measures emissions and the computer formats and displays the data. These emissions have no color. It is the operator using a computer who assigns various colors to various numbers of emissions. For example, a brilliant yellow color may be used to demonstrate a high level of emissions while a less brilliant level indicates lower emissions (counts). A brilliant color is generally believed by the populous to be the color of radioactive emissions. Any other color could just as easily be used. Great care must be given in establishing the cut-offs for each of the various colors. Black and white studies should be reviewed with color studies. (See Fig. P.) Black and white studies refuse to acknowledge what might otherwise appear to be a glaring contrast in a color presentation because the black and white study shows gradual gradations of brightness while color presentations may not. With inappropriate color cutoffs, a color study may appear to show significant differences between levels of emissions which are actually quite close together. 12

14 FIGURE P A normal black and white SPECT (top of slide are the slices taken from the bottom of the brain) FIGURE Q SPECTS of the same normal brain demonstrating the problem associated with lower counts obtained from a single detector unit. (The lower count SPECTS were read as abnormal.) Ensure that an adequate number of counts are obtained before a SPECT is read. The older single head system not only produces a noisy, difficult to read picture, but also often produces too few counts to properly fill in the picture. (See Fig. Q.) The same brain which would show normal with adequate counts, shows asymmetry with limited counts. The background settings and cutoffs are also critical. A background of 0-10% is generally accepted. A normal brain reviewed as normal at 0% (see Fig. R) is read as borderline abnormal at 20% (see Fig. S) and is read as abnormal with a background of 40%. (See Fig. T.) Even the identification of a defect is the subject of some dispute. Trained human observers found that a defect of approximately 10% of surrounding brain counts was required for recognition in clinical practice. It was felt that the sensitivity of scanning in mild disease was quite poor. 13 FIGURE R FIGURE S A normal brain(read as normal) with an appropriate The same normal brain as Figure R (read as borderline) background setting of 0%. with a background of 40% 13 Juni, J., sup ra. 13

15 FIGURE T The same normal brain as Figures R and S (read as abnormal) with a background of 40%. (Figures R, Seattle, WA and T all used the same filter.) 7. Interpretation and Reporting. Database. In order for SPECT to be of any assistance it must be compared with a database of SPECTs from normal subjects who were tested using the same techniques. It should be understood that there is a great deal of acceptable variability present in normals. 14 The extent of anatomic variability amongst normals must also be recognized and accounted for. Few truly normal scans or studies of normal patients have, as yet, been conducted. In the past, patients were not imaged unless they were suspected of, or had signs or symptoms of some neuropathology. Only now are various research centers acquiring scans from volunteers without any known neurological deficit, history of head trauma, drug abuse, or psychiatric or psychological disorder. Some physicians are developing a database made up from average composites of a number of brains which, when averaged, yields a uniform norm. In many instances, the individual SPECTs of the various normal volunteers, when compared with the averaged composite, would appear abnormal. Further, not all brains are the same size and shape. To prepare composites using different size or shaped brains, without careful modification, tends to wash out acceptable variations from one normal SPECT to another normal SPECT. Even amongst norms, there are differences. There are clear age-related changes in cortical perfusion. A comparison of a given plaintiff should be to a norm of persons in the same age group, i.e., within 10 years of the plaintiff s age. Further, no true studies have been done comparing the perfusion in men and women. 15 Dr. Levin found significant differences in perfusion deficits 14 Juni, J., supra. 15 Dr. Levin (Levin J.M., Holman B.L., Mendelson J.H., et al., Gender Differences in Cerebral Profusion in Cocaine Abuse, 99 MTc-HMPAO SECT Study of Drug Abusing Women. J. Nucl. Med. 1994; 35:

16 when he compared healthy male vs. healthy female cocaine users. Most of the abnormalities occurred in the frontal and temporal lobes and the basal ganglia. When non-cocaine drug users were excluded, eight of nine male users had defects compared with only one of nine female users. In fact, the female group of exclusive cocaine users was indistinguishable from a matched group of normal women. Even some asymmetry, such as temporal lobe asymmetry, is an accepted normal variability in patients. 16 Normal variations are also expected in SPECTs taken of the same patient on different days. Alcohol or during usage, emotional status, cigarette smoking, coffee drinking and even diseases like atherosclerosis, depression or hypertension can affect blood flow to the brain. (See Fig. K.) When trying to evaluate the SPECT, images should first be reviewed in cinematic format in order to evaluate the potential for motion artifacts, target to background ratios, or other artifact production which may become apparent in this format. Hard copy information is acceptable for record keeping but interpretation should be done using a computer screen to allow adjustments of contrast, color selection and other display parameters. SPECTs should rarely be used by physicians to assign a specific pattern of abnormality to a specific disorder or to a specific origin. SPECT brain studies which do show defects are often nonspecific because there are so many injuries, ailments, and diseases which can cause SPECT defects in the brain. Further, even if a defect is observed, SPECT is incapable of determining when the defect occurred, i.e., in the accident which is the subject of your lawsuit or in a prior traumatic event. In few instances are SPECT patterns of defects so well known that one can identify a given ailment by that pattern. Patients suffering from chronic fatigue syndrome (see Fig. U and V) (an ailment which in itself is a subject of controversy in the neurological/psychiatric /neuropsychological community) may demonstrate SPECT similarities to a person suffering from unipolar depression (see Fig. W) or AIDS Dementia Complex (ADC). Indeed, even when one is suspected of chronic fatigue syndrome, experts question whether it is the result of a viral infection by a novel (as yet undiscovered) infectious agent or an unrecognized and untreated underlying primary psychiatric disorder similar to unipolar depression. Likewise, studies suggest that the Epstein Barr virus, enteroviruses, retroviruses, or the human herpesvirus 6, alone or in concert, may play a role in chronic fatigue syndrome Marcus, et al. Alterations in Regional Cerebral Blood Flow with Increased Temporal Interhemispheric Asymmetric in the Normal Elderly. Nuclear Medicine Communications 1993, Vol. 14, pgs Schwartz, R., Komaroff, A. Gordada, B., Gleit, M., Doolittle, T., Bates, D., Vasile, R. Holman, B., SPECT Imaging of the Brain. Comparison of Findings in Patients with Chronic Fatigue Syndrome, AIDS, Dementia Complex, and Major Unipolar Depression, AJR 1994; 162:

17 FIGURE U Patient suffering from Chronic Fatigue Syndrome FIGURE V Patient suffering, by history, from Chronic Fatigue Syndrome FIGURE W Color SPECT using an older camera with a different color scale. This demonstrates the effect of a psychological disorder (depression) on the blood flow. FIGURE X The SPECT of a patient suffering from Multiple Infarct Dementia (multiple small strokes). Symptoms include problems with language, reasoning, concentration. 16

18 FIGURE Y Patient with a posterior cerebral infarct. Systemic lupus erythematosus, cocaine abuse, and multiple infarct dementia likewise demonstrate nonspecific multi-regional perfusion abnormalities on SPECT. (See Fig. X and Y.) Correlating neuropsychological test performance with SPECT has both been promising and disappointing. The correlation between neuropsychological test results and some SPECT findings seemed predictive in one study while a contrasting study by Dr. Goldenberg. 18 Dr. Goldenberg revealed a loose correlation between the two. It was found that the ratio of anterior to posterior activity in the brain generally correlated with the degree of neuropsychological deficit. On the other hand, the ventricle to brain ratio associated with traumatic brain injury correlated poorly with neuropsychological testing. 19 A patient with a history of head trauma might demonstrate a SPECT pattern similar to a patient with unipolar depression. (See Fig. Z.) The same type of pattern has been demonstrated in a Manganese toxicity case as well as in cases involving AIDS encephalopathy, chronic fatigue syndrome, and drug abuse. 20 The controversy continues in that some clinicians have testified that exposure to chemicals such as pesticides, solvents, and glues result in specific and readily identifiable patterns on brain SPECT. 21 Some clinicians wittingly or unwittingly have overstated the specificity of various SPECT patterns. Having observed a defect, they have then been willing to diagnose a specific illness, disease or injury (specifically brain damage) which they then attribute to a specific insult or event. In some instances, the SPECT patterns can be used to 18 Goldenberg, Oder W., Spratt, J., Podrenka, I., Cerebral Correlates of Disturbed Executive Function and Memory in Survivors of Severe Closed Head Injury: A SPECT Study. J. Neurol. Neurosurg. Psych. 1992, 55: Juni, J., supra. 20 Reiman, E.M., Fusselman, M.J., P.T., Raichele, M.E.: Neuro Anatomical Correlates of Anticipatory Anxiety. Science 243: , Thornton J.I.; Courts of Law vs. Courts of Science: A Forensic Scientist s Reaction to Daubert Shephard s Expert and Scientific Evidence Quarterly 1:475:486, Huser, G., Editorial: Diagnostic Markers in Clinical Immunotoxicology and Neurotoxicology. J. Occ. Med. & Tox. 1:V-X,

19 diagnose certain disease entities whereas in other instances the patterns do nothing more than identify a defect which could be the result of a host of injuries, insults or exposures, unrelated in time or origin to the subject of the lawsuit. FIGURE Z. SPECT of a patient, in suit, who was depressed and who sustained a very mild impact to the skull without L.O.C. but demonstrating an inability, in subsequent weeks, to adequately perform his high skill, high stress job. V. CONCLUSION When confronted with SPECT testimony in a brain damage case, the defense attorney must first attempt to exclude the testimony through a Daubert challenge. If the defense motion in limine is not granted, the defense must be prepared to question the protocol used to administer the test and then to challenge not only the techniques used but also the physician s evaluation of the results. CC[C&O1]407227\

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