New imaging techniques may help prove, or disprove, brain injuries

Interesting reprint of article from VLW:

New imaging techniques may help prove, or disprove, brain injuries

By Peter Vieth
Published: January 3, 2011

Lawyers trying to prove brain injury claims – and the lawyers contesting those claims – now have new tools that sharpen the focus on what’s happening inside a patient’s head.

New developments in brain imaging techniques promise more objective evidence for proving, or disproving, brain injury.

Nearly a dozen plaintiffs’ lawyers watched intently this month as doctors demonstrated two major advances in image studies that allow more precise measurements of brains affected by trauma. “Modern science lets us reach inside the brain,” said Matthew W. Broughton, who hosted the show-and-tell session at his Roanoke law office.

Lawyers stared at colored images on a screen, with different colors representing water moving in different directions within the brain.

The images were created through Diffusion Tensor Imaging (DTI), a method of displaying water in brain tissue that indicates the direction of water flow. Colored images are produced that contrast the direction of diffusion. Scientists can use the images to pinpoint areas of activity, and non-activity, in the brain.

Another new technique is really a refinement of the long-standing Magnetic Resonance Imaging (MRI) study. More detailed MRI images are now available, and doctors are making use of the better pictures to measure changes in the brain over time. Sophisticated software can be applied for even more detailed analysis.

One critical diagnostic tool is measurement of the volume of brain matter over time, according to psychiatrist Dr. David E. Ross of the Virginia Institute of Neuropsychiatry in Midlothian.

“This is a major advance in looking for a quantitative, objective finding of brain injury in our patients,” Ross said.

Fairfax lawyer Scott A. Surovell lauded the impact of colorful DTI images in a recent jury trial. He said the pictures, along with expert testimony to explain what they show, helped him prove the extent of traumatic brain injury for a woman injured by a fireworks display that went awry.

Hampton lawyer Stephen M. Smith, who has been handling brain injury cases for 30 years, said many lawyers are still “behind the curve” on the new technology.

A key advantage of the new diagnostic tools for lawyers is the opportunity to show fact finders objective evidence of changes in the brain, rather than just psychological tests interpreted by clinicians.

“We’ve finally got a clearly objective lab test that no one can really refute,” Ross said. “If we show the brain has shrunk or if they have abnormal diffusion tensor imaging, I think everyone has to agree that’s an objective sign of injury.”

Ross explained that recent studies showed a connection between shrinkage of parts of the brain with decreased performance on tests of brain function.

Being able to show that something is wrong can help TBI patients and families better handle the situation. Families might notice patients are not behaving the way they used to, but there was often a question of why. Observers might question whether a head injury victim had a lasting brain injury or was just unmotivated. “There’s a lot of heartache that goes along with that,” Ross said.

“If you have a lab test showing signs of brain injury, it can help people understand – something really bad has happened to this patient, and they are not the same person they used to be,” he said.

The knowledge that there is a true brain injury can encourage patients to be more compliant with taking medications and understanding their limitations, Ross said.

“MRI may be the best chance for clearly, beyond-a-shadow-of-a-doubt objective finding of brain injury for many patients, especially for those with mild traumatic brain injury,” Ross said.

Defense lawyers caution the new tests don’t close the door on disputes in brain injury claims. For one thing, said John D. McGavin of Fairfax, the science is new and may still be subject to challenge in court. “I’m not sure it’s yet reached the stage of being fully peer-reviewed,” he said.

One concern, McGavin said, is false positives. He noted that earlier imaging advances, such as MRIs and CT scans, turned up evidence that many people without symptoms nonetheless had findings consistent with spinal problems. He said it’s important to develop baselines for normally functioning brains and valid means for comparison to studies of similar resolution.

Attorney Kevin D. Sharp of Norfolk has handled brain injury cases for both plaintiffs and defendants.
He also points out the technology is new, and no image, no matter how detailed, shows what has happened in the past. “I don’t think anybody should take it that we’re going to take this snapshot and that will be the end of it.”

Moreover, Sharp said, better brain images don’t supplant old-fashioned litigation techniques. Lawyers still need to be prepared to question witnesses to examine why and how a patient’s functioning has changed.

Ross said the best advice for lawyers and other professionals confronted with suspected brain injury is, first of all, to get an MRI as soon as possible after the incident. “The first few months are critical,” Ross said.

Doctors want to look for shrinkage of the brain, and most of the shrinking occurs in the first few months, especially the first three months, according to Ross. “The clock’s ticking on this.”

The type of MRI is important. Previously, MRIs commonly used a level of detail measured as 1.5 Tesla. Nowadays, the better choice is 3.0 Tesla, according to Ross and his colleagues.

In addition, Ross said, the patient or doctor should seek an MRI technique that will allow analysis through a medical device called NeuroQuant. “It’s got to be a very specific protocol,” Ross said.

NeuroQuant analysis provides a “really good understanding of what goes on in the brain,” Smith said. “It helps jurors understand.”

The new brain study equipment is predictably expensive. “These are not cheap for facilities to have, and the tests themselves are quite expensive,” Sharp said. A high resolution MRI machine could cost $2-to-3 million, he said.












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