BACKGROUND: The aim of this report was to assess the usefulness
of cerebral blood flow (CBF) scanning utilising the
SPECT technique in forensic medicine cases in the area of civil
law cases.
MATERIAL AND METHODS: CBF SPECT scanning was performed
in four patients utilising 99mTc-ECD and a triple-head gammacamera.
In the analysis both the asymmetry index and cerebellar
normalisation were applied. Reference values were obtained
by studying 30 healthy volunteers.
RESULTS: In those cases CBF SPECT scanning played an important
role in forensic argument. It influenced the sentence
and the amount of financial compensation.
CONCLUSIONS: CBF SPECT scanning may provide valuable
information in forensic medicine argument in civil law cases,
but only when taken together with psychometric tests and other
neuroimaging methods (CT, MRI). The value of CBF SPECT
scanning alone may be limited in judicial proceedings

Bandurski, Tomasz

Krzyżanowski, Maciej

Lass, Piotr

Piskunowicz, Maciej

English

Via Medica Journals

45Nuclear Medicine Review 2003 Vol. 6, No. 1, pp. 45–47Copyright © 2003 Via MedicaISSN 1506–9680www.nmr.viamedica.plShortcommuni-cationsThe usefulness of CBF brain SPECTin forensic medicine: the civil lawcode cases. A description of four casesMaciej Piskunowicz1, Maciej Krzyżanowski2, Piotr Lass1,Tomasz Bandurski11Department of Nuclear Medicine, Medical University, Gdańsk, Poland2Department of Forensic Medicine, Medical University, Gdańsk, Poland[Received 7 III 2003; Accepted 7 IV 2003]AbstractBACKGROUND: The aim of this report was to assess the use-fulness of cerebral blood flow (CBF) scanning utilising theSPECT technique in forensic medicine cases in the area of civillaw cases.MATERIAL AND METHODS: CBF SPECT scanning was per-formed in four patients utilising 99mTc-ECD and a triple-head gam-macamera. In the analysis both the asymmetry index and cere-bellar normalisation were applied. Reference values were ob-tained by studying 30 healthy volunteers.RESULTS: In those cases CBF SPECT scanning played an im-portant role in forensic argument. It influenced the sentenceand the amount of financial compensation.CONCLUSIONS: CBF SPECT scanning may provide valuableinformation in forensic medicine argument in civil law cases,but only when taken together with psychometric tests and oth-er neuroimaging methods (CT, MRI). The value of CBF SPECTscanning alone may be limited in judicial proceedings.Key words: SPECT, cerebral blood flow, forensic medicine IntroductionNuclear medicine CNS studies, SPECT and PET, in recentyears have slowly but increasingly started to become a tool offorensic medicine, most often in the USA [1]. In our previous com-munication we described a series of cerebral blood flow (CBF)SPECT scanning applications in criminal cases [2]. These meth-ods are starting to be applied in civil law cases as well, most oftenwhen insurance companies are being sued.The most frequent cases involve the suing of those compa-nies by the victims of head trauma, following car accidents andaccidents at work. The insurance companies tend to underesti-mate the loss of health following such accidents, while the victimstend to overestimate this loss. Additional claims involve the costof additional medical tests, physiotherapy etc.Most often SPECT and PET are used in forensic argument inthe USA [2–4]. The crucial point in post-traumatic brain injury isthe frequent incidence of unspecific complaints, like vertigo, per-sistent headaches, memory loss, emotional disorders and sleepdisturbances. CT and MRI scanning may be normal. On the otherhand, the simulation of these disorders is frequent [5].In the years 2000–2002 in our Department we performed about30 CBF SPECT scans ordered by the Public Prosecutor’s Office,prisons health service or Social Security. Ten of them were per-formed for subsequent use in civil law cases. We would like topresent below the four most interesting ones.Material and methodsCBF SPECT scanning was performed using three-head gam-macamera Multispect-3 (Siemens, Erlangen, Germany) 1 hr posti.v. injection of 740 MBq of 99mTc-ECD (FAM, Łódź, Poland) usinga low energy, ultra-high resolution collimator.The data were collected into a 128 × 128 matrix, 4.8 mm perpixel. The raw data were smoothed with a Butterworth filter, cut-offfrequency 0.35. Chang attenuation correction was not performed.Correspondence to: Maciej PiskunowiczDepartment of Nuclear MedicineMedical Universityul. Dębinki 7, 80–211 Gdańsk, PolandTel./fax: (+48 58) 349 22 04e-mail: mpiskunowicz@wp.pl46Nuclear Medicine Review 2003, Vol. 6, No. 1www.nmr.viamedica.plShortcommuni-cationsThe images were reoriented in the axial, coronal and sagittal planes.The data were displayed on a 10-grade colour scale. Focal perfu-sion abnormalities were read twice by two independent observ-ers. Their depth was assessed utilising an asymmetry index (AI):AI = R – L/(R + L)/2 × 100%, where R and L are mean counts/pixelvalues in the right and left hemisphere, respectively.Regional cerebral blood flow was assessed semiquantitative-ly by calculating the index of regional mean counts/pixel valuesdivided by those in cerebellum.As significant were considered focal perfusion deficits withasymmetry index values exceeding 2 standard deviations (SD)below the mean for the control group. As significant were consid-ered regional cerebral blood flow deficits with regional/cerebellarratio values 2 SDs below the mean in the control group.ResultsCase 1Patient WT, aged 30, had a car accident with a short loss ofconsciousness. Initial diagnosis was brain stem concussion. Therewere no changes in CT scanning. Following this accident shebecame apathetic and mournful, had strong headaches, sleepdisturbances and concentration problems, occasionally hadblurred vision, hearing hallucinations and suicidal thoughts.Her claims for financial compensation were rejected twice bythe Social Security medical commission. The patient appealed tothe court, which asked for more detailed forensic expertise.Psychometric testing: Benton’s tests, Bender test and MMPItesting argued for a functional dysfunction of CNS. CBF SPECTscanning revealed two fields of hypoperfusion in the right frontallobe (asymmetry indices 14% and 23%) and the third one in the lefttemporo-occipital border (22%), perhaps following the contre-coup.The psychiatric experts stated post-concussion syndrome withdepression accompanied by some paranoid symptoms. The ex-perts underlined the small probability of simulation, based on thepatient’s CV prior to the accident — she was a very active inde-pendent entrepreneur.The hypothesis of organic brain lesion was supported by the re-sults of psychometric testing and SPECT scanning. Finally, the patientwon the case and obtained permanent financial compensation.Case 2Patient RS, aged 36, had a car accident with multiple injuriesto the head, thorax and right arm and a mild right-side paresis.Following discharge from the hospital, the patient had head-aches, memory and concentration problems, right limbs weak-ness, he became apathetic and neurotic. The insurance compa-ny acknowledged a 30% health loss and paid corresponding fi-nancial compensation. The patient disagreed with this opinion andturned to the civil law court.The forensic expertise confirmed the multiple body injury, par-ticular in the thorax and thoracic lumbar spine column and mildright-side paresis.MRI scanning revealed a small ischaemic focus (2–3 mm) inleft temporal area. CBF SPECT scanning showed a diffuse leftprefrontal perfusion deficit (13%) and a second one in right cen-tral area (9%). The counter-argument of the barrister of the suedside was that it could not be surely stated that those changescould be attributed to the accident. His hypothesis was that theycould not be distinguished from e.g. ones caused by brain arte-riosclerosis. This hypothesis was rejected by the court on the ba-sis of forensic medicine expertise.The case has not been closed to this day on the grounds ofother formal objections.Case 3Patient WT, aged 65, a medical doctor working in the Emer-gency Unit, had a car accident involving his medical ambulance.There was no loss of consciousness.Following the accident, the patient developed vertigo, stub-born headaches, cognitive and memory impairment, sleep prob-lems. The insurance company acknowledged a 34% health lossand paid corresponding financial compensation. The patient dis-agreed with this opinion and turned to the civil law court.The court asked the forensic medicine experts three ques-tions:— what injuries directly related to the accident had the patienthad;— what was the health of the patient after the incident;— what had been the health loss connected with the accident?Neurological evaluation stated cognitive impairment. CT andEEG were normal. CBF SPECT scanning revealed a diffuse hypop-erfusion of the left part of the frontal lobe and the frontal part of theleft frontal lobe (AI mean 13%) with a sharply-bordered focus ofhypoperfusion in the back part of the left frontal lobe (AI 33%).The final verdict stated that the loss of health was not 34%, asin the initial opinion, but 70%. The court agreed that the presentcomplaints were connected with the car accident and not with thepatient’s previous health state.Case 4Patient DS, aged 18, had multiple body injuries followinga car accident. He had a fracture of the thoracic spine column,subluxation in cervical spine, head and lung contusion, asepticnecrosis of heel bone. Following hospital discharge he had mem-ory problems and his school learning results deteriorated.  Thepatient became moderately depressed and kept obsessively think-ing about this accident.The insurance company stated a 28% loss of health. Thepatient disagreed with this opinion and turned to the civil lawcourt. The court asked the medical experts about the presentstate of health, its connection with the car accident and the pa-tient’s prognosis.The psychologist stated a persistent mood disorder and mem-ory problems, which did not exclude learning at school, but whichmade learning more cumbersome. In the expert’s opinion thepatient needed long-term psychological help.CT scanning revealed fractures of the 2nd and 3rd cervical ver-tebrae but no changes within the CNS. There was no paracere-bral haematoma. CBF SPECT scanning revealed a diffuse hypop-erfusion of the right frontal lobe (12%) and left occipital lobe (22%).A small focal deficit of perfusion (AI = 20%) was seen in the leftprefrontal area. A diffuse hypoperfusion of the left cerebellar hemi-sphere might reflect a crossed cerebellar diaschisis.The court supported the patient’s claims, focusing on his learn-ing problems. The final verdict stated that the loss of health was47www.nmr.viamedica.plMaciej Piskunowicz et al., The usefulness of CBF brain SPECT in forensic medicineShortcommuni-cationsnot 28%, as in the initial opinion, but 35%. This decision was inpart based upon CBF SPECT scanning results.DiscussionThe role of functional neuroimaging is increasing. The crucial prob-lem in its utility in medico-legal argument is the too small number ofcontrolled studies, insufficiently precise sensitivity and specificity andthe lack of analysis and interpretation standardisation [1, 6–8].In the USA PET and SPECT scanning results are accepted asevidence in mild head trauma, if forensic medicine experts cancredibly describe in court the technique of scanning, interpreta-tion of results and their help in the particular case [9].SPECT scanning is a well-established tool in evaluating thesequelae of head trauma [10, 11]. As a tool in forensic expertisethey have been used in the USA since the early 1990s [1, 3, 4].In 1993 the Supreme Court of the US, in the case of Daubertversus Merril Dow Pharmaceuticals, accepted a series of medicaltests (including PET scanning), which did not fulfil the traditionalrules: s.c. “Frye test” and rule No. 702 of federal law concerningthe court evidence [4, 12, 13].The Supreme Court ruled that the following facts about themethods accepted as evidence should be established [4]:— whether the particular method or theory presented by the ex-pert can be tested;— whether the known and/or potential pitfalls of the method areestablished;— whether there is sufficient scientific evidence about the method;— whether there is a “wide acceptance” for the particular meth-od in the scientific world?Therefore, US courts have transparent rules on new methodsof scientific evidence.In Poland the civil law accepts evidence either as regulated bythe Civil Code or on the basis of cases ruled by the Polish Su-preme Court, but there is no general regulation of the assessmentof scientific evidence in forensic processing. Some criteria can bemet in particular verdicts.In verdict II CR 898/74, dated Feb. 25th 1975, the Polish Su-preme Court advised the use of even the newest scientific achieve-ments, if they were proven for sure. In verdict III CRN 305/74 (Dec.12th, 1974) the Supreme Court argued, that the evidence might beaccepted if it is based on a uniform and well tested evidence [14].Coming back then to our cases, the question as to whetherfunctional neuroimaging fulfils the criteria of judicial evidence andwhat will be the future of those methods is open. For sure, thenumber of such cases will grow, but due to tits insufficient speci-ficity SPECT scanning will remain only an auxiliary method togeth-er with CT, MRI and psychometric testing. In some cases, howev-er, its role will probably be very important.References1. Brown B, Tarry S. Does your PET bite? The misapplication of brainscans in toxic tort litigation. For the Defense 1997; 39: 8–16.2. Lass P, Piskunowicz M, Krzyżanowski M, Studniarek M. The useful-ness of CBF brain SPECT in forensic medicine. A description of fourcases. Nucl Med Rev 2001; 4: 47–50.3. Monnett III CG, Jordan KM. Scientific evidence following Daubertvs. Merrill Dow. In: Charles G. (ed.) Are PET scans admissible to es-tablish traumatic brain injury? Monnett III & Associates, 2000.4. Daubert versus Merrell Dow Pharmaceuticals. U.S. Supreme Court.113 Supreme Court 1993: 2786. (US courts sentences available atweb page: http://www.findlaw.com/casecode/supreme.html)5. Muńoz-Céspedes JM, Paúl-Lapedriza N. La detección de los posiblescasos de simulación después de un traumatismo craneoencefálico.Rev de Neurol. 2001; 32: 773–778.6. Catafau AM, Carrio I. The end of the “Decade of the brain”: reflectionson European neuroimaging and implications of the EANM Congress.Eur J Nucl Med 1999; 26: 955–957.7. Flower D. SPECT: Respect or Suspect? Inhealth 2000; 12: 4–5.8. Ethical Clinical Practice of Functional Brain Imaging. Report of Soci-ety of Nuclear Medicine Brain Imaging Council. J Nucl Med 1996; 37:1256–1259.9. Mehr SH, Gerdes SL. Medicolegal applications of PET scans. NeuroRehab 2001; 16: 87–92.10. Bavetta S, Nimmon CC, White J et al. A prospective study comparingSPET with MRI and CT as prognostic indicators following severe closedhead injury. Nucl Med Commun 1994; 15: 961–968.11. Jacobs A, Put E, Ingels M, Bossuyt A. Prospective evaluation of tech-netium-99m-HMPAO SPECT in mild and moderate traumatic brain in-jury. J Nucl Med 1994; 35: 942–947.12. Frye versus United States. U.S. Supreme Court. 1923; 293 F. 1013. 1014.(US courts sentences available at web page: http://www.findlaw.com/casecode/supreme.html)13. McGraw WR, Taylor S. Judicial overview of expert scientific testimonyfor independent medical examiners: A perspective from the Bench.Disab Med. 2002; 2: 17–19.14. Wójcikiewicz J. Dowód naukowy w procesie sądowym (in Polish). Wy-dawnictwo Instytutu Ekspertyz Sądowych, Kraków 2002.

The usefulness of CBF brain SPECT in forensic medicine: the civil law code cases. A description of four cases

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