Opinion ID: 4556341
Heading Depth: 4
Heading Rank: 1

Heading: Traumatic Brain Injuries

Text: {¶ 146} Dr. Joseph Wu testified on Kirkland’s behalf at the resentencing hearing. Dr. Wu is a diplomate in psychiatry and professor emeritus at the University of California, Irvine. He has studied, and published peer-reviewed articles on, the use of positron-emission tomography (“PET”) and magneticresonance imaging (“MRI”) to diagnose various psychiatric conditions, including traumatic brain injury. He is not, however, a radiologist. {¶ 147} Dr. Wu had three brain scans performed on Kirkland at the Wexner Medical Center: a PET scan, an MRI quantitative volumetric scan, and an MRI diffusion tensor imaging (“DTI”) scan. {¶ 148} According to Dr. Wu, the PET scan revealed two significant abnormalities in Kirkland’s brain. Dr. Wu found that the frontal cortex showed “metabolic decrease” relative to the occipital cortex. He also found decreased activity in the neocortex compared to the cerebellum; normally, he explained, the neocortex has a significantly higher level of activity than the cerebellum. This pattern, Dr. Wu believed, was consistent with multiple head traumas. {¶ 149} Dr. Wu analyzed the DTI scan using a “voxel-wise” quantitative analysis. According to Dr. Wu, this is a “much more reliable, much more sensitive way of detecting abnormalities” in DTI scans of people with histories of traumatic 39 SUPREME COURT OF OHIO brain injury and this analysis showed abnormal decreases and increases in fractional anisotropy, indicating brain injury in Kirkland. {¶ 150} Dr. Wu testified that the MRI quantitative volumetric scan showed an “abnormal increase in the right amygdala,” and he stated, “[T]he only condition that I’m aware of that cause[s] a significant increase in the amygdala is significant early childhood neglect.” But only one side of the amygdala was enlarged; Dr. Wu was aware of no studies showing such a result. According to Dr. Wu, this is another indication of brain trauma, because trauma causes shrinkage; in Dr. Wu’s opinion, trauma probably caused one side of Kirkland’s enlarged amygdala to atrophy to normal size. {¶ 151} Dr. Wu also looked at Kirkland’s medical history. He found “at least four separate events” consistent with the abnormalities he found in his reading of the PET and MRI scans. Kirkland allegedly was abused by his father from age 6 to age 14, resulting in head contusions. At 17, he was involved in a workplace accident, following which he reported memory loss and numbness in his extremities. In 2004, at age 36, Kirkland fell off a bicycle, fracturing the right side of his face. In 2006, Dr. Wu testified, Kirkland “sustained a traumatic brain injury with a small hematoma in the left upper temporal area” in an auto accident. Dr. Wu testified that both the “significant abnormalities” in Kirkland’s scans and his medical history were consistent with multiple traumatic brain injuries. {¶ 152} Dr. Wu testified about how such injuries can affect the personality. Frontal-lobe damage can cause “significant alteration in your ability to regulate aggression,” which can affect judgment and impulse control. The effect is exacerbated by “significant abuse and neglect” in childhood; the combination “cause[s] a dramatic increase in the inability of an individual to regulate aggression.” {¶ 153} Dr. Wu concluded that Kirkland lacks the ability to control his aggressive impulses in “an uncontrolled, unmanaged environment” because of the 40 January Term, 2020 combination of brain injury, neglect, and abuse. When asked whether the degree of planning and execution involved in Kirkland’s crimes was inconsistent with an inability to control impulses, Dr. Wu explained that a person whose history includes multiple brain traumas, neglect, and abuse loses the ability to calm his anger or aggressive impulses; hence, instead of being “momentary,” his aggressive impulses continue to “rage on.” {¶ 154} The state called three witnesses to rebut Dr. Wu’s testimony: Drs. Chadwick Wright, Alan Waxman, and Daniel Boulter. {¶ 155} Dr. Wright, a radiologist at the Ohio State University Wexner Medical Center, examined the images from Kirkland’s PET scan. Dr. Wright found the scan to be “a normal appearing scan” that indicated that “the brain is functioning properly.” He saw no evidence in the PET scan to indicate traumatic brain injury. {¶ 156} Dr. Waxman is the director of nuclear medicine at Cedars-Sinai Medical Center in Los Angeles. He sharply criticized Dr. Wu’s theories and methods regarding PET scans. {¶ 157} According to Dr. Waxman, PET scanning is not accepted as a tool for diagnosing traumatic brain injury. Dr. Waxman noted that it is the view of the American College of Radiology that PET scans are “not usually appropriate” for diagnosing head injuries, that the American Academy of Neurology regards PET scanning as still “investigational” as a tool for diagnosing head trauma, and that the European Association of Nuclear Medicine also does not recognize or accept brain imaging as a method for diagnosing head trauma. Dr. Waxman also cited a United States Department of Defense study finding that PET scans are not useful for diagnosing head trauma and a peer-reviewed 2015 article in the Journal of Neurotrauma finding that PET scans do not yield a “recognizable pattern” for traumatic brain injury. 41 SUPREME COURT OF OHIO {¶ 158} Dr. Waxman examined Kirkland’s PET scan and found it “textbook normal,” yielding “no evidence of traumatic brain injury.” According to Dr. Waxman, Kirkland’s scan “looked really good.” {¶ 159} Dr. Waxman disagreed with Dr. Wu’s contention that metabolic decreases in the frontal cortex relative to the occipital cortex are an abnormality. Dr. Waxman testified, “You can’t prescribe a particular psychological construct to these patterns” and, in fact, “a high percentage of people”—50 percent in one study—show metabolic decreases in the front of the brain relative to the back. {¶ 160} In general, Dr. Waxman testified, Dr. Wu is wrong in seeing asymmetries as abnormal. Normal brains—including brains characterized as normal in Dr. Wu’s database—have asymmetries. In Dr. Waxman’s view, Dr. Wu is interpreting “normal variations” as abnormalities, resulting in false positives. Dr. Waxman testified that Dr. Wu “has read almost a thousand scans    and every single scan except one he has called abnormal.” (On cross-examination, Dr. Wu testified that he has read about 100 scans, but he admitted that he had found abnormality in all but “a couple” of them.) In fact, Dr. Waxman said, “Dr. Wu has no idea what his error rate is” because it has never been scientifically determined. {¶ 161} Dr. Waxman noted that the normal brains in Dr. Wu’s database are usually those of people in their 30s, while Kirkland was nearly 50 at the time of his PET scan. Dr. Waxman testified that it would be normal for there to be a metabolic decrease in Kirkland’s frontal lobe in comparison to those of people in their 30s. Indeed, according to Dr. Waxman, Kirkland’s PET scan “is in the mid range of normal variation compared to Dr. Wu’s own subjects.” {¶ 162} Dr. Boulter is a neuroradiologist and the clinical director of MRI at the Wexner Medical Center. He reviews MRI scans daily and has reviewed at least 20,000 brain MRI scans in his career. He reviewed the results of one of the MRI scans performed on Kirkland. He found no abnormality, and specifically, no evidence of traumatic brain injury. 42 January Term, 2020 {¶ 163} Unlike Dr. Wu, Dr. Boulter did not perform a voxel analysis. A voxel analysis, he testified, may be a useful tool in the future, but at present, it cannot be used to differentiate normal from abnormal. He further testified that the American College of Radiology’s position is that it is not an appropriate tool for determining whether a person has suffered a traumatic brain injury.