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Use and admissibility of positron emission tomography PET scanning in head injury

Anatomy and function. PET fluorodeoxyglucose. Uptake of artificial radiolabeled sugar (FDG) over 30 minutesSubject does task during uptakeFDG metabolically trapped in brainMove to scanner after uptake to image brain activity during task. After uptake, subject lies in scanner. PET shows abnormalities in:.

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Use and admissibility of positron emission tomography PET scanning in head injury

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    1. Monte S. Buchsbaum, M.D. Professor of Psychiatry Director, Neuroscience PET Laboratory New York Use and admissibility of positron emission tomography (PET) scanning in head injury

    3. 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 to image brain activity during task

    4. After uptake, subject lies in scanner

    5. PET shows abnormalities in: Head injury Schizophrenia Alzheimer’s disease Stroke Chronic methamphetamine abuse

    6. Visualizing brain injury Computerized tomography (CT) Magnetic resonance imaging (MRI) Single photon emission computed tomography (SPECT) Electroencephalographic mapping Positron emission tomography (PET)

    7. Head injury by dropping at delivery

    8. Head injury after birth

    9. Statistical probability map

    10. Statistical probability map

    11. Frontal lobe damage lack of insight disinhibition loss of mental models of social rules

    12. Automobile head injury

    13. 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.

    15. Van Heertum et al. In evaluating acute head injury, CT and MR are the primary diagnostic tools. They play a critical role in detecting intracranial lesions that may require neurosurgical intervention. It should be noted, however, that SPECT and PET brain imaging have been found to be better than CT or MRI as prognostic indicators and thus may play a valuable role in the critical care management of these patients. In general, patients with larger and or more numerous lesions encountered on SPECT or PET relative to CT or MRI tend to have a poorer prognosis and conversely an initial negative

    16. 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.

    17. Skull fracture, orbital surface

    19. Typical adult and patient

    20. PET and statistical analysis

    21. PET and MRI Elizabeth RonessElizabeth Roness

    22. MRI PET statistics Elizabeth Roness civial caseElizabeth Roness civial case

    23. 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.

    24. Subtraction of right from left in severe hemispheric injury

    25. Statistical survey of brain

    26. Basal ganglia and temporal lobe

    27. 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

    28. Head injury in a violent offender

    29. Multiple regions of decreased function

    30. Two head injuries before crime

    32. Competency

    33. Gigante statistical contrast

    35. 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 research studies

    36. PET has wide scientific base

    37. 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 for Alzheimer’s disease vs. Picks disease since it changes treatment, not confirms untreatable diagnosis

    38. Scientific basis of PET 18-F deoxyglucose widely accepted for assessment of metabolic rate and regional brain function DNA testing is widely accepted as forensic evidence but is not paid for by insurance because it doesn’t affect patient care

    39. 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 and physical examination

    40. Diagnosis and lab measures Validation based on scientific principle Watch for “too few scientific articles on PET scans in this disease in this type of patient at this age…” PET helps corroborate history and physical examination

    41. 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

    42. “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

    43. Admissibility in New York

    44. Kelly/Frye Rule People 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 of the new procedure (summary by Terri Towery Feb 18, Monterey Capital Case Conference)

    46. We found these two in the group of normals

    47. Diffusion tensor imaging

    48. Monte S. Buchsbaum, M.D. Mount Sinai School of Medicine 212-241-5294 monte.buchsbaum@mssm.edu

    49. Temporal lobe change

    50. Parietal lobe metabolic decrease

    56. A man infected with cholera is not allowed to mix freely with the population, but we do not think him wicked. We may similarly be obliged to interfere with the freedom of a murderer, but we should not have a feeling of moral reprobation in the one case more than in the other.

    57. Aging change

    58. Performance on CPT task during FDG uptake Murderers 3.6 SD= 0.71 Controls 3.5 SD =0.77

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