NEURORADIOLOGY 101 for attorneys: Spine and Brain Trauma Imaging Mark D. Herbst, M.D., Ph.D. FJA February 19, 2014 Orlando, FL
Medicine relies on Medical Imaging
Personal injury cases often rely on objective radiological evidence.
Objective evidence of brain injury may not be visible on the images you have.
New, advanced methods are now available to image changes in MTBI that were previously invisible.
Personal injury attorneys would benefit from knowing more about new methods in neuroradiology.
Radiography = x-rays
Various modalities are used in spine radiology.
How you use images can influence the outcome of your personal injury cases.
Not all experts see medical images the same way. This is completely normal.
Know the answers before you ask the questions of a radiologist.
Avoid pitfalls in using radiology studies.
Whose expert is Whose Whose expert is wrong about the radiology findings? wrong about the images?
Mistake: Failing to use accepted terminology Spine, 26(5):E93-E113 find the link at www.independent-dr.com
Endorsements
Endorsements 2003
Disc Nomenclature Normal Bulge Protrusion Extrusion Sequestration or Free Fragment Intravertebral Herniation (Acute Schmorl s node) Annular tear
Normal Discs
Symmetrical Bulging
Asymmetrical Bulging
Intravertebral Herniations
Herniation
Normal Disc
Focal Herniation
Broad-based Herniation
Protrusion and Extrusion
Sequestration
Protrusion and Extrusions--New
Subligamentous Herniations
Degenerative Changes
Modic I changes: Fibrovascular
Modic II changes: Fatty
Modic III changes: Sclerotic
Fatty Endplate Changes and Normal Disc
Marked fatty endplate changes with Spondylolisthesis
What imaging test should be ordered?
Lateral radiograph shows narrow L4-5 disc space
Which may indicate a herniated disc
or not.
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.
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.
Myelogram
CT Myelogram
Cervical Spine after MVA
Cervical Spine after MVA
CT to see C7-T1
Annular Tear
Free Fragment
Cervical Herniations
Extrusion of a Desiccated Disc
Disc Herniation + Osteophytes = Disc- Osteophyte Complex? NO!
Bulges and Herniations look the same on sagittal images
Small herniations are important to find, since they can get bigger.
Large osteophytes that surround the herniation indicate it is old.
Herniation with annular tear that goes away after 18 months.
Large osteophytes that surround the herniation indicate it is old.
New herniation with hydrated nucleus extruded, no degeneration.
Old herniation with surrounding osteophytes and degenerative changes.
New herniation with no degenerative changes.
Posterior soft tissue edema in the fat that goes away in 8 months.
Facet joint effusion on the patient s left, not on the right
Facet joint effusions on both sides
Facet joint effusions, ligament hypertrophy, and synovial cyst
Pitfalls in MRI
Different slices do not show the same anatomy.
Comparing different slices makes it look like a change has occurred.
Using an insensitive MR protocol can hide abnormalities that are visible otherwise.
Whole Body Nuclear Bone Scan
Compression Fracture
Pitfalls in nuclear medicine
Don t allow experts to hide behind radiology findings.
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.
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.
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
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
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
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
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 13-15 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
Headache Nausea/vomiting Dizziness Vision disturbance Sleep disturbance Weakness/Paralysis Sensory loss/numbness Spasticity Aphasia/Dysphasia Dysarthria Apraxia Balance disorders Seizures Pain Physical Symptoms
Cognitive Symptoms Problems with Attention/Concentration Memory/Speed of processing/new learning Planning/Organizing Reasoning/Judgment Executive control Self-awareness Language Abstract thinking
Behavioral/emotional Symptoms Depression Anxiety Agitation/Irritability Impulsivity/acting out/inappropriateness Confusion/Frustration Anger/aggression/violence Paranoia Mood swings
Which tests are considered appropriate for imaging mtbi?
American College of Radiology Appropriateness Criteria www.acr.org Quality and patient safety Appropriateness Criteria Access Appropriateness criteria Expert Panel on Neurologic Imaging Head Trauma PDF file www.acr.org
ACR says DWI and DTI may be helpful
ACR says SPECT and PET may reveal abnormalities in TBI.
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
Skull Fractures Linear skull fracture Most common type of skull fracture
Skull Fractures Linear skull fracture. Most common type of skull fracture. Plain film may show a line or band of decreased or increased density.
Skull Fractures Linear skull fracture Most common type of skull fracture. This case also shows subcutaneous swelling.
Skull Fractures Depressed Skull Fracture
Skull Fractures Skull Base Fractures, aka Basilar Skull Fractures Linear fractures that occur at the base of the skull
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.
Dura Mater Subdural=below dura Epidural=extradural=above dura (between skull and dura)
Subdural Hematoma Occurs between brain and dura Pushes on soft brain This illustration shows midline shift
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.
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.
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.
Epidural Hematoma Occurs between skull and dura
Epidural Hematoma Occurs between skull and dura
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
Brain Contusion Acute contusion, with right frontal hemorrhage and edema, right temporal tip hemorrhage, and left frontal subdural hematoma
Brain Contusion Coup-contrecoup injuries Pattern of contusions at the site of impact and on the opposite side of the brain
Coup-contrecoup injury video
Brain Contusion Coup-contrecoup injuries Pattern of contusions at the site of impact and on the opposite side of the brain
Brain Edema First sign is loss of the gray-white junction This case shows mass effect also
Subrachnoid Hemorrhage Blood in the sulci of the brain (between the gyri)
Pneumocephalus Air inside the head From open fracture through skin or sinus
Pneumocephalus Air inside the head From open fracture through skin or sinus
Pneumocephalus Air inside the head From open fracture through skin or sinus
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
Shear Injury Video
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
MRI Appearances of TBI Shear injury T2-weighted images Bright spots on T2WI
MRI Appearances of TBI Shear Injury Diffusionweighted MRI
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
New Methods PET, SPECT, fmri, fpet, microhemorrhage MR, DTI, DTI-tractography
MRI Appearances of TBI Shear Injury Gradient Echo image, aka microhemorrhage technique This technique can show abnormalities not seen on CT or regular MRI
Gradient Echo Microhemorrhage Technique
SWI Susceptibilityweighted Imaging another Microhemorrhage Technique
SWI
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.
CT and SPECT in acute TBI SPECT=single photon emission computed tomography Shows area of hypoperfusion
PET in chronic TBI PET=positron emission tomography
PET in chronic TBI PET=positron emission tomography
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
Volumetric MR Automatic segmentation of gray matter, white matter, and CSF, from which volumes are measured
Normal Brain Volumes
Volumetric MR
Volumetric MR
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
DTI in TBI Inspection of FA maps and color eignenvalue maps: Normal TBI TBI
C-FAST = Cerebral Fractional Anisotropy Score in Trauma
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
Functional MRI fmri=functional MRI, shows oxygen use in the brain This image shows normal activity during various tasks
fmri in TBI The abnormal brain shows increased activity compared to normal
MEG Abnormal Slow wave activity in mtbi
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: 1213-1226. 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.
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: 1213-1226.
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
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.
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.
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
CT Good for fractures, blood, atrophy
CT Good for fractures, blood, atrophy All images are viewed digitally, not from films but on computer monitors, to bring out subtle features.
MR Good for aging blood, atrophy, shear injury
PET Good for finding areas of decreased metabolism in areas of subtle brain damage
Comparison of Patient with Normals Compared with 50 Normal Controls
Comparison of Patient with Normals Compared with 50 Normal Controls
MR with DTI-tractography A new technique Shows where nerve fibers are normal or abnormal in or between various brain regions
MR with DTI-tractography A new technique Shows where nerve fibers are normal or abnormal in or between various brain regions
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
Golfer with TBI
Golfer with TBI
Golfer with TBI
Golfer with TBI
Right fronto-parietal gliosis
Decreased Axons in the left external capsule
MTBI Patient with normal CT and PET
Compare frontal lobe axons
Look back at MRI to see a subtle abnormality that is now visible.
DTI tractography makes subtle lesions appear more obvious on routine MRI.
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.
Alexia Without Agraphia
Alexia Without Agraphia
Brain s Golf Center
Brodmann s areas Lateral View
Brodmann s Area Medial View
Detailed functional localization in the brain
Detailed functional localization in the brain
DOES DTI SURVIVE DAUBERT S TEST? BRAIN PET? BRAIN VOLUMETRICS? MEG? SPECT?
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.
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.
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.
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.
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.
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
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.
Conectomes and Connectometrics The Future of DTI
Conectomes and Connectometrics The Future of DTI
Conectomes and Connectometrics The Future of DTI
Conectomes and Connectometrics The Future of DTI
Conectomes and Connectometrics The Future of DTI
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 727-327-5006 for current pricing and scheduling
Independent Diagnostic Radiology Mark D. Herbst, M.D., Ph.D. 727-327-5006 727-424-0106 cell www.independent-dr.com
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?