Medical Exhibits - Demonstrative Evidence Expert Blog - MediVisuals

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations,MediVisuals Incorporated

Long before science had advanced to allow imaging of the body in sectional views by computed tomography (CT) and magnetic resonance imaging (MRI), medical illustrators were illustrating the body in sectional views because these views are the best way to appreciate some anatomical relationships. 

Medical illustrators, physicians, and others who have studied anatomy are familiar with sectional views of the body and appreciate the value of these views in explaining the relationship of anatomical structures. However, accomplished and well respected jury consultants and non-medical illustrator legal graphics experts have expressed concerns that sectional views may be difficult for some jury members to understand. These individuals' opinions are valuable to those of us in the legal graphics business, and I agree with their opinions that, when other views can communicate a particular relationship message equally as well or better, sectional views should be avoided. I also believe most of these experts will agree that there are times and places in which sectional views of anatomy are the best way to appreciate some anatomical relationships. Granted, there have been times when we have been working on specific cases and experts have insisted that sectional views be absolutely and unconditionally avoided. Unfortunately, in these situations the experts were unable to suggest a more effective view to communicate the relevant anatomical relationships (at least in a way that was practical in terms of time and expense). That being the case, sometimes the sectional views were used despite the input of the experts, and at other times, the relationships of the structures had to be explained without the benefits of graphics.

A way to perhaps explain how sectional views help decision makers appreciate relevant anatomical and pathological relationships is to compare them to aerial views or photographs of the scene of a collision.  Space is defined in three planes. Only two of these planes can effectively be demonstrated in a two-dimensional rendering. For example, aerial views have long been used to help explain the positions of vehicles and structures that simply can't be appreciate from "street views". When viewing the scene of a collision from a "street view", one can appreciate vertical and horizontal distances, but not depth; distances close to and far from the viewer's perspective are very difficult to appreciate (see the below figures). By comparison, when viewing an operative site through a "surgeon's view", vertical and horizontal distances can be appreciated, but the depth of the incision and the relationships of the various structures within and around the incision are very difficult or impossible to appreciate.

The "aerial view" of the collision scene allows the viewer to appreciate distances in two geographical planes as well (distances right and left, and toward and away from the "street view," but the ability to appreciate up and down is lost). Also, the locations of relevant structures or vehicles that may have been obstructed by nearby structures (such as buildings trees, signs, or other vehicles) can now be appreciated. Similarly, a sectional view of anatomy can help decision makers appreciate depth relationships of structures. Or, a sectional view of a step in a surgical illustration can allow the viewer to appreciate the depth of the surgery as well as the additional structures that may have been injured (or at risk of injury) during the invasive procedure.  These specific depth  relationships could not be appreciated from the "surgeon's view" of the same surgery shown in the above illustration.

Exhibits developed to help explain the invasive nature of a surgery and the disruption of the soft tissues during operative procedures are critical. For that reason, sectional views are critical in aiding a testifying physician to explain these issues. For example, the exhibit panel that demonstrates an anterior cervical discectomy and fusion (ACDF) that does not include a cross-section through the neck fails to emphasize the depth of the incision and disruption of tissues (essentially all the way to the center of the neck). This depth simply cannot be appreciated in a "surgeon's view".

In order to appreciate cross-sections, orientation views that show the level and direction of the section are helpful (see below), or when time, budget, and presentation format (digital as opposed to a physical panel) allow, a short animation showing the sectional view actually coming out of the orientation view such as MediVisuals' "Scan Selector^TM" can be used.

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated

This article is a continuation of a two-part article on traumatic brain injury. Part 1 covered severe traumatic brain injury while part 2 addresses "mild" less severe traumatic brain injury.

A person suffers a brain injury once every few seconds in the United States, with many going undiagnosed. Significant facts associated with these injuries include: 1) MRI or CT imaging studies not showing injuries, 2) the injured person might not think anything is wrong with them, and 3) physicians and others who did not know the patient prior to the traumatic brain injury may not appreciate the cognitive deficits and diagnose the condition. (Often, only persons who knew the injured person before the accident notice differences in personality, behavior, or cognitive function.)

During trauma, illustrated above, the brain impacts against the inside of the skull. Shearing injuries often occur because the gray and white matter are of different densities; therefore, the axons tear at the junction of the white and gray matter. The injuries can consist of torn or twisted axons, or the axons can pull away from their synapse.

Axonal injury can also occur without the head striking an object. This often occurs in collisions. During a sudden deceleration injury, the brain impacts the inside of the skull in a coup - contracoup fashion, which means that the brain first impacts the area of the skull receiving the trauma and then impacts the area of the skull directly opposite of the trauma, as seen in the animation below. As a result, shock waves of the forces travel through the brain.

During sudden deceleration, the brain impacts on the hard jagged ridges of the base of the skull causing shearing forces, as depicted in the illustration below.

Blood vessels may also become torn or broken during a TBI, resulting in bleeding (see image below). An MRI or CT is not capable of detecting individual or even relatively large areas of axonal injury. Lesions detected by MRI or CT are typically areas of hemorrhage, if the hemorrhages are large enough.

Axons range in diameter from 1/4 of a micron to 10 microns while blood vessels range in diameter from 30 to 240 microns. If forces are sufficient to tear the much larger and resilient blood vessels (see illustration below), it is certain that numerous axons in the adjacent and other areas are torn as well.  However, axons may be torn without injury and significant hemorrhage from nearby blood vessel is not torn, so the absence of findings on MRI or CT DO NOT RULE OUT traumatic brain injuries.

When hemorrhaging is not involved, traditional imaging studies, such as MRI or CT, are able to detect only large areas of axonal injury where thousands of axonal injuries create an area of abnormality large enough to be detected. 

The loss of the sense of smell is an indicator of traumatic brain injury. The image below depicts the normal olfactory anatomy with the olfactory nerves extending through the cribiform plate and innervating the nasal passages. During trauma to the head, the forces can be great enough to sever the relatively large olfactory nerves, which affects the sense of smell. Forces sufficient to injure the olfactory nerves are certainly sufficient to result in diffuse axonal injuries throughout the brain whether evident on imaging studies or not.

Problems with many functions (such as hearing, speech, and balance) following head trauma can result from injury to axons anywhere along the pathway involved in performing those function. For example, the ability to repeat a spoken word requires the proper function of the neural pathways for hearing and speaking, as shown in the animation below.

Keys to detecting and proving "mild" less severe traumatic brain injuries are as follows:

1) Rely on changes of behavior and cognitive function as reported by family members, coworkers and friends. Casual examinations by a physician may not result in a diagnosis.

2) The absence of physical brain injuries on traditional MRI or CT DOES NOT RULE OUT brain injuries.

3) Correlation of traumatic forces with injury to the specific areas of the brain  that control those functions is very important when proving a "mild" less severe traumatic brain injury.

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, Medivisuals Incorporated

Brain injuries are classified into two basic categories; those that are associated with obvious, incontestable evidence of intracranial injury and those that are not.

Obvious intracranial injuries include those with evidence of pathology within the brain itself (intraparenchymal injuries) as well as areas of bleeding around the brain but within the skull. The light area in the scan below indicates blood within the brain tissue, and the surrounding dark area shows associated edema. Both of these are considered to be intraparenchymal injuries. Contusions and hematomas found outside the skull are not considered intracranial but are frequently illustrated to help emphasize the force and direction of the trauma to the head. 

The areas of hemorrhage shown in the illustration below are scattered around the junction between the grey and white matter of the brain, which is consistent with injuries from shear forces. The grey and white matter are of different densities, and when the brain impacts the skull during a traumatic event, the subsequent unequal movement between the two causes damage at their junction.

Head trauma can cause tearing of the blood vessels around the brain, which can result in areas of bleeding (hematomas). As the bleeding continues, the hematoma may expand to compress the brain tissue (as shown in the following illustration) and may require an emergency decompression. Significant compression must be relieved quickly in order to avoid further neurological damage and/or death. 

Introducing a ventriculostomy catheter is one approach used to alleviate increased intracranial pressure. A hole is drilled directly into the patient's skull, and a catheter is advanced through the brain tissue into one of the ventricles. The catheter allows some of the cerebrospinal fluid to escape, thereby relieving the pressure on the brain itself.

In other situations, a craniotomy may be performed to allow the blood to be suctioned from the area surrounding the brain. A bone flap is created by first drilling three holes into the skull and then making cuts between them with a saw. This flap is removed and the blood is cleared from the areas above and beneath the dura. In some cases, the bone flap is not replaced if the brain is swollen or if there is a significant concern over recurrence of the hematoma. For a more detailed look at the craniotomy procedure, please review MediVisuals Craniotomy Surgery Animation.