NEURORADIOLOGY 101 For Attorneys

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
wrong
about
the
findings?
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 = DiscOsteophyte 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?
Follow
-up
MTBI
Package
Risk
factors
Coma
Scale
First
CT
scan
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
Physical Symptoms
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Headache
Nausea/vomiting
Dizziness
Vision disturbance
Sleep disturbance
Weakness/Paralysis
Sensory loss/numbness
Spasticity
Aphasia/Dysphasia
Dysarthria
Apraxia
Balance disorders
Seizures
Pain
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. 1st and 2nd
concussions separated by a few weeks, and 3rd a few months later. After the 1st injury: headaches.
After the 2nd injury: headaches, dizziness, and extreme fatigue while performing any mental task.
Following the 3rd concussion: pressure headaches, dizziness, fatigue, altered sleep (taking longer to
fall asleep), and changes in speech. Multiple CT and MRI scans all negative.
L
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.
R
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
p<.01
TBI
Control
R
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?”