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Medicolegal—Malpractice and Ethical Issues in Radiology. Neuroimaging Evaluation of Sports-Related Concussion QUESTION: I am a Certificate of Added Qualification (CAQ)-certified neuroradiologist who interprets most of the neuroimaging examinations performed in our 200-bed community hospital. I have been asked to evaluate radiologic examinations of a young college student who has a history of having suffered several concussions while playing football and is now complaining of frequent headaches and memory problems. As a clinical neuroradiologist, I am somewhat familiar with traumatic brain injury (TBI) and its evaluation by functional MRI (fMRI) and diffusion tensor imaging (DTI). Are fMRI and DTI findings accepted by the courts as evidence of TBI? What is the current legal status of these examinations? DR. BERLIN’S REPLY: It is estimated that 1.6–3.8 million sports- and recreationrelated traumatic brain injuries, including concussions, occur every year in the United States. A number of research studies have been published in scientific journals over the past several years; some indicate that fMRI and DTI are accurate in diagnosing TBI and postconcussion syndrome, but others indicate there is no correlation between the radiologic findings and those pathologic entities. Clearly, TBI sustained by young people from sports and recreational activities has been increasing. As a consequence, the courts have been confronted with lawsuits claiming that head injuries leading to brain encephalopathy have been caused by repeated concussions sustained during participation in sports, particularly football. Indeed, thousands of former National Football League players have filed a lawsuit against the league claiming permanent brain injury due to repeated concussions. Diffuse axonal injury, which is a common finding after TBI, is rarely diagnosable with
standard neuroimaging. Currently DTI is the method of choice in assessing axonal integrity. Some researchers believe that DTI is an objective and accurate method of determining the relationship between cognitive deficits and TBI, but others have pointed out that such findings are meaningless, if not misleading. The nation’s courts have for many years been confronted with controversial scientific evidence. Lawsuits involving personal injury sustained from an accident or other type of trauma usually require research- or scientificoriented experts to offer testimony regarding medical tests that substantiate injuries that are not obvious clinically. There are two dominant standards by which courts judge the reliability of scientific evidence: the “Daubert” rule and the “Frye” rule. The Frye rule simply requires that the evidence submitted by the expert is “generally accepted within the relevant scientific community;” the Daubert rule considers whether the expert’s theory has been tested, subjected to peer review, and accepted in the relevant scientific community. Which one of these two rules is adhered to depends on the state in which a given court is located. In a personal injury trial, the presiding judge makes the determination of whether an expert witness is qualified to testify and whether the evidence submitted by the expert has sufficient scientific credibility to be presented to a jury. Relative to your question, it is up to you to evaluate the imaging examinations that have been provided or will be provided. You will have to determine for yourself after reviewing the pertinent published scientific evidence related to these examinations whether you have sufficient data by which you can testify that the test results either do or do not support the diagnosis of the injury that is being claimed.
More often than not in most of these cases, the plaintiff’s attorney will retain an expert who will testify that the neuroimaging does support the injury claimed, and the defense attorney will retain an expert who will testify that the test results are insufficient to draw that conclusion. The judge or the jury presented with such conflicting testimony will have to resolve these conflicts and reach a decision in a given case. The reference list provided cites several recent articles on this subject [1–5]. Leonard Berlin NorthShore University HealthSystem, Department of Radiology, Skokie Hospital, Skokie, IL; Professor of Radiology, Rush University and University of Illinois, Chicago, IL ([email protected]) DOI:10.2214/AJR.14.12686
References 1. Valerio J, Illes J. Ethical implications of neuroimaging in sports concussion. J Head Trauma Rehabil 2012; 27:216–221 2. Patel P, Meltzer CC, Nayberg HS, Levine K. The role of imaging in United States courtrooms. Neuroimag Clin N Am 2007; 17:557–567 3. Wortzel HS, Kraus MF, Filley CM, Anderson CA, Arciniegas DB. Diffusion tensor imaging in mild traumatic brain injury litigation. J Am Acad Psychiatry Law 2011; 39:511–523 4. Rivara FT. Sports-related concussions in youth: report from the Institute of Medicine and National Research Council. JAMA 2014; 311:239–240 5. Berlin L. Neuroimaging, expert witnesses, and ethics: convergence and conflict in the courtroom. AJOB Neuroscience 2014; 5:1–6
F O R YO U R I N F O R M AT I O N
We invite your reply to this Medicolegal Q&A series. Send your questions and comments to the attention of AJR Q&A at [email protected]. The comprehensive and updated book, Malpractice Issues in Radiology, 3rd edition, by Leonard Berlin, is now available! For more information or to purchase a copy, see www.arrs.org. All opinions expressed herein are those of the author and do not necessarily reflect those of the American Journal of Roentgenology or the American Roentgen Ray Society. This monthly column answers common professional liability questions. The legal advice provided herein is intended to be general in nature and in specific circumstances is not a substitute for formal legal opinions obtained from the reader’s personal legal counsel. AJR 2014; 202:W408 0361–803X/14/2024–W408 © American Roentgen Ray Society
W408
AJR:202, April 2014
Medicolegal—Malpractice and Ethical Issues in Radiology. Neuroimaging Evaluation of Sports-Related Concussion QUESTION: I am a Certificate of Added Qualification (CAQ)-certified neuroradiologist who interprets most of the neuroimaging examinations performed in our 200-bed community hospital. I have been asked to evaluate radiologic examinations of a young college student who has a history of having suffered several concussions while playing football and is now complaining of frequent headaches and memory problems. As a clinical neuroradiologist, I am somewhat familiar with traumatic brain injury (TBI) and its evaluation by functional MRI (fMRI) and diffusion tensor imaging (DTI). Are fMRI and DTI findings accepted by the courts as evidence of TBI? What is the current legal status of these examinations? DR. BERLIN’S REPLY: It is estimated that 1.6–3.8 million sports- and recreationrelated traumatic brain injuries, including concussions, occur every year in the United States. A number of research studies have been published in scientific journals over the past several years; some indicate that fMRI and DTI are accurate in diagnosing TBI and postconcussion syndrome, but others indicate there is no correlation between the radiologic findings and those pathologic entities. Clearly, TBI sustained by young people from sports and recreational activities has been increasing. As a consequence, the courts have been confronted with lawsuits claiming that head injuries leading to brain encephalopathy have been caused by repeated concussions sustained during participation in sports, particularly football. Indeed, thousands of former National Football League players have filed a lawsuit against the league claiming permanent brain injury due to repeated concussions. Diffuse axonal injury, which is a common finding after TBI, is rarely diagnosable with
standard neuroimaging. Currently DTI is the method of choice in assessing axonal integrity. Some researchers believe that DTI is an objective and accurate method of determining the relationship between cognitive deficits and TBI, but others have pointed out that such findings are meaningless, if not misleading. The nation’s courts have for many years been confronted with controversial scientific evidence. Lawsuits involving personal injury sustained from an accident or other type of trauma usually require research- or scientificoriented experts to offer testimony regarding medical tests that substantiate injuries that are not obvious clinically. There are two dominant standards by which courts judge the reliability of scientific evidence: the “Daubert” rule and the “Frye” rule. The Frye rule simply requires that the evidence submitted by the expert is “generally accepted within the relevant scientific community;” the Daubert rule considers whether the expert’s theory has been tested, subjected to peer review, and accepted in the relevant scientific community. Which one of these two rules is adhered to depends on the state in which a given court is located. In a personal injury trial, the presiding judge makes the determination of whether an expert witness is qualified to testify and whether the evidence submitted by the expert has sufficient scientific credibility to be presented to a jury. Relative to your question, it is up to you to evaluate the imaging examinations that have been provided or will be provided. You will have to determine for yourself after reviewing the pertinent published scientific evidence related to these examinations whether you have sufficient data by which you can testify that the test results either do or do not support the diagnosis of the injury that is being claimed.
More often than not in most of these cases, the plaintiff’s attorney will retain an expert who will testify that the neuroimaging does support the injury claimed, and the defense attorney will retain an expert who will testify that the test results are insufficient to draw that conclusion. The judge or the jury presented with such conflicting testimony will have to resolve these conflicts and reach a decision in a given case. The reference list provided cites several recent articles on this subject [1–5]. Leonard Berlin NorthShore University HealthSystem, Department of Radiology, Skokie Hospital, Skokie, IL; Professor of Radiology, Rush University and University of Illinois, Chicago, IL ([email protected]) DOI:10.2214/AJR.14.12686
References 1. Valerio J, Illes J. Ethical implications of neuroimaging in sports concussion. J Head Trauma Rehabil 2012; 27:216–221 2. Patel P, Meltzer CC, Nayberg HS, Levine K. The role of imaging in United States courtrooms. Neuroimag Clin N Am 2007; 17:557–567 3. Wortzel HS, Kraus MF, Filley CM, Anderson CA, Arciniegas DB. Diffusion tensor imaging in mild traumatic brain injury litigation. J Am Acad Psychiatry Law 2011; 39:511–523 4. Rivara FT. Sports-related concussions in youth: report from the Institute of Medicine and National Research Council. JAMA 2014; 311:239–240 5. Berlin L. Neuroimaging, expert witnesses, and ethics: convergence and conflict in the courtroom. AJOB Neuroscience 2014; 5:1–6
F O R YO U R I N F O R M AT I O N
We invite your reply to this Medicolegal Q&A series. Send your questions and comments to the attention of AJR Q&A at [email protected]. The comprehensive and updated book, Malpractice Issues in Radiology, 3rd edition, by Leonard Berlin, is now available! For more information or to purchase a copy, see www.arrs.org. All opinions expressed herein are those of the author and do not necessarily reflect those of the American Journal of Roentgenology or the American Roentgen Ray Society. This monthly column answers common professional liability questions. The legal advice provided herein is intended to be general in nature and in specific circumstances is not a substitute for formal legal opinions obtained from the reader’s personal legal counsel. AJR 2014; 202:W408 0361–803X/14/2024–W408 © American Roentgen Ray Society
W408
AJR:202, April 2014
