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DiagnosticBrainReportCereScanpoweredbyCereMetrix®

720.259.1976,[email protected]|1

BRAINPERFUSIONREPORTBRAINPERFUSIONREPORTPATIENT CLINICAL

FIRSTNAMEXXX

EXAMQuantitativeSinglePhotonEmissionComputedTomography(qSPECT)

LASTNAMEXXX

REFERRINGPROVIDERXXX

MR#XXX

INDICATIONSFORREFERRALDiffusetraumaticbraininjurywithlossofconsciousnessofunspecifiedduration,initialencounter(S06.2X9A)

DOBXXX

INTERPRETINGPHYSICIANXXX

AGEXX

EXAMDATEXXX

HANDEDLeft

XXX

RADIOLOGICFINDINGSHigh-resolution,brainSPECTimagingwasperformedatbaselineandwithaconcentrationbattery.Noabnormalmotionorartifactwasdetected.Ablindreviewofthetomographicimageswasperformed.

Atrest,theoverallcorticalactivitywasslightlyreduced.

Focalareasofabnormalcorticalhypoperfusionwerenotedintherightanteriorfrontal,rightorbitofrontal,bilateralsuperiorparietal,bilateralanterior,medialandposteriortemporal,bilateraloccipitalandbilateralposteriorcerebellarareas.

Focalareasofabnormalsubcorticalhypoperfusionwerenotedinthelefthippocamapalareas.

Focalareasofabnormallyincreasedcorticalperfusionwerenotnoted.

Focalareasofabnormallyincreasedsubcorticalperfusionwerenotedintherightthalamusandbilaterallentiformareas.

Corticaldeactivationisnotedwiththeconcentrationtask.

CereMetrixclusteranalysiscomparisonsofthepatient’sbaselinedatatoa1000patientcompositeaveragesample,aswellasthe3D/surface-renderedimages,revealedabnormalitiesconsistentwiththoseseenonthetomographicimages

RADIOLOGICIMPRESSIONS

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720.259.1976,[email protected]|2XXX

1. ThisisanabnormalbrainSPECTstudydemonstratingfocalareasofabnormalcorticalhypoperfusioninthefrontal,temporal,parietal,occipitalandcerebellarareasaspreviouslydescribed.

Thenature,location,andpatternoftheseabnormalitiesisprimarilyconsistentwiththescientificliteraturepertainingtotraumaticbraininjury(TBI)andthepatient’sclinicalhistory,asobtained,whichwasreceivedaftertheblindreview.Corticaldeactivationwiththeconcentrationtaskisanabnormalfindingassociatedwithanon-specificbraininjuryprocess.Alternativeconsiderationsforthesefindings,suchasneurodegenerative,neurovascularandtoxic/hypoxicprocesseswereconsidered,butwereconsideredtobelesslikelygiventhepatient’sageandspecificclinicalhistory,whichwasobtainedaftertheblindreview.

2. Thefindingsofincreasedthalamicactivitycoupledwithorbito-frontalhypoperfusionhasbeenassociatedbyseveralauthorswithvariousmooddisorders.

3. Thefindingofincreasedactivityinthebasalganglia,alongwiththepatient’sclinicalhistoryandresultsofhisstructuredMINIinterviewhere,hasbeenassociatedbyseveralauthorswithvariousanxietydisorders.

Closeclinicalcorrelationwiththepatient’sentiremedicalhistoryisadvised.

QSPECTBRAINIMAGINGThepatientwasseenforthefollowinghigh-resolutionbrainSPECTimagingstudies,whichwereperformedwithinthecriteria,establishedguidelinesandqualitycontrolsforimagingsetbytheAmericanCollegeofRadiologyincludingtheACR-SPRPracticeParameterforthePerformanceofSinglePhotonEmissionComputedTomography(SPECT)BrainPerfusionImaging,IncludingBrainDeathExaminations.

MethodsDuringthebaselinescan,thepatientisplacedinacomfortablerecliningchairinaquietdimlylitroomwitheyesclosed,withambientnoise,andanIVlineisstarted.Thepatientisthenallowedtoacclimatetoaquietsemi-darkenedroomwithsound-dampeningheadphonesonfor15minutes,inaccordancewiththeACRpracticeguidelines.TheTc99-mlabeledHMPAOtraceristheninjectedthroughtheIVlineandflushedwithsaline.Thetraceristhentakenupbythebrainwithinthenext2minutes.Thisresultsinaperfusionpatternthatisanalyzedandinterpreted.Afterinjection,thepatientremainsinthequietsemi-darkenedroomforanadditional5minutes.TheSPECTscanisacquiredaminimumof60minutespostinjection.

Duringtheconcentrationtask,thepatientisplacedinaquietroomandanIVlineisstarted.Thepatientperformsaconcentrationbatteryonatablet.Approximately5minutesintothetask,theTc99-mlabeledHMPAOtraceristheninjectedthroughtheIVlineandflushedwithsaline.Thepatientcompletesthetaskandscanisacquiredaminimumof60minutespostinjection.

ScansareobtainedusingaSiemensSymbiaESPECTgammacamerawithalowenergyhighresolution(LEHR)parallelholecollimator.Countsarecollectedina128X128matrixwith32stopsof5.625degreeseach,withazoomof1.78.Totalcountsexceeded5million.DataisfilteredusingaButterworthfilterat.25withanorderof5,correctedformotionasneededandattenuationcorrectionisperformed.Thevolumeismaskedto

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excludeasmuchnon-neuralstructureaspossible.Thereisnopost-filtering.Dataispresentedinaxial,sagittalandcoronalviewsin2mmsections.StatisticalanalysisisperformedusingCereMetrixsoftwarerelativetoacompositedatabaseofaverageperfusioncontaining1000individuals.

Date Status TC99-HMPAODose Count

XXX SPECT-Baseline 30.70mCiTc99HMPAO 5.645million

XXX SPECT-Concentration 31.30mCiTc99HMPAO 5.703million

ProceduresTheutilizationofSPECTinthediagnosticevaluationofvariousneurologicaldisordersiswellestablished.TheprocedureandpracticeguidelinesoftheAmericanCollegeofRadiology,theSocietyofNuclearMedicineandtheEuropeanAssociationofNuclearMedicineestablishtheutilityandscientificvalidityofSPECTfunctionalbrainimagingfordetectionandevaluationofcerebrovasculardiseaseandstroke,evaluationofdementiaandAlzheimer’sdisease,pre-surgicallocalizationofepilepticfoci,diagnosticevaluationofencephalitisandevaluationofsuspectedbraintrauma.Theseprocedureandpracticeguidelinesareadheredtoinallofouracquisitionandprocessingprotocols.Researchhasalsodemonstratedregionalperfusionpatternsassociatedwithotherneurologicaldisordersandwithexposuretoneurotoxins,hypoxiaandsubstancesofabuse.

Althoughthereisaverylargebodyofpeer-reviewedscientificarticlesshowingcertainbrainpatternsassociatedwithcertainpsychiatricconditions,theutilizationofSPECTfortheevaluationofpsychiatricdisordersisstillconsideredanemergingscienceandthereforeintheinvestigationalstage.AlthoughwewillreportonbrainpatternsofcertainpsychiatricconditionssuchasAttentionDeficitHyperactivityDisorder,BipolarDisorder,Anxiety,ObsessiveCompulsiveDisorder,etc.,basedonpatternspublishedinpeer-reviewedjournals,suchfindingsarenotconsideredstandaloneordiagnosticperseandshouldalwaysbeconsideredinconjunctionwiththepatient’sclinicalcondition.Thesedatashouldonlybeusedasadditionalinformationtoaddtotheclinician’sdiagnosticimpression.

ThebrainSPECTimagingstudieswereperformedunderthegeneralsupervisionofaqualifiedstatelicensedphysician.

Sincerely,

Date:XXXTime:XXX

Radiologist SignatureRadiologist License

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CLINICALHISTORYREPORTCLINICALHISTORYREPORT

NEUROPSYCHIATRICANDCOGNITIVEASSESSMENTS1. TheMiniInternationalNeuropsychiatricInterviewwasadministeredonXXX.Accordingly,hemetthe

followingdiagnosticcriteria:

GeneralizedAnxietyDisorder2. TheSavonixCognitiveAssessmentwasadministeredonXXX.Hiscognitivestatusprofile

generatedthefollowingresults:

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AngermanagementproblemsBalanceproblemsCompulsivebehaviorConfusionDifficultyfollowinginstructionsDifficultylearningnewthingsDifficultywithconcentrationDisorganizationDisorientationtotimeand/orplaceDistractibilityElevatedmoodFatigueFlashbacksoftraumaFrequentHeadachesGeneralanxiety

LossofmotivationLowfrustrationtoleranceMakingcarelessmistakesMoodswingsMusclespasmsNauseaNightmaresObsessivethoughtsPanicattacksParanoiaPerformanceanxietyPersonalitychangesProblemspayingattentionProblemswithlanguage/wordfindingRacingthoughts

CLINICALOVERVIEWOFCHIEFCOMPLAINTPatient XXXisa39yearoldlefthandedmale.

XXX isaretiredAirForceVeteran.Duringhismilitarycareer(bothintheUnitedStatesandalsoin Iraq)thepatientworkedasanExplosiveOrdnanceDisposalOperatorfrom1999-2006.Heperformedandwas subjectedtomultipledetonationsrangingfrom0.5lbofC-4to100,000poundsofhighexplosive.Heestimated thenumberofdetonationstobe50,000.On05/03/2006,whileinIraq,thepatientsustainedanIEDattack duringconvoyoperationsinIraq.Theimpactcausedhisrifletostrikethefrontofhishead.Theblastand impactrequiredhimtobeplacedinamedicallyinducedcomaforthreedays.

Thepatient'sprimarysymptomsofconcernincludetinnitus,balancingissues,wordmisplacementchallenges, headaches,moodswings,episodesofanger,emotionalregulationchallenges,andlowfrustrationtolerance occasionally.Thesechronicsymptomsdevelopedaftertheblastin2006.

PATIENT’SSELF-REPORTEDSYMPTOMSSAMPLE



ImpulsecontrolproblemsInsomniaLong-termmemoryproblemsLosingthingsLossofinterestinthings

Restlessness/FidgetinessRinginginearsRiskybehaviorShorttermmemoryproblemsSocialanxiety

ADD/ADHD(07/2010)Anxiety(07/2006)Backinjuries(07/2007)Braininjury(05/03/2006)Headaches(migraine)(08/2006)

Headaches(tension)(08/2018)Hearingproblems(07/2006)Posttraumaticstressdisorder(07/2006)Sleepapnea(10/2009)

Motrin(800mgasneeded) Sumatriptan(asneeded)

Lyrica(300mg) Oxycotin(20mgtwicedaily)

MEDICALHISTORY

HistoryofBrainInjuryBlastWaveInjury:ThepatientworkedasanExplosiveOrdnanceDisposalOperatorfrom1999-2006.Heperformedandwassubjectedtomultipledetonationsrangingfrom0.5lbofC-4to100,000bsofhighexplosive.Heestimatedthenumberofdetonationstobe50,000.CombatInjury(05/03/2006):On05/03/2006,thepatientsustainedanIEDattackduringconvoyoperationsinIraq.AnEFPIEDdetonatedwithin5ftofhisvehicle.Hisweapon"hit[him]intheface,knocked[him]outandblastwavethrew[him]acrossthevehicle."Hewashitonthefrontandrightsideofhisface.Hesaid,"IalsosustainedmassivefacialtraumaandafracturedL5S1duringtheattack."Helostconsciousnessfor30-60secondsandafterregainingconsciousness,herememberedwatchinghisfriendtakehislastbreath.Hewasnotwearinganarmoredhelmet;onlyaplatecarrier.HereportedPTamnesia,confusion,disorientation,headaches,anddizziness.Aftertheexplosion,hewasmedivacedandplacedintoamedicallyinducedcoma.HewasthenseenatLandstuhlMedicalCenter,SentaraNorfolkGeneralHospital,wherehewasdiagnosedwithaconcussion.

IncomingDiagnoses

CurrentMedications

PastMedications

Pre-ScanMedicationRecommendationsCertainclassificationsofmedicationsmayhaveanimpactonbloodflowinthebrain.ThepatientwasadvisedtoreviewCereScan’srecommendationsregardingtheuseofstimulants,benzodiazepines,opiatesandbarbiturates,amongothersubstancesandmedications,anddiscussthemwithhis/herphysician.

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He hashad59+surgeriestohis face,rightarm, uppermandible,etc.associatedwithhisblast injuryinIraq

Father:Melanoma PaternalUncle:Schizophrenia

MRI(Unknown,05/05/2018),ReportUnavailable CT(Unknown,05/15/2006),ReportUnavailable

AllergiesNonereported

Surgeries/Hospitalizations

FamilyHistoryofMajorMedicalandPsychiatricIllness

BRAINIMAGINGHISTORY

DEVELOPMENTALHISTORYThepatientdeniesanyknownhistoryofbirthtraumaordevelopmentaldelays.

CURRENTUSEOFALCOHOLANDRECREATIONALSUBSTANCESAlcohol:Nonereported

Caffeine:Nonereported

Nicotine:Nonereported

Drugs:Nonereported

Thepatientreportsthathequitusingnicotinesevenyearsago.

PASTHISTORYOFALCOHOLORDRUGABUSE

AlcoholNonereported

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DrugsThepatientusedmarijuanaoccasionallyinhispast.Hedoesnotcurrentlyusemarijuana.

EDUCATIONALANDEMPLOYMENTSTATUSThepatient'shighesteducationlevelisBachelor'sDegree.Thepatient'semploymentstatusisEmployedPart-Time.

VETERANHISTORYThepatientisadischargedAirForceveteran.Hehadanon-combatdeploymentinKuwait.

Sincerely,

Date:XXXTime:XXX

Clinician Signature

Clinician License

Wearehappytocommunicatewithanyofyourtreatingclinicians.Thankyouforthisopportunitytoparticipate inyourcarewiththisconsultation. SAMPLE



APPENDIXAPPENDIX

ANNOTATIONS

Anteriorview:bilateralanteriorfrontal(rightgreaterthanleft),bilateralanteriortemporalhypoperfusion

Inferiorview:rightorbitofrontal,bilateralanteriorandmedialtemporalareasofhypoperfusion,bilateralposteriorcerebellarhypoperfusion

Superiorview:bilateralsuperiorparietalhypoperfusion

Leftview:leftlateralfrontalhypoperfusion,leftanteriorandposteriortemporalhypoperfusion

Posteriorview:bilateraloccipitalhypoperfusion

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Rightlateral:rightanteriorandposteriortemporalhypoperfusion,rightlateralfrontalhypoperfusion

Limbicview:increasedrightthalamusandbilaterallentiformperfusiondecreasedlefthippocampalperfusion

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