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Monte S. Buchsbaum, M.D.Professor of Psychiatry

Director, Neuroscience PET

Laboratory

New York

Use and admissibility ofpositron emission tomography

(PET) scanning in head injury

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Anatomy and function

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PET fluorodeoxyglucose Uptake of artificial radiolabeled

sugar (FDG) over 30 minutes Subject does task during uptake

FDG metabolically trapped in brain

Move to scanner after uptake toimage brain activity during task

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After uptake, subject lies in

scanner

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PET shows abnormalities in: Head injury

Schizophrenia

Alzheimers disease

Stroke

Chronic methamphetamine abuse

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V

isualizing brain injury Computerized tomography (CT)

Magnetic resonance imaging (MRI)

Single photon emission computed

tomography (SPECT)

Electroencephalographic mapping

Positron emission tomography (PET)

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Head injury by dropping at

delivery

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Head injury after birth

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Statistical probability map

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Statistical probability mapNormal group mean=1.20

standard deviation .10

lower limit of normal=1.00

Patient value=0.90

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Frontal lobe damage lack of insight

disinhibition loss of mental models of social

rules

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Automobile head injury

Frontal lobe

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Closed head injury imaging The most promising aspects of the

application of nuclear medicine techniques

relate to the demonstration of neuronal

dysfunction in regions that look structurally

intact on CT or MRI

Oder et al.

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Newberg AB, Alavi A.

Division of Nuclear Medicine, Philadelphia, PA 19104, USA.

Neuroimaging techniques provide some of the most important

diagnostic, prognostic, and pathophysiological information in themanagement of brain injury.Anatomical imaging modalities can

help assess intracranial hemorrhage, fractures, and other structural

lesions. Functional imaging has been shown to be helpful in

assessing the areas of the brain affected by the trauma as well as

determining long term prognosis and rehabilitation potential. Thisarticle will review the current uses of neuroimaging techniques in

head trauma and delineate future applications.

Semin Nucl Med. 2003Apr;33(2):136-47

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Van Heertum et al.

In evaluating acute head injury, CT and MR are theprimary diagnostic tools. They play a critical role indetecting intracranial lesions that may require

neurosurgical intervention. It should be noted, however,that SPECT and PET brain imaging have been foundto be better than CT or MRI as prognostic indicatorsand thus may play a valuable role in the critical caremanagement of these patients. In general, patients with

larger and or more numerous lesions encountered onSPECT or PET relative to CT or MRI tend to have a

poorer prognosis and conversely an initial negative

Seminars in Nuclear Medicine 34:300 2004

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Closed head injury The PET scans in each study demonstrated

cerebral pathology not visualized by CT and

in some cases, not visualized by MRI,

either.

Boller et al.Annals New YorkAcademy of Sciences,769:23, 1995

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Skull fracture, orbital surfaceEncephalomalacia

on MRI

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Typical adult and patient

ab

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PET and statistical analysis

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PET and MRI

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MRI PET statistics

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Closed head injury The PET scans in each study demonstrated

cerebral pathology not visualized by CT and

in some cases, not visualized by MRI,either.

Boller et al.Annals New YorkAcademy of Sciences,769:23, 1995

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Subtraction of right from left in

severe hemispheric injury

Left minus right of patient minus mean normal score/normal sd

Left minus

Right 2 sd low

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Statistical survey of brain

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Basal ganglia and temporal lobe

Temporallobe

Basal ganglia

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Mitigative evidence Brain change associated with mental

illness

brain damage to executive functions

brain damage to areas involved in

impulse control brain diseases diminishing capacity for

cognitive function

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Head injury in a violent offender

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Multiple regions of decreased

function

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Two head injuries before crime

Patient AB

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Competency

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Gigante statistical contrast

Patient and areas

in lowest 5% of elderly

33 patients with AD

statistically contrasted with

33 normal elderly

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Regressi95% c fi .

Prediction of Patient MMSE Score from PETc ttergr f 1 tients t ri s st ges f A

C rrel ti n: r = .4212 < . 5

Relative Glucose Metabolic Rate in Right Temporal Lobe

1

14

18

22

26

.7 .8 .9 1. 1.1 1.2 1. 1.4

VG

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Scientific basis of PET More than 5000 scientific articles in

reviewed journals

18-F deoxyglucose widely accepted as valid

and reliable assessment of metabolic rate

Quantitative analysis on pixel-by-pixel

basis widely used in hundreds of researchstudies

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PET has wide scientific base

Research tools may

receive more detailedscientific scrutiny

thanclinical tools

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Scientific basis of PET Insurance coverage is not a measure of

scientific acceptability

18-F deoxyglucose widely accepted in the

scientific community for assessment of

metabolic rate and regional brain function

Insurance pays forAlzheimers disease vs.

Picks disease since it changes treatment,not confirms untreatable diagnosis

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Scientific basis of PET

18-F deoxyglucose widely accepted for

assessment of metabolic rate andregional brain function

DNA testing is widely accepted as

forensic evidence but is not paid for byinsurance because it doesnt affect

patient care

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Diagnosis and lab measures Diagnosis requires history, physical

examination and laboratory tests

Few diagnoses are made on the basis

of a single laboratory test

PET helps corroborate history andphysical examination

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Diagnosis and lab measures Validation based on scientific principle

Watch for too few scientific articleson PET scans in this disease in this

type of patient at this age

PET helps corroborate history andphysical examination

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Exclusion of evidence More often rejected on non-disclosure than

scientific merit

Disclose displays, especially normal images

Specify what material was used to arrive at

opinion of experts to avoid unreasonable

requests for information and data

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just for research Research published in peer-reviewed

journals

Research requires statistical confirmation

Clinical usage may not always be supported

by rigorous research

Insurance may be paid for tests not

supported by research

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A

dmissibility in New York

R 4532-a. X-rays, magnetic resonance images,

computed axial tomograms,positron emission tomographs,

electromyograms, sonograms and fetal heart rate monitor

strips in personal injury actions

Admissible if photographically identified,disclosed 10 days before the date of trial

Amended CPLR 4532, May 23, 1986

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Kelly/Frye RulePeople v. Kelly (1976) 17 Cal.3d 24

The scientific method must have been

shown to be reliable

The witness utilizing the new procedure

must be qualified as an expert in the field

It must be shown that correct scientific

procedures were used in the application ofthe new procedure (summary by Terri Towery Feb 18,Monterey Capital Case Conference)

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Diminished frontal lobe function

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We found these two in the group of

normals

Two standard deviations means just that

below 5% of the population

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Diffusion tensor imagingWhite

matter of

Corpus

callosum

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Monte S. Buchsbaum, M.D.

Mount Sinai School of Medicine

212-241-5294

monte.buchsbaum@mssm.edu

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Temporal lobe change

Pt. JH

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Parietal lobe metabolic decrease

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NatNeurosci 1999 Nov;2(11):1032-7

Impairment of social and moral behavior related to early

damage in human prefrontal cortex.

Anderson SW, Bechara A, Damasio H, Tranel D, Damasio AR

The long-term consequences of early prefrontal cortex

lesions occurring before 16 months were investigated in

two adults. The two early-onset patients had severely

impaired social behavior despite normal basic cognitive

abilities, and showed insensitivity to future consequences

of decisions. Unlike adult-onset patients, however, the

two patients had defective social and moral reasoning,

suggesting that the acquisition of complex social

conventions and moral rules had been impaired.

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A man infected with cholera is not allowed tomix freely with the population, but we do not

think him wicked. We may similarly be

obliged to interfere with the freedom of amurderer, but we should not have a feeling of

moral reprobation in the one case more than in

the other.

Bertrand Russell

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Aging change

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Neurology 1998 Jul;51(1):142-8

Clinicometabolic dissociation of cognitive

functions and social behavior in frontal lobe lesions.

Sarazin M, Pillon B, Giannakopoulos P, Rancurel G, Samson Y, Dubois B

Case studies suggest a dissociation between cognitive functions

that have been impaired after damage to the dorsolateralprefrontal cortex and social skills disturbed when the

ventromedial prefrontal areas are affected.Because this dissociation had not been confirmed in a clinical setting,

clinicometabolic PET correlations were sought in 13 patients with various

lesions of the prefrontal cortex.: Executive-function test performance was significantly correlated with activity

in the dorsolateral prefrontal cortex) and anterior cingulate cortex. Behavioral

scores were significantly correlated with activity in the frontopolar and

orbitofrontal cortex.