NEURORADIOLOGY 101 for attorneys: Spine and Brain Trauma Imaging. Mark D. Herbst, M.D., Ph.D. FJA February 19, 2014 Orlando, FL

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1 NEURORADIOLOGY 101 for attorneys: Spine and Brain Trauma Imaging Mark D. Herbst, M.D., Ph.D. FJA February 19, 2014 Orlando, FL

2 Medicine relies on Medical Imaging

3 Personal injury cases often rely on objective radiological evidence.

4 Objective evidence of brain injury may not be visible on the images you have.

5 New, advanced methods are now available to image changes in MTBI that were previously invisible.

6 Personal injury attorneys would benefit from knowing more about new methods in neuroradiology.

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8 Radiography = x-rays

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21 Various modalities are used in spine radiology.

22 How you use images can influence the outcome of your personal injury cases.

23 Not all experts see medical images the same way. This is completely normal.

24 Know the answers before you ask the questions of a radiologist.

25 Avoid pitfalls in using radiology studies.

26 Whose expert is Whose Whose expert is wrong about the radiology findings? wrong about the images?

27 Mistake: Failing to use accepted terminology Spine, 26(5):E93-E113 find the link at

28 Endorsements

29 Endorsements 2003

30 Disc Nomenclature Normal Bulge Protrusion Extrusion Sequestration or Free Fragment Intravertebral Herniation (Acute Schmorl s node) Annular tear

31 Normal Discs

32 Symmetrical Bulging

33 Asymmetrical Bulging

34 Intravertebral Herniations

35 Herniation

36 Normal Disc

37 Focal Herniation

38 Broad-based Herniation

39 Protrusion and Extrusion

40 Sequestration

41 Protrusion and Extrusions--New

42 Subligamentous Herniations

43 Degenerative Changes

44 Modic I changes: Fibrovascular

45 Modic II changes: Fatty

46 Modic III changes: Sclerotic

47 Fatty Endplate Changes and Normal Disc

48 Marked fatty endplate changes with Spondylolisthesis

49 What imaging test should be ordered?

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56 Lateral radiograph shows narrow L4-5 disc space

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58 Which may indicate a herniated disc

59 or not.

60 Discography Before MRI, used commonly. Almost abandoned when MRI became available. Has resurfaced as a useful technique to confirm the level that needs surgery in patients with multiple abnormal levels. Can accelerate degeneration in normal discs.

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70 Positive Discogram Three criteria must be met: 1. Must be easier to inject contrast into the abnormal disc than into a normal disc. 2. Must be abnormal in appearance on radiograph or CT. 3. Must exactly reproduce the pain described in the chief complaint.

71 Myelogram

72 CT Myelogram

73 Cervical Spine after MVA

74 Cervical Spine after MVA

75 CT to see C7-T1

76 Annular Tear

77 Free Fragment

78 Cervical Herniations

79 Extrusion of a Desiccated Disc

80 Disc Herniation + Osteophytes = Disc- Osteophyte Complex? NO!

81 Bulges and Herniations look the same on sagittal images

82 Small herniations are important to find, since they can get bigger.

83 Large osteophytes that surround the herniation indicate it is old.

84 Herniation with annular tear that goes away after 18 months.

85 Large osteophytes that surround the herniation indicate it is old.

86 New herniation with hydrated nucleus extruded, no degeneration.

87 Old herniation with surrounding osteophytes and degenerative changes.

88 New herniation with no degenerative changes.

89 Posterior soft tissue edema in the fat that goes away in 8 months.

90 Facet joint effusion on the patient s left, not on the right

91 Facet joint effusions on both sides

92 Facet joint effusions, ligament hypertrophy, and synovial cyst

93 Pitfalls in MRI

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97 Different slices do not show the same anatomy.

98 Comparing different slices makes it look like a change has occurred.

99 Using an insensitive MR protocol can hide abnormalities that are visible otherwise.

100 Whole Body Nuclear Bone Scan

101 Compression Fracture

102 Pitfalls in nuclear medicine

103 Don t allow experts to hide behind radiology findings.

104 Beware of Fake terminology! Broad-based Bulge -- No such thing! Disc Osteophyte Complex misleading phrase that implies there is a relationship between osteophytes and a herniation and that the condition is long-standing. Degenerative protrusion misleading phrase that implies the herniation arose from a degenerative process.

105 Experts can make mistakes, or lie Plaintiffs expert: May call a bulging disc a herniation. May exaggerate the effect of upright position or flexion and extension. May ignore chronic degenerative changes like osteophytes and facet joint arthritis. May assume symptoms that are not present. May overcall findings from DMX or DXD/CRMA. Defense s expert: May call a herniated disc a bulge. May report a disc-osteophyte complex or report osteophytes when osteophytes are not there. May report calcified discs that are not able to be detected on MR. May ignore the possibility of herniation occurring at a previously degenerated level that had prior osteophytes and dehydration. May assert that a herniation is not acute or from trauma unless there is hemorrhage, edema, and swelling.

106 Brain Imaging for Trauma Intro Role of Radiology Appropriate tests for TBI and mild TBI Obvious findings in TBI on CT and MR Advanced and New Imaging Methods for mtbi DTI, PET, SPECT, Volumetrics, DTI, fmri, MEG Dr. Herbst s TBI protocol Matching Imaging with Symptoms Daubert and Frye Future Directions

107 Overview Medical imaging is one piece of the puzzle. Imaging tests are complementary with each other and with other tests, and must be viewed in clinical context. Will your client s case benefit from a new study or a new set of studies? MTBI Package Follow -up First CT scan Risk factors Coma Scale 2nd CT LOC Amnesia 1st MRI scan

108 DoD/VA Common Definition of TBI Any period of a loss of or decreased level of consciousness Any loss of memory for events immediately before or after the injury Any alteration in mental state at the time of the injury (feeling dazed, confused, disoriented, thinking slowly, etc.) Neurological deficits (weakness, loss of balance, change in vision, apraxia, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient Intracranial lesion

109 TBI Symptoms Immediate LOC, AMS, PTA, Abnormal GCS Normal or abnormal imaging Delayed Physical, Cognitive, Behavioral/Emotional Normal or abnormal imaging KEY FACTOR symptoms and imaging findings are not explained better by preexisting conditions or other medical, neurological, or psychological causes, except in cases of exacerbation of a preexisting condition

110 Mild TBI Loss of consciousness lasting less than 30 minutes Alteration of consciousness or mental state lasting up to 24 hours Posttraumatic amnesia up to 24 hours Glasgow Coma Scale (best available score during the first 24 hours) of This definition has been widely used by the Congress of Rehabilitation Medicine, American Academy of Neurology, Centers for Disease Control and Prevention, and the World Health Organization

111 Headache Nausea/vomiting Dizziness Vision disturbance Sleep disturbance Weakness/Paralysis Sensory loss/numbness Spasticity Aphasia/Dysphasia Dysarthria Apraxia Balance disorders Seizures Pain Physical Symptoms

112 Cognitive Symptoms Problems with Attention/Concentration Memory/Speed of processing/new learning Planning/Organizing Reasoning/Judgment Executive control Self-awareness Language Abstract thinking

113 Behavioral/emotional Symptoms Depression Anxiety Agitation/Irritability Impulsivity/acting out/inappropriateness Confusion/Frustration Anger/aggression/violence Paranoia Mood swings

114 Which tests are considered appropriate for imaging mtbi?

115 American College of Radiology Appropriateness Criteria Quality and patient safety Appropriateness Criteria Access Appropriateness criteria Expert Panel on Neurologic Imaging Head Trauma PDF file

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117 ACR says DWI and DTI may be helpful

118 ACR says SPECT and PET may reveal abnormalities in TBI.

119 Abnormal Head CT findings that are obvious on routine scans Skull fractures Epidural hematoma Subdural hematoma Contusions Intraparenchymal hemorrhage Brain edema (focal or diffuse) Subarachnoid hemorrhage Pneumocephalus

120 Skull Fractures Linear skull fracture Most common type of skull fracture

121 Skull Fractures Linear skull fracture. Most common type of skull fracture. Plain film may show a line or band of decreased or increased density.

122 Skull Fractures Linear skull fracture Most common type of skull fracture. This case also shows subcutaneous swelling.

123 Skull Fractures Depressed Skull Fracture

124 Skull Fractures Skull Base Fractures, aka Basilar Skull Fractures Linear fractures that occur at the base of the skull

125 Skull Fractures Skull Base Fractures, aka Basilar Skull Fractures. Linear fractures that occur at the base of the skull. Transverse and longitudinal petrous bone fractures.

126 Dura Mater Subdural=below dura Epidural=extradural=above dura (between skull and dura)

127 Subdural Hematoma Occurs between brain and dura Pushes on soft brain This illustration shows midline shift

128 Subdural Hematoma Occurs between brain and dura. Pushes on soft brain. This illustration shows midline shift. Acute blood is bright on CT, and it gets darker in time.

129 Subdural Hematoma Occurs between brain and dura or along the falx. Pushes on soft brain. This example shows no midline shift. Acute blood is bright on CT, and it gets darker in time.

130 Subdural Hematoma Occurs between brain and dura or along the falx. Pushes on soft brain This example shows midline shift. Acute blood is bright on CT, and it gets darker in time.

131 Epidural Hematoma Occurs between skull and dura

132 Epidural Hematoma Occurs between skull and dura

133 Brain Contusion Commonly affected areas in red are in the anterior frontal and temporal lobes and posterior superior temporal gyrus Less commonly affected areas in blue are the lateral midbrain, posterior inferior cerebellum, and superior midline cortex

134 Brain Contusion Acute contusion, with right frontal hemorrhage and edema, right temporal tip hemorrhage, and left frontal subdural hematoma

135 Brain Contusion Coup-contrecoup injuries Pattern of contusions at the site of impact and on the opposite side of the brain

136 Coup-contrecoup injury video

137 Brain Contusion Coup-contrecoup injuries Pattern of contusions at the site of impact and on the opposite side of the brain

138 Brain Edema First sign is loss of the gray-white junction This case shows mass effect also

139 Subrachnoid Hemorrhage Blood in the sulci of the brain (between the gyri)

140 Pneumocephalus Air inside the head From open fracture through skin or sinus

141 Pneumocephalus Air inside the head From open fracture through skin or sinus

142 Pneumocephalus Air inside the head From open fracture through skin or sinus

143 Shear Injury Shearing between brain tissue of differing firmness, between gray matter and white matter Produces microhemorrhages at the gray-white junction Aka DAI=diffuse axonal injury

144 Shear Injury Video

145 Shear Injury Shearing between brain tissue of differing firmness, between gray matter and white matter Produces microhemorrhages at the gray-white junction Aka DAI=diffuse axonal injury

146 MRI Appearances of TBI Shear injury T2-weighted images Bright spots on T2WI

147 MRI Appearances of TBI Shear Injury Diffusionweighted MRI

148 Shear Injury Shearing between brain tissue of differing firmness, between gray matter and white matter Aka DAI=diffuse axonal injury If the lesions are not hemorrhagic, they are dark on CT

149 New Methods PET, SPECT, fmri, fpet, microhemorrhage MR, DTI, DTI-tractography

150 MRI Appearances of TBI Shear Injury Gradient Echo image, aka microhemorrhage technique This technique can show abnormalities not seen on CT or regular MRI

151 Gradient Echo Microhemorrhage Technique

152 SWI Susceptibilityweighted Imaging another Microhemorrhage Technique

153 SWI

154 MRI of blood--gradient Echo Gradient echo images may show blood not shown on regular MRI images, here shown at the right cortical surface. The shear injury in this case is not hemorrhagic.

155 CT and SPECT in acute TBI SPECT=single photon emission computed tomography Shows area of hypoperfusion

156 PET in chronic TBI PET=positron emission tomography

157 PET in chronic TBI PET=positron emission tomography

158 Volumetric MR Temporal lobe white matter and hippocampal volume are decreased, and volume of the temporal horn of the lateral ventricle is increased in TBI

159 Volumetric MR Automatic segmentation of gray matter, white matter, and CSF, from which volumes are measured

160 Normal Brain Volumes

161 Volumetric MR

162 Volumetric MR

163 DT-MRI in DAI DTI-MRI=diffusion tensor MRI Shows where axons are malfunctioning This case show abnormal splenium in an injured patient, compared to twin brother

164 DTI in TBI Inspection of FA maps and color eignenvalue maps: Normal TBI TBI

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169 C-FAST = Cerebral Fractional Anisotropy Score in Trauma

170 PET in chronic TBI PET=positron emission tomography Patients recovering from TBI show increased brain activity when performing memory tasks This may indicate reorganizing memory pathways or regions of less efficient brain activity

171 Functional MRI fmri=functional MRI, shows oxygen use in the brain This image shows normal activity during various tasks

172 fmri in TBI The abnormal brain shows increased activity compared to normal

173 MEG Abnormal Slow wave activity in mtbi

174 Mild TBI due to Several Sport-related Accidents with NO Visible Lesion on CT or MRI, but with Abnormal MEG Slow-waves and DTI History: 17-year old, male football player, who suffered 3 mtbis while playing football. 1 st and 2 nd concussions separated by a few weeks, and 3 rd a few months later. After the 1 st injury: headaches. After the 2 nd injury: headaches, dizziness, and extreme fatigue while performing any mental task. Following the 3 rd concussion: pressure headaches, dizziness, fatigue, altered sleep (taking longer to fall asleep), and changes in speech. Multiple CT and MRI scans all negative. L R MEG results show abnormal slow-waves generated from two regions in a TBI patient: 1) left column -- left lateral superior-posterior temporal region, 2) right column --- right inferior-temporal areas. Color threshold p<0.01. The top, middle, and bottom rows are lateral-view, ventral-view, and middle-view, respectively. Huang et al., J. NeuroTrauma 2009; 26: Left column: coronal and axial view show abnormal DTI in superior-posterior temporal lobe of the left hemisphere in a TBI patient. Right column: abnormal DTI in inferior-temporal lobe as part of the inferior longitudinal fasciculus of the right hemisphere.

175 Mild TBI patient with blast injury with NO Visible Lesion on CT or MRI, but abnormal MEG slow-waves and DTI findings in a Major white-matter tract History: blast-induced mtbi patient (male, age 27) caused by an IED. He experienced a loss of consciousness for several seconds and he experienced post-concussive symptoms of fatigue, disordered sleep, dizziness, irritability, anxiety, psychosocial and personality disturbances, and memory loss since the incident. His clinical MRI and CT scans were negative (a) (b) L TBI Control R p<.01 p<.001 Multiple neuronal sources that generated MEG slow-waves in a mild TBI patient. Bilateral LPFC, left OFC, left ACC, and left temporal areas regions showed abnormal slow-wave activities. DTI reveals profound abnormality of left SLF in a TBI patient. The normal control showed much thicker anterior-posterior oriented diffusion in SLF (green color) than the TBI patient in the left hemisphere. The white boxes are used for ROI analysis. Huang et al., J. NeuroTrauma 2009; 26:

176 What to do when your TBI client has normal CT and MR scans Consider a re-read by an independent expert Consider repeat studies on more modern equipment Consider newer imaging techniques, like DTI, DTItractography, PET, functional MR, functional PET, Volumetric MR, MEG

177 The MTBI Package A set of various imaging modalities done on the same patient, on the same day, at the same slice thickness, and the same slice angle, done to show subtle abnormalities with a high level of confidence.

178 The TBI Package A set of various imaging modalities done on the same patient, on the same day, at the same slice thickness, and the same slice angle, done to show subtle abnormalities with a high level of confidence.

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180 TBI Package CT MR, with DTI-tractography and microhemorrhage technique and Volumetric measurements PET scan Correlation of all of these studies Cover letter in plain English with glossary

181 CT Good for fractures, blood, atrophy

182 CT Good for fractures, blood, atrophy All images are viewed digitally, not from films but on computer monitors, to bring out subtle features.

183 MR Good for aging blood, atrophy, shear injury

184 PET Good for finding areas of decreased metabolism in areas of subtle brain damage

185 Comparison of Patient with Normals Compared with 50 Normal Controls

186 Comparison of Patient with Normals Compared with 50 Normal Controls

187 MR with DTI-tractography A new technique Shows where nerve fibers are normal or abnormal in or between various brain regions

188 MR with DTI-tractography A new technique Shows where nerve fibers are normal or abnormal in or between various brain regions

189 SPECT scan Nuclear Medicine Brain Scan Shows where blood flow goes in the brain May or may not correlate with other tests Cornerstone of some brain injury diagnostic and theraputic regimens

190 Golfer with TBI

191 Golfer with TBI

192 Golfer with TBI

193 Golfer with TBI

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195 Right fronto-parietal gliosis

196 Decreased Axons in the left external capsule

197 MTBI Patient with normal CT and PET

198 Compare frontal lobe axons

199 Look back at MRI to see a subtle abnormality that is now visible.

200 DTI tractography makes subtle lesions appear more obvious on routine MRI.

201 Where is the lesion that causes achromatopsia (inability to match colors and hues)? Achromatopsia results from a lesion of the dominant occipital lobe (Brodmann s area 18, splenium of corpus callosum) and is a feature of the syndrome of alexia without agraphia.

202 Alexia Without Agraphia

203 Alexia Without Agraphia

204 Brain s Golf Center

205 Brodmann s areas Lateral View

206 Brodmann s Area Medial View

207 Detailed functional localization in the brain

208 Detailed functional localization in the brain

209 DOES DTI SURVIVE DAUBERT S TEST? BRAIN PET? BRAIN VOLUMETRICS? MEG? SPECT?

210 Daubert s 4-prong test 1. Whether the conclusion or methodology proffered can be or has been tested (that is, whether the expert s theory can be challenged in some objective sense, or whether it is instead simply a subjective, conclusory approach that cannot reasonably be assessed for reliability); 2. Whether the conclusion or methodology has been subjected to peer review and publication; 3. Whether standards exist that control the methodology s operation, and if so, the known or potential rate of error; and 4. Whether the conclusion or methodology is generally accepted.

211 Daubert answers for DTI 1. Tested, objective, not subjective? Yes. Data can be independently reviewed. 2. Subjected to peer review and publication? Yes, many publications in peer-reviewed journals. 3. Standards available and error rate known? Yes, normal values are published, and false negatives have been reported. No data on false positives available. 4. Generally accepted? Yes. More centers in Florida are doing these studies all the time.

212 Daubert answers for brain PET 1. Tested, objective, not subjective? Yes. Data can be independently reviewed. 2. Subjected to peer review and publication? Yes, many publications in peer-reviewed journals. 3. Standards available and error rate known? Yes, normal values are published, and patient data can be compared to a database of normal individuals. Error rate not yet published. 4. Generally accepted? Yes. More centers in Florida are doing these studies all the time.

213 Daubert answers for Brain Volumetrics 1. Tested, objective, not subjective? Yes. Data can be independently reviewed. 2. Subjected to peer review and publication? Yes, many publications in peer-reviewed journals. 3. Standards available and error rate known? Yes, normal values are published. Error rates not yet published. 4. Generally accepted? Yes. More centers in the US are doing these studies all the time.

214 Daubert answers for MEG 1. Tested, objective, not subjective? Yes. Data can be independently reviewed, but experts are rare. 2. Subjected to peer review and publication? Yes, publications in peer-reviewed journals. 3. Standards available and error rate known? Not yet. 4. Generally accepted? Not yet.

215 Daubert Summary for mtbi imaging CT MR PET SPECT Volumetrics DTI MEG Objective Y Y Y Y Y Y Y Published Y Y Y Y Y Y Y Standards Y Y Y Y/N Y Y/N N Accepted Y Y Y Y Y/N Y/N N

216 Frye Criterion 1. Frye is just #4 of Daubert general acceptance. Not defined in the law. 2. A Frye challenge was raised against Dr. Herbst regarding DTI-tractography for mtbi, but was withdrawn after his deposition.

217 Conectomes and Connectometrics The Future of DTI

218 Conectomes and Connectometrics The Future of DTI

219 Conectomes and Connectometrics The Future of DTI

220 Conectomes and Connectometrics The Future of DTI

221 Conectomes and Connectometrics The Future of DTI

222 The TBI Package Not a medical test: Dr. Herbst obtains the images for the TBI package with CT, MR, PT, DTI with tractography, possible Volumetric MR, possible SPECT Private consultation that is considered attorney privileged work product. Not covered by insurance Call Chery Castano for current pricing and scheduling

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225 Independent Diagnostic Radiology Mark D. Herbst, M.D., Ph.D cell

226 Supplementary Materials ACR documents Low Back Pain Chronic Neck Pain Suspected Spine Injury Evidence Tables Lumbar Disc Herniation Nomenclature Article NEXUS and CCR articles How old is that herniation?

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