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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 APPEARANCES: GRADY NELSON, vs. STATE OF FLORIDA,

IN THE CIRCUIT COURT OF THE 11TH JUDICIAL CIRCUIT, IN AND FOR MIAMI-DADE COUNTY, FLORIDA CASE NO. F05-00846

Plaintiff, REDACTED TESTIMONY ROBERT WAYNE THATCHER, PhD

Defendant. ------------------------------------/ Gerstein Justice Building Miami, Florida November 19, 2010

The above-entitled case came on for hearing before the Honorable JACQUELINE HOGAN-SCOLA, as Judge of the Circuit Court, in court pursuant to notice.

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OFFICE OF THE STATE ATTORNEY KATHERINE FERNANDEZ-RUNDLE BY: ABBE RIFKIN, ASA -AND- HILLAH MENDEZ, ASA -AND- JOEL ROSENBLATT, ASA FOR THE DEFENDANT: TERENCE LENAMON, ESQUIRE -AND-DAVID MARKUS, ESQUIRE

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FRIDAY, NOVEMBER 19, 2010, 9:57 A.M. (The following proceedings are a redacted version of the testimony of Robert Wayne Thatcher, PhD, omitting objections, rulings and sidebars at the request of the ordering party). ROBERT WAYNE THATCHER, PhD, called as a witness on behalf of the Defense having been duly sworn by the Cler , was examined and testified as follows: DIRECT EXAMINATION (RESUMED) BY MR. LENAMON: Q A Q Good morning, Dr. Thatcher. Good morning. Yesterday when we left off you were tal ing about

a specific piece of data in Mr. Grady's evaluation that was a sharp wave. Right now I want to go to his evaluation generally at the beginning, and I want you to wal us through the process and your evaluation of the data and why it is important, o ay?

Q

Would anything aid in assisting showing the jury

information about that?

through the important issues. Q Where do you want to start, Doctor?

 

A

Yes. I thin

 

A

O ay.

this PowerPoint would help step

 

 

 

 

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A

I'll start with this PowerPoint, which the first who is illustrating how you apply

electrodes to the scalp. As shown here, there's little dis s that have a little bit of paste on them so it ma es contact with the scalp, and it can measure the electrical energies of the human brain. These wires are then connected to a -- here they are here, connected to an amplifier, just li e an amplifier for your radio or TV. It's a very special one that ma es the music loud and it will increase the amplitude of the EEG, which then goes into a computer. The general approach to dealing with lin ing basically patient's symptoms and complaints to different parts of the brain, is that you begin with the patient's symptoms, which is shown on this triangle on the left side, go through what the history is, what their complaints are, what their issue is, whatever that may be with an individual, and often there are neuropsychological tests that are done. In the case of Mr. Nelson, there was a neuropsychological test indicating problems with wor ing memory.

A Q

Dr. Ouaou, Robert Ouaou. Did you have an opportunity to review that test?

 

Q

Do you now who did that test, Doctor?

 

 

 

 

 

 

 

slide is of Dr. Gluc

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A Q the QEEG? A

Yes, I did. Are his findings consistent with the findings of

Yes.

(Omission). Q A Go on, Doctor. I will go through this to show how that lin s.

But, yes, there was a series of tests that were performed, neuropsychological tests that deal with things li e wor ing memory, deal with things li e what's called the Wisconsin Card Sort, which requires you to sort groups of items and that challenges your frontal lobes. Your frontal lobes are involved in inhibiting your behavior and ma ing judgments and wor ing memory is part of the role of the frontal lobes. The frontal lobes are a little bit li e a conductor of a symphony. They are the part of your head that are connected to your emotions, and the bac of your head is li e the instruments of the symphony.

The conductor then orchestrates the resources at the bac of your head to meet your drives and your needs. That's basically what you are doing all the time. And without the frontal lobes wor ing right, then there are problems on some of the neuropsychological tests that Dr. Ouaou found.

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that show that there's deregulation in the parts of the brain responsible for certain aspects of behavior. It could be judgment, wor ing memory, attention, and that's what this diagram shows. You have already gone through a lot of what an EEG is, I don't have to spend a lot of time on this particular slide except for the third item on normative databases. Essentially Quantitative EEG does sometimes include, doesn't always, but many times it includes a normative database where you have a group of very healthy, well functioning individuals that have no history of neurological disorders, no epilepsy, no traumatic brain injury, no drug abuse or nothing. They are doing well in school or they are functioning well in society. The normative database that Dr. Gluc used and that I also used in the evaluation of Mr. Nelson ranged in age from two months of age out to 82 years of age. It was carefully screened individuals. A normative database wor s a lot li e what happens when you get a blood test. A doctor will withdraw maybe a vial of blood, send it to a laboratory, and what's done is the

 

 

 

 

 

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of the brain wor , and then identify features in the EEG

 

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symptoms and complaints are and

 

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One measures the EEG

eeping in mind what the patient's nowing how different parts

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enzymes and your red blood cells, they are compared to a normative database. You get a report bac saying your cholesterol is too high. That's with respect to a group of healthy people, or your liver enzymes are too low. You now they're too low because they are being compared to a group of healthy people. The normative database is exactly the same essentially is what's done, except now it's with the EEG. Q Before you move on from the normative database, I

just have a couple of questions. Can you tell the jury where this normative database that you used to include in the NeuroGuide software evaluation process came from and what it consisted of? A The normative database was created at the

University of Maryland. It began in 1979 and ended about 1988. It was funded by the National Institutes of Health and the USA -- the Department of Agriculture, USDA. The purpose of that funding was to identify relationships in the environment, particular in diet and environmental toxins, what effect does that have on a child's development. Things li e lead and cadmium, mercury, things li e that, plus good diet. So over 1,300 children and adults were brought into the

 

 

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constituents of your blood, li e cholesterol and your liver

 

   

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University of Maryland, carefully screened with neuropsychological tests, school performance tests, reading, spelling and arithmetic, neurological history, dietary

amount of lead in the body. The total amount of funding was about $2 million, and it too roughly eight years. There was about 30 or 40 people wor ed on this, highly trained people, school psychologists, neuropsychologists, computer programmers and technicians to put on the electrodes. And then out of that 1,300 subjects, roughly 670 or so were considered to be normal. They had no problems, because they are very carefully screened. There was oversight by the National Institutes of Health. We had to meet the criteria that they laid down, and also we had to have a balance of demographics, the same ethnic ma eup in the State of Maryland determined by the Census for Hispanics, African-American, Caucasian, Asian, et cetera. So it was a very carefully constructed normative database. Q Now, Doctor, you had mentioned that the measure of

blood uses a normative database. What other technologies or tests or procedures use a normative database? A In medicine there's many that are used. Bone

density, for example. There's eye measurements. Just many

 

recall, some blood analyses and hair analyses to loo

at the

 

 

 

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measurements. Urine analyses. When any of these types of tests are done by yourself, let's say, or me, then it's compared to one of those referenced normative databases. Q How is Mr. Nelson's findings compared to the

normative database? Would you describe that briefly? A Let me show some of the findings. I'll just

briefly show. This is a diagram to show how different parts of the brain have different functions. Over here is the frontal lobe. It's involved in the executive functions, the decisions you ma e in life, thin ing, abstract thin ing, planning. If you do anything in sequence where you are going to do something in the morning and then in the afternoon you are going to do something else and the evening something else, that ind of planning on what you're going to do is done by your frontal lobes. Damage to the frontal lobes interferes with the ability

control, depression, elation, that's mediated by the frontal lobes. The anterior singular that's down here (indicating), that's involved in volitional motor movements. If there's a stro e in that part of the brain, which happens to be right here (indicating), and these numbers are made up by an individual by the name of Broadman in 1909 that are used today.

 

 

to clearly thin

through Step 1, Step 2, Step 3. Mood

 

 

 

 

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They turn out to be very, very accurate and it's used by the National Institutes of Health and all the

different functions of the brain. The anterior singular is involved, li e I said, in volitional motor movements. So if you had a stro e there, a person would not move, they would just sit. You would have to say, o ay, John, stand up and then John would stand up. Then, John, go to the door and John would go to the door; otherwise, John would sit there.

And it's involved in attention and being able to sustain your attention and shift your attention and it's also involved in mood. The other relevant part with Mr. Nelson is the hippocampal gyrus which is involved in short-term memory and it's the creation of new memories. This is the most energetic part of the brain. It's part of that default networ I was mentioning. And Alzheimer's disease, for example, one of the first parts of the brain that's affected is the hippocampus. The temporal lobes are li e a continuation of the hippocampus. They are involved in auditory information processing and in short-term memory, and so when you read, for example, as you scan the letters and words on a page, what you are

 

 

It's carded

inesis.

 

 

 

 

brain neurosciences to lin

symptoms and complaints to

 

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doing is actually translating what you are reading into words, into sounds that you don't hear, necessarily, unless you hear yourself read. That then goes into what's called the lymphic system where the hippocampus is, that's deep in the center of the brain and that's where the meaning of the words arises. What you do with the meaning of that word, that depends on your frontal lobes. In the case of Mr. Nelson, there were five different conditions that we mentioned yesterday. One was resting with the eyes closed. Resting with eyes open.

energy, and then hyperventilation to see if there's any epilepsy, to bring it out if you can. Then active tas s where now the default brain is turned off and different parts of your brain start doing a tas . This is just an illustration of what a normative database is. It happens to be that any measurement that you ta e, could be height, weight, size of your feet, et cetera, they all tend to follow a bell-shaped curve. This is a bell-shaped curve where roughly 67 percent or 68 percent is plus or minus one standard deviation, that's in the center. Out at the extremes, this is three standard deviations, that's very rare to find out at the tails of the

 

 

 

That's where the default networ

is consuming all this

 

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out that way. It's not necessarily bad to have an extreme unusual value. If somebody is six foot 11, that's very rare. That's out at the two or three standard deviations, but they can dun a bas etball, they can do great things and they can also function quite well. When it comes to biological functioning in different parts of your body that are lin ed to the symptom, if you find a value on the EEG, let's say in the frontal lobe, that is very rarely if ever found in normal population, then a

lobes to the patient's symptoms. Similarly if you had a liver enzyme problem, you may come to the doctor with being jaundice and being lethargic and sleepy and low energy, and the doctor will see three standard deviations, elevated liver enzyme. That doesn't mean that your liver is bad, there's a number of different things that can happen. But the doctor will lin that to your symptom because it's very rare to find the enzymes that low or that elevated. And that's the same that's done here, but it's a bell-shaped curve. This is an example of the quantitative analyses of Mr. Nelson compared to the normative database. And the circles here, this is loo ing down at the top of

 

 

clinician will lin

that unusual property of the frontal

 

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distribution. But every measure that you ta e tends to come

 

 

 

 

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And these are different frequencies, and basically what is seen is that the red means that there is more than two standard deviations elevated energy. And the blue means there's over two standard deviations too little energy being generated by the brain. Q Doctor, can you hold up there for a second?

(Omission). Q Doctor, I'm showing you what's been previously

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of -THE COURT: That's for identification. MR. LENAMON: Identification, I'm sorry. BY MR. LENAMON: Q same -THE COURT: What is that? A That's the topographic maps of the Z scored I'm showing you Page 34 of 63. Is that the

deviation from normal, which is the same as what's being shown to the jury at this time. BY MR. LENAMON: Q Doctor, could you step down for a moment? THE COURT: The same as what's on the screen? MR. LENAMON: Yes. THE COURT: You don't need to show them that.

 

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mar ed as Defense Exhibit No. A-47. I'm showing you Page 34

 

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Mr. Nelson's scalp or s ull.

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It's on the screen. (Omission). Q A Q You are going to use the television screen? Yes. You may step down, Doctor.

(Omission). Q Doctor, explain where is the front of the head and of the head and where is the nose?

A

This is what's called a topographic map. It's a

diagrammatic representation. It's not an actual photograph of Mr. Nelson's head. The nose right up here (indicating). It's that little dot. That's the left ear and that's the right ear (indicating), and the red is where there's significant deviation from normal based on the normative database, there's effect on the left frontal lobe and there's bilateral results of some on the right, but there's a lot of frontal lobe red at different frequencies.

blue, that means that part of the brain is not generating a lot of energy, as much as it should. The neurons are not being synchronized, and if they're not synchronized and wor ing as a group and that generates a large amplitude. So they are not doing that. Basically, that's what this diagram shows.

 

There's also a lot of posterior bac

 

 

where is the bac

of the brain is

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Q

What does that mean in the evaluation process of

A

Well, it means that there's deregulation of the

frontal lobe. The neurons there that have a certain job to do or different functions, they are not able to do their job very well. The role of the frontal lobes, li e I mentioned, is involved in executive function and judgment. It's mostly impulse control also, being able to inhibit our actions and for us to be able to plan and sequence and to do things that meet our needs and our drives in an

example, the frontal lobe starts to go. You ma e bad judgments -(Omission). Q What about when people use drugs and they have

frontal lobe damage? (Omission). THE WITNESS: It will ma e it worse. A drug that does affect the frontal lobes and the frontal lobes have been damaged by traumatic brain injury or malfunctioning, if the neurons are not synchronized and operating properly, then the alcohol or the medication can ma e these things. BY MR. LENAMON: Q Can you explain to the jury how these images

are created through the use of the EEG?

 

 

 

effective way. So we have people drin

alcohol, for

 

 

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A

The EEG from Mr. Nelson is measured and then it is

compared to the normative database. This is done mathematically very quic ly and transformed into what are called Z scores. That bell-shaped curve I showed, it shows where in the bell-shaped curve these particular measures are. If they are way out at the tail of the bell-shaped curve, then they'll be red li e they are here to the right. That's li e having an elevated liver enzyme. If they are way to the left, I mean blue, that's the left of the distribution, that means there's not enough of whatever it is. Could be not enough red blood cells, for example, or white blood cells.

couple of questions? A Q (Witness complies). Now, you had mentioned that the majority of the

population would fit into the middle part of this deviation? A Q A Q A Yes. Where would that be? It's in this region here (indicating). And the middle part being what? Well, it's plus or minus one standard deviation.

It's roughly 68 percent of the normal population.

 

standards deviation that you had shown so I can as

 

 

Q

Doctor, could you just go bac real quic to that you a

 

 

 

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Mr. Nelson, because of that, would fall into another part of this deviation? A Many of Mr. Nelson's deviations are four or

five standard deviations. It would be out here (indicating). Q What does that mean in the realm of the frontal

lobe and how it's wor ing?

normal brain would wor . It's so rare to find a normal individual that you don't find somebody with five standard deviations outside the normal. It would be li e somebody that would be, li e, you now, ten or nine foot tall if you loo at the distribution

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of height. If this was the distribution of height Michael Jordan would be out here about two and a half standard deviations.

A

With impairment, so it means that the neurons are

deregulated. The inhibitory neurons are not holding the powerful parietal neurons, those are the excitatory neurons, in chec . When you release the inhibition from those parietal neurons, then they just start doing their own thing. They

 

don't tal

to their neighbors, they don't process

 

Q

We are tal ing about impairment?

 

 

 

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A

It means that it's not wor ing the way that the

 

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Q

You mentioned by loo ing at that red that,

 

 

 

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information. The way that neurons wor , they wor with large groups

If one just starts doing its own thing and it gets deregulated or a group of them deregulate, then they are not able to process information. So, it's li e ta ing the neurons off-line and removing them from the larger scheme with the entire brain. Many other parts of the brain are dependent on the frontal lobes. But if they are absent, sort of AWOL, they are without leave, they are not wor ing and they don't contribute to the proper functioning of the brain.

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that you conducted, using the information as obtained from Mr. Nelson, this shows from his brain -(Omission). Q damage? A It shows that there's a focal line deviation What does it show in terms of his brain, the

from normal, deregulation in the left and the right frontal lobe, especially in the left frontal lobe. And we can see from the sharp wave I was showing yesterday where it's what is called phase reversal, they go in different directions, cannot be produced by muscle.

 

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loo ing at, Mr. Nelson's brain. So based on the evaluation

 

Q

Let's go bac

to the slide again that we were

 

in different parts of the brain and they tal

 

 

to each other.

 

 

 

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There are no muscles up there. You can try to move your scalp and you can't do it. The only way for this to be generated is by the brain itself. That happens when the inhibitory neurons are not wor ing right. The principal cells, the excitatory neurons just run away. It's li e a bunch of indergarteners playing in the sandbox. Q Does this image show that Grady Nelson's brain is

significantly impaired? (Omission). THE WITNESS: It does show that there's significant impairment. There's a significant dysfunction of the frontal lobe. BY MR. LENAMON: Q And in your experience and education and

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to where this damage came from? (Omission). Q Doctor, you testified earlier yesterday about your

report. You testified extensively about your experience yesterday in doing research and wor ing with various individuals doing that research? A Q Yes. Can you explain in relation to your experience

what ind of doctors you have wor ed with in doing both

 

 

 

 

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bac ground in studying the brain, do you have an opinion as

 

 

 

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A

Well, with psychiatrists, neurologists, a lot with

neurosurgeons. Those are the most medical doctors. Q Is it usual to rely on the information they

provide you in helping formulate your opinion? A Q Yes. In this particular case have you relied on --

besides the actual findings of the QEEG, have you relied on any other individual's repots or information that you were provided? A Q A Q A Yes, I have. And who have you relied on?

What have you relied on in regards to Dr. Ouaou? Well, Dr. Ouaou did a clinical evaluation loo ing

at the clinical history of Mr. Nelson involving traumatic -incidences of traumatic brain injury. Dr. Ouaou then performed a series of neuropsychological tests that are commonly used to evaluate traumatic brain injury, and Dr. Ouaou concluded that there was a traumatic brain injury. (Omission). Q Doctor, if I was to tell you, hypothetically, that

there was testimony consistent with brain dysfunction and consistent with a traumatic brain injury, would that be consistent with what you found in the QEEG?

 

 

Well, Dr. Gluc

 

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research and wor ing on the QEEG?

and Dr. Ouaou.

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THE COURT: Sustained. You may reword it. BY MR. LENAMON: Q Doctor, is this, what you see, the results of the

QEEG, consistent with brain dysfunction? A Q Yes, it is. Is what you see in the results of the QEEG

consistent with traumatic brain injury? (Omission). Q Doctor, why are there 14 representations of

Mr. Nelson's brain instead of just one? Can you step down and explain that? A These are just different frequencies from slow

frequencies to higher frequencies. The slow waves to the really fast ones. It shows that there is a broad spectrum of deregulation and it's focal. Most important, it's particular locations, a small location. That is commonly seen, in my experience, with traumatic brain injury patients. If there's a focal impact on your s ull, the tissue that's near the point where the object or wherever it is struc the s ull, received most of that energy. That disrupts those neurons, especially the small fragile neurons that are involved in regulating the big sturdy neurons.

 

That results in this

ind of deregulation that you see,

 

 

 

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so it's very common. Other types of insults to the brain are usually very diffuse. For example, excessive drug use, it's rarely just focal, it affects a whole lot of neurons. So this cannot be explained by just one place. Also, it cannot be explained by artifact.

analysis. What does this represent, Doctor? A This is just a topographic view of that.

Yesterday I was showing you the sharp wave that was just -Q A Why don't you step down? Yesterday I was showing you the sharp wave, and

I'll show that next, and this is just another way to see that but it's using the computer, the Z scores, the

sharp wave event. That's a good example of how neurons, when they get deregulated, they suddenly will discharge and there's a burst of activity and then they will get regulated after that.

What is the Z score? A The Z score is the distance from the normal. So

if you have elevated liver enzymes, it will give a score.

 

Q

Let's tal a little bit about this demonstrative.

 

comparison to the normative database to loo

 

Q

Let's tal about the continuation of your test

at that one

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This is three times -- or three standard deviation, rarely seen in the normal population. So it's a measure of distance. Q What does each one of those -- each one of those

represents a top view of the head of Mr. Nelson? A Yes. The nose is here (indicating). Each of

these little dots is where the electrodes were located. One, it shows that there are slow waves in addition to the -- this is the high frequency and this is the low frequency. So both parts are there. That's not uncommon to see the neurons because when they are deregulated, the oscillates are slow and then there are areas of high frequency activity.

is showing the slow wave areas? A Q Yes. That is the low frequency. Why is that significant in the part of the

evaluation process? A Well, number one, it shows that it's not, again

artifact, li e muscle artifact. Because muscle artifact is a very high frequency and it would be largest right around the ears and not be in the center of the head because there's no muscles. Secondly, it's a characteristic pattern of deregulated neurons. This is the way they would loo .

 

 

Q

So is this, which is li e the second picture here,

 

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Q A

What does this, I guess, the fourth picture show? That's just an intermediate frequency, that slow

mid-frequency, real frequency. Q Describe how that frequency is measured and how

the processes are run. A Well, in computer analyses, there's a lot

of waves. If you loo at it as the ocean, it has slow waves and riding on top of those is a lot of movement. They are all mixed together and you can use an analysis that's referred to as Fourier transform, invented to Joseph Fourier in 1810. Without his invention, we wouldn't have microwave ovens or computers a lot of modern things, and we used Joseph Fourier's method to decompose all those mixtures

waves. That's what quantitative analysis does. Q When you measure using the QEEG, do you use hertz

to measure? How do you measure? A Hertz is cycle per second. That's called

frequency. How many cycles is there per second? Q A Is that important in the measurement process? Again, that's what's -- when I say slow, that's

relative, that's -- here it's about four or five cycles per second and here is about 25 cycles per second. It's five times as fast.

 

of waves and loo

at how much energy there is at each of the

 

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A

This is the same thing I showed yesterday. It's

just a sharp waves. Let me move on to the next one. (Omission).

A

This is a view of the sharp waves that I was

showing yesterday. This is just an overview to see how these waves or this event suddenly occurs out of nowhere. This is just the bac ground EEG, then this event occurs suddenly. It's several times larger than the bac ground EEG. This is where the neurons have become deregulated, then they re-regulate and it continues on in a regulated state until a little bit later, then there's a whole series of these that just suddenly appear.

this, that uses what's referred to as a different montage. You can create different combinations of these channels of these particular notations in order to examine the details of the event. So let me just move the slide to that. Q Doctor, while you are doing that, is there

anything that Grady Nelson did through his own personality or his own ma ing that caused this to happen to him? (Omission).

 

Q

When you say do something, are you tal ing about

 

I'll move to the next one that just

 

Q

Doctor, what are we loo ing at here?

ind of zooms in on

 

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Q

What's the next thing that you loo ed at, Doctor?

 

 

 

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injure themselves intentionally? A Q Sure. Putting aside the intentional injury, is there

anything within his personality that caused him to create this? (Omission). Q A Go on, Doctor. This is just an example of that event, zoomed up a

bit. What's important is you can see this is going down and that wave is going up. That is not possible to happen except by a source that's inside the s ull. You cannot do that by muscles. Q A Why are you emphasizing that to the jury? Well, because often there's a criticism about the

use of this quantitative EEG that's pretended by artifact.

criticism that you are aware of in this particular case by an individual by the name of Dr. Epstein. (Omission). Q We'll get to that later.

Can Grady Nelson create his own sharp wave? A No he cannot. This is a spontaneous event that

it's focal in the left frontal. You saw topographic map, this is li e a zoom now in on the one event in detail. That's all this is, to

 

 

 

Q

I want to ta e a moment now to tal about some

 

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illustrate -- this provides a lot of information to a professional who loo s at this. And one is that it creates -- there's only one way for this to happen. There has to be what's referred to, as I said yesterday, a dipole, which is a battery. It has a positive and a negative, that's two poles. And if that battery is oriented parallel to the surface of the scalp or the s ull then one end is going to be positive, the other end is going to be negative. That's what this is, positive and negative. That's why it's reversed. If that battery has been rotated so it's at right angles to the surface, this would not happen. This is important because it tells the clinician that the source is a group of neurons that are basically -- they're gyring in your brain, go li e this.

not at the top li e this, but they are tangential, they're parallel to the surface. Q What are those to the right, there's letters and

numbers, what does that mean? A This helps illustrate the electrode locations in

the frontal lobes. These lines go to these traces to show where they are. I don't have a line-up here, but, actually,

 

this, the pea of this event versus the pea

 

They're on the ban

 

 

   

of the gyri, the edge of the gyri,

of that event

 

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is ten milliseconds difference. It tells us that this event started here (indicating), and then it moved to a different part of the brain. Q Just so that we are understanding, in terms of

this material here that we are seeing, how long is that a measure of? A This entire period here is 200 milliseconds, so

this is around, that event is around 50 milliseconds. Q A And how many milliseconds go into one second? A thousand. It's very short. We can be aware of

things at about every -- a reaction time is about 150 milliseconds is the best people can do. And most of the time we are aware of things about 200 or 300 milliseconds. When the TV is going, that's going at about -- well, at 15 times per second everything becomes smooth, it's no longer jer y. So,at 20 times per second that's, about 50 milliseconds. Q Now, is the computer -- are you able to interpret

this because the computer is able to read the definitive time period? A It's one of the purposes of the quantitative EEG

that allows you to zoom and examine things in great detail, and including the sources of it.

we had tal ed about eyeball EEG versus the quantitative EEG.

 

Q

Let's tal about that a little bit. Historically,

 

 

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Can you explain to the jury the advancement that you are seeing here through the quantitative process and just a little bit about the history behind that? A Well, before the digital computer was developed in

the 1950s and 1960s, the only thing that could be done to evaluate the traces is to eyeball, to visually examine the traces, and it was shown that that was very low reliability. So, for example, a group of readers, let's say a neurologist read a record of EEG and six months later those same people were given the same records, they wouldn't agree with themselves, maybe .4 is the correlation, or if you got a group of independent readers, the correlation is about .02. It's so insensitive because it's too complicated and it's also different at different ages. So computers when they came on the scene in the '50s and '60s were provided to try to quantify the EEG and provide the reliability measures that, for example, are here, and augment and enhance the ability of a person to understand the EEG. In terms of the conduction velocities, that tells you things about the white matter in your -- there is -- you may have nown people who have multiple sclerosis, for example.

the insulation on the fibers deteriorates and things slow down.

 

That's a disorder of the white matter, the insulin or

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You can measure how much slowing of the conduction velocity there is using a computer, but you cannot do that by eye, and you can see where in the brain the sclerotic plaques are most dominant, for example, in that patient. Or in the case of traumatic brain injury, what happens is one part of the brain moves faster than the other part of the brain. Somebody hits their head on a windshield, let's say, the heavy part of the brain or the neurons, they move faster than the part of the brain that has the fibers. That stretches the fibers, the fibers then swell, and that slows down the conduction velocity, so they have slowness of tal . They can't be multitas ing. People that can drive and have no trouble navigating in traffic suddenly can't multitas . They can't deal with the stress of cars coming one way and having to get off on an exit because things have slowed down inside their brain because of the white matter the axons are on. Now, over time that can be repaired, but if it is

disconnection. And that's where we use a measure called coherence and phase. Those are measure phases, measure of the time delay. Coherence is the measure of how much conductivity there is between one part of the brain and another. Those are

 

really severe, then the axons actually brea

and there's a

 

 

 

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affected by traumatic brain injury.

Doctor, are you familiar with PET Scans? A Q A Yes. And have you used them in your research? Yes.

(Omission). Q A How have you used it in your research? We use the -- at the National Institutes of

Health, we did experiments to have people perform tas s, let's say, move their hands and you could see, using the PET Scan where the blood flow changes when you move your hand. And we would measure the EEG also, and we would see that the inverse solution that will be shown in a little while that gives you where inside the brain the electrical energy comes from and we can verify and cross validate that using the PET Scan, that will give you the same location. The EEG gives you the same location as the PET Scan. That's been done on many, many studies and that was done in the 1990s when the inverse solutions was a method to measure the electrical energy from the scalp, you can determine what the sources are.

first thing the team wanted to do was to verify and validate that. They did that by -- with electrodes implanted in the

 

The early wor

on that was in the late 1980s, and the

 

 

Q

Than

you, Doctor.

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brain of epileptic patients, for example, and they stimulate those electrodes and be able to then use the inverse solution to see exactly where it's coming from. So, there's been a whole series of studies to validate the inverse solution, including PET Scans, the MRI, functional MRI and stimulating of the brain and then also using what are called phantom heads. Those are s ulls that are filled with conductive media and then you stimulate inside the s ull and determine where it is coming from. Q Is there a disadvantage to being able to show

frontal brain injury through the process of using a PET Scan? (Omission). Q Is there a disadvantage to showing frontal brain

injury by giving a PET Scan as comparison to QEEG? (Omission). Q Doctor, can you tell me about your experience

using PET Scans? A Well, I --

(Omission). THE WITNESS: I have been a subject of PET Scan studies and I published papers that combine PET Scans with the inverse solution, with the QEEG from the surface as well as the inverse solution, the source of the EEG.

 

 

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Q

Approximately when did you begin using PET Scan

technology and being involved in that? A Q Around 1991. And for how long were you involved in the use of

PET Scan technology and research? A Well, the studies I published were performed in

1992 and 1993. I left the National Institutes of Health and since then I have reviewed studies on PET Scans. Q Do you continue to review peer-review journal

material on PET Scans? A Q A I have, yes. Up to the present day?

reviewed one. Q As far as you are aware, in your professional

opinion, has the science of PET Scan changed significantly since 1993? A No.

(Omission).

information, PET Scans have not changed. (Omission). Q And, Doctor, is there a difference between the

results that you see on a PET Scan and the QEEG? Can you tell the jury --

 

THE WITNESS: To the best of my

 

I thin

the last maybe three years ago that I

nowledge and

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(Omission). Q And can you tell the jury what the difference is,

if there is? A There's a -- when the neurons become active, first

of all as I mentioned, they consume 40 to 60 percent of our glucose. That's delivered by the blood. When the neurons become active, then there's a bigger demand for blood to deal with their increased metabolism. So, there's a delay, though, the neuron first get active, they send out little signals to the -- they're called galeal cells that are around the arteries that cause the arteries around your brain or in that region that's active to dilate. It's a little bit li e if one flower in your garden becomes doesn't -- have much water, the brain will water the entire garden. It won't just water one small patch. So, it lac s spatial resolution because the small group of neurons can get active but there's a big change in blood flow. Second, it's delayed. It ta es five, ten, 20 seconds for there to be a shift in change in the blood flow. It's one of the limitations. The positive part of the -- the advantage of PET Scans is, number one, they can help validate and verify the sources of EEG, which is in milliseconds, so it's very fast.

 

 

 

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Our thoughts are occurring 100 or 200 milliseconds.

subcortex. That's one of the advantages of the PET Scan whereas the EEG cannot. Q Would the frontal lobe damage that you observed on

the EEG appear on a PET Scan? A It can, essentially it would usually come up as

what is called hypometabolism. There's a lac of proper demand because the neurons are not being used li e they normally would, so they are not demanding as much blood. So, you'll see less blood flow in the PET Scan. But it's usually very diffuse in general. Q In terms of visual observation and being able to

describe the details of the injury, which would be more accurate, EEG or PET Scan? (Omission). Q Which of the two in your opinion detail more of

the injury -(Omission). Q A -- the PET Scan or the EEG? Well, there's a very large scientific literature

that shows that PET Scans are not very sensitive. The EEG measures the electrical energies of your brain. Where there's disturbance of the circuits, the actual generators of the electricity or the fibers that are

 

The PET Scan is too slow to see that, but it can loo

at the

 

 

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conducting the impulses, then that's seen in the EEG. That's what the EEG is all about. That's what the EEG is measuring. The PET Scan doesn't measure that. The PET Scan measures blood flow that's secondary to the neurons as ing for more blood and it's slow. If you loo at the scientific literature, you see in mild head injury, the PET Scan has a very, very low sensitivity, whereas Quantitative EEG is above 90 percent sensitive in detecting a mild head injury. In very severe head injury, a considerable loss of brain cells, then the PET Scan begins to see clearly there's no blood being required. The PET Scan will start to see it. But the Quantitative EEG, even with a mild head injury is very sensitive to detecting head injury. Q Is QEEG used in research as well as what was done

here in treating -(Omission). Q A Is QEEG used in research? Yes, QEEG is used in research of a variety of

things, from perception, to emotions, to memory, to judgment, to movements. All aspects of movement and functioning, the EEG is used for, including sleep and wa efulness studies.

Q

You said you haven't done anything since 1991,

 

 

 

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research involving PET Scans? A Q 1993. Subsequent to 1993, you continued -- did you

continue -- is that when you left to go to the VA? A Q Yes. And you continued with your use of the QEEG from

1993 up to the time that you left the VA? A Then -- yeah. My program was in charge of both

the MRI and then EEG and then the neuropsychological evaluations would come in. But our job, what we had, was integrating the MRI and the EEG in determining where in the brain the severity of the -- and where in the brain -- what parts of the brain were affected by the traumatic brain injury and the extent of the effect on the brain. And then how different parts of the brain are tal ing to each and how different parts of different groups of neurons are able to synchronize. Neurons are -- they have to shout. They have to operate together as a group. A single neuron that tal s doesn't do anything. It recruits a bunch of its neighbors and they scream or shout, then that has a signal in the brain that has meaning. So we measure that, and the MRI was important as a landmar . We could register the part of the brain affected by the

 

   

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injury, we can see where in the brain that was and then we lin that to the patient's performance on the neuropsychological tests. Q So as early as the mid-1990s, were you using the

MRI as a confirmation with the QEEG? A Q A Yes. That was as early as the 1990s? Yeah. My program was 1993 up to 2006. We were

doing it in all that time. Q A And your program uses an alternate database? Yes.

you primarily doing research or primarily doing evaluations on patients and related matters? A Q We did both. Are you aware that there was a study done out of

Emory University recently involving the comparison of QEEG -(Omission). Q Are you aware of any studies from Emory

University -(Omission).

time.

 

 

 

(Omission). Q Doctor, from 1995 until when you left the VA, were

Q

O ay. Doctor, we may get bac

to that at a later

38

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 sir?

What is the next thing that you evaluated in this particular case?

THE COURT: Yes, we can. THE WITNESS: I'm not going to spend time on this slide. It's a little too complicated for everybody. But it just shows one of the things that quantitative EEG can do compared to what you can do by eye. I mean, you can see from this -- what this does, it can loo at the lower frequency part of that event, that deregulation in Mr. Nelson's left frontal lobe. It's just another way to loo at it. BY MR. LENAMON: Q Can you step down and show me. These things are

complicated, but this is important for the jury to understand. Let's just -A Essentially what it is, this is the deregulation

event and here's the EEG here (indicating).

these jurors. I now it's difficult. THE WITNESS: This top trace is the EEG. The bottom trace is a mathematical reconstruction of just the component, this one component that is the deregulation event.

 

THE COURT: Doctor, be careful you don't bloc

 

MR. LENAMON: Luis, can we move this bac

over,

 

 

 

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2 3 4 5 6 7 8 9 10 11

detail into what that deregulated event is made up of in terms of its frequency component. This is the frequency (indicating). It's a little too complicated to get into, but the maximum here is four -- or six point -- 4.4. I can barely see that. It's four seconds per second, which is low frequency. It cannot be accounted for by eye movement or artifact. BY MR. LENAMON: Q Why is it important to their consideration in

13 14 15 16 17 18 19 20 21 22 23 24 25

determination of the reliability of the material you're presenting? Why is that important? (Omission). THE WITNESS: Because artifact cannot explain this event. This event is coming from Mr. Nelson's brain.

it. This proves that. There are many different things that have proved it already, but this is just another addition to prove it. But that's not artifact. Q Can Grady Nelson intentionally cause

a deregulation event in his brain? A No, he cannot.

 

There's no other way to get these

ind of pictures without

 

 

12

ma ing a determination, the jury's consideration in ma ing a

 

1

And this is li e a zoom lense that goes into great

40

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A

The next thing I want to present is what's

referred to as electrical neural imaging. We briefly spo e about that before. That's where you can measure the EEG from the scalp surface and then mathematically you can determine where inside the s ull the source of that event is occurring. MR. LENAMON: Can I move this, Judge? Can I move it a little closer? THE COURT: You may. BY MR. LENAMON: Q A Go ahead, Doctor. This is an example essentially using

what's referred to as low resolution electromagnetic tomography. The acronym is LORETA, li e a woman Loretta. It's referred to as low resolution because it's able to mathematically come up with an exact solution, an exact number. And it does that by smearing the sources, which is here (indicating), smearing them out a little bit so it ma es a little low resolution. But it's highly accurate and it's been verified by implanted electrodes in epileptic patients, as I mentioned,

 

 

 

 

 

1

Q

O ay. Go ahead and have a seat, Doctor.

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PET Scans and verified by physiological measurements on moving your left finger or your right finger and showing that these sources shoo from one hemisphere to the other. Your right hand is ta ing control over your left hand and your left hand is ta ing control of your right hand. When you move your right hand you'll see a red spot come up in the left hemisphere and you move your left hand, it comes up in the right hemisphere. So, it's been verified in over 700 peer-reviewed journal articles. So it's a well established method. Q Is this a demonstration or is this actually

Mr. Nelson -A Q A This is actually Mr. Nelson's EEG. Point out where the ears are, the nose? The front of the brain is here (indicating). This

is different sections, MRI sections, that are averaged in a normative MRI from the National Institutes of Health. Q A Explain that. Essentially a large group of normal individuals

were scanned in an MRI scanner and then they were added together and an average MRI was created that use normal people. That way you don't have to actually measure Mr. Nelson's MRI. You can actually use this average, and -for anybody, and then see where inside the brain in

 

 

 

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reference to these particular coordinate systems -- these numbers down here are coordinate systems that the National Institutes of Health uses so everybody nows exactly where anything comes from inside your brain. Q Now, Mr. Nelson didn't have an MRI. So can you

explain -- are you referencing that what the shape that we're seeing is standard and then you're comparing that to the actual results of the tests through an QEEG? (Omission). Q Clarification. What you are saying is that these

are normal loo ing -- these are normative s ull patterns from an MRI ban and then you are comparing them to results of Grady Nelson's data from the QEEG? (Omission). Q A Explain exactly again. Essentially what happens is when you place

electrodes on the scalp surface, the locations of those electrodes are registered with respect to landmar s. You've got one on your forehead between your eyes and

your ears. Your ear oracle canal in your ears. Those are landmar s that are -- could be registered to the MRI, anybody's MRI, and to the average MRI. So that registration happens with the computerized EEG. That allows one then to determine given the electrical

 

another is a little notch in the bac

of your head, and then

 

 

 

 

 

 

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energy at the scalp surface where in the brain that energy originated, what its source is. In the case of Mr. Nelson's left frontal lobe surface that we were loo ing at earlier on the topographic made, now we are going inside the brain and as ing him where inside the brain. Inside the brain is here (indicating). This is called the superior frontal gyrus, there's a name for it, and that's the source of the deregulated activity in Mr. Nelson's brain. Q pictures? A Yes. What we saw initially at the surface, the Is that consistent with what we saw before in the

red we saw, now we are going inside the brain and we're saying where in greater precision the event arose. Q Why are you able to use the LORETA technology

without giving Mr. Nelson an MRI? A Well, it was designed that way. The National

Institutes of Health wanted to be able to develop software and method, but you don't have to have an expensive

source of the EEG. So, a standard MRI was developed that became a norm, a normative MRI. And -- which as I described was made up of a group of health individuals where they just scan their brains and add them up and divided by the number, and that

 

thousand-dollar MRI every time you want to loo

 

 

at the

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then became a reference that allows the over 700 peer-reviewed journal articles and many, many ongoing research and clinical applications, for example, the part of the brain -- you don't see it very well here -- let's say that's involved in memory would be down here in the temporal lobes. Studies have been done where people have problems with memory and then you'll see that this part of the brain is not wor ing right. So, out of those 700 papers, so the vast majority are clinical papers, and by allowing -- by creating this method, that has been able to really advance our understanding of brain function without having to spend a lot money putting the head in a big magnet. (Omission).

important? A No. It's just important to see it has a source

and we can determine what the source is. Q A What is the next piece of analysis that you did? This is another deviant activity of the brain. In

this case it's in the frontal lobes also, more anterior. It's, again, a group of neurons that have deregulated in the frontal lobes. Q Is this a different separate analysis that's done?

 

Q

 

Is there anything else that you thin

would be

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Can you explain that, Doctor? A Well, it's a different frequency. This is done in

the theta frequency band. The previous one we were loo ing at is the high frequency, li e 25 cycles per second, and this is around five cycles per second. Q Why do we see different results? What is the

importance of that? A The deregulation that occurs is expressed in

different frequency bands. This is called Broadman arias 10, which is involved in decisions, executive function, emotional memory and judgment. Q These are things that affect all those things you

just tal ed about? A Q A Q

Yes. Including judgment? Yes. And a person who is using drugs in addition to

having this impairment, how does that affect -(Omission). Q A person who is using drugs in addition to having

this impairment, how does that affect the person? (Omission). Q What is the effect -- in addition to this damage

that we're seeing, adding the ingredients of cocaine? (Omission).

 

 

 

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Q

How would drug use affect the results showing in

the QEEG that we are seeing? A Well, number one, drugs cannot have a focal

effect. It's impossible for a drug to actually do this. Drugs are very general, and they come in from your bloodstream. Q drug use? (Omission). Q You said it was impossible for drugs to cause This damage, without question, is not caused by

this, explain to the jury why. A Drugs come in from the middle and enter the

arteries and they bathe the whole brain. What they affect are the neurotransmitters in the brain which are chemicals that allow one neuron to communicate with another neuron. But those neurochemicals are distributed everywhere in the brain. There is no one place where you have one neurochemical and another one where you have another chemical. They are everywhere. So drugs affect everything. Drugs cannot affect just the left frontal pole and not the right frontal pole or the left frontal pole and not the rest of your brain. That's just not possible. I'm sure the pharmaceutical industry would li e to be able to do that, but you just simply cannot do that.

 

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But the issue, though, is that when there's deregulation in a particular part of the brain and then you superimpose drug use on top of that, this shows dysfunction. And drug use is a global dysfunction and does not add to better function for this part of the brain. Q So hypothetically a person who -- the damage that

we are seeing existed as we see and the person used drugs, how would that affect their behavior? (Omission). Q How would that affect the result?

(Omission). THE WITNESS: If drugs were there at the time that they are recording? BY MR. LENAMON: Q A Yes. It would not affect the location of this at all.

It could ma e it larger or worse, but the location would be the same. Q A What is the next piece of analysis that you did? This is just another example of deregulation.

This time it's in the part of the brain that's referred to as the hippocampus on the right side. This is the hippocampus here (indicating). You can see it over here. This is the part of the brain that's involved in creating new memories and wor ing memory.

 

 

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It's the part of the brain that's involved in the retrieval of recent memories, not long-term memories, but recent. So, that shows there's a group of neurons that are deregulated in part of the brain. It is several standard deviations outside of normal. So it's just another aspect of dysfunction that can be seen in Mr. Nelson's EEG. Q Doctor, without getting into the specifics of what

you saw, if I was to tell you that there was -- is this consistent with impatient of wor ing memory?

Q

And are you aware of Dr. Ouaou's findings in

regards to the results of the test that he did regarding wor ing memory?

(Omission). Q If I was to tell you that there was evidence in

this trial outside your testimony of impairment of wor ing memory, would this result be consistent with that? (Omission).

that still up there? A Q A Q On the hippocampus, yes. Is that consistent with prior brain injury? It's possible, yes. What is the next analysis that you did?

 

Q

Doctor, the slide you were just tal ing about is

 

 

A

It can, yes, affect wor ing memory.

 

 

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A

The next, again, is showing the same thing as

before. It's just the Z scores showing in the left frontal region that is significantly deviant from normal. It's replicative or duplicate of the previous slide, the earlier slide. The difference is that this is in one cycle per second resolution. This is 24 cycles per second, 26, 30, 29, 28, 27, 26, 25, 24, 23, 22, 21. It just shows that this is building up at one cycle per second range in that location. Q Why are you able to see it more clearly as you

build up more cycles per second? A It's just a different analysis. The analysis

previously was a group of frequencies. It was not a one cycle per second resolution. Q seeing? A It's the left frontal lobe that we were showing Where is the impairment or the dysfunction you are

previously. The middle and the superior frontal gyri. Q A What was the next analysis that you did? This is just a one cycle per second resolution of

the lac of energy, the blue, that I showed before, from one to about seven cycles per second. That is at the lower frequencies in the posterior part of the brain.

 

Q

 

What causes that lac

of energy?

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A

Traumatic brain injury sometimes, the brain when

there is an impact to the s ull, the brain bounces around inside of the s ull. If the frontal lobes are not demanding or orchestrating energy, essentially what I was mentioning, the frontal lobe is li e the conductor of a symphony.

Your feelings and drives are connected to the frontal lobes, and then the frontal lobes orchestrates the resources

to ta e action, to be able to see and perceive and shift your attention. So, there's just an overall reduction of the efficiency and speed that that is happening. Q A Keep going. This is duplicative. Let me just move to the next

one. This is bilateral frontal. What this is showing a little bit different is the right frontal also. It's focusing in on the right frontal lobe. It's bilateral. Q A Q A When you say bilateral? The left and right side of the s ull or the brain. There is dysfunction on both sides? Yes. There's dysfunction on both sides. This is

the source using the LORETA analysis of the right frontal where that deviation from normal is. The right frontal differs a little different from the

 

 

in the bac

of your head to meet your needs and your drive

 

 

   

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left frontal, both the left and right are involved in executive functions, but social s ills are related to the right frontal. Q A What is the importance of executive functions? The executive functions are those, you ma e

decisions in your life to do certain things, to ta e certain actions, for example, that's an executive function. Where you veto doing something, that's an executive function. But your frontal lobes are involved in that process. If there's damage to the frontal lobes, then the ability to ma e proper choices and decisions is reduced.

The ability to inhibit behavior is reduced. The ability to recognize social subtleties is reduced. And all of those are all part of the functions of the frontal lobe. Q Now, when there's evidence to the separate lobes

the right and the left side, is that consistent with one blow or multiple blows? How do you measure that and how do you determine how it originates? A You really can't. It can happen with one blow.

It just depends on the magnitude of the force. Q You can have one blow and have damage on both

sides of the head? (Omission). Q Can you have damage from one blow in more than one

place on the frontal lobes?

 

 

 

 

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A Q A

Yes, you can. Can you explain how that happens? Essentially the brain is li e a bloody sponge in a

way. It's floating, actually, inside your s ull. And if there's a sudden stoppage of the movement, let's say your head hits the windshield and you sort of visualize that, and

moving, so it stops. So, your brain -- what is called -- it will get bruised. It's called a contusion. That's what happens. There's rapid acceleration and deceleration, or if there's an impact to one side on one day and a year or two later you get smac ed on the other side, you can do it that way, too. It doesn't have to happen at the same time. Q Doctor? A This is just another part of the frontal lobe. What was the next analysis that you conducted,

It's the middle frontal lobe. It's a little bit more on the right, so it's contributing to the previous slide. This is an illustration of the anterior singular gyrus, which is the second slide that shows that. The anterior singular gyrus is here, (indicating), it's deep inside your brain. The frontal lobes are near the forehead, and the anterior singular gyrus is involved in attention shifting.

 

you hit the front of your head where your brain

 

 

eeps

 

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the jury box. Your memories will come into your anterior singular and then you'll operate on them. You'll you be protected, they will stay there. It's li e actors coming on to a stage. There's a stage for Act 1. And then the actors have to go off the stage and another group of actors come onto the stage. If this part of your brain isn't wor ing right, then the actors are banging into each other as they go on and off the stage or they will be leaving the stage before the end of the act. The frontal lobes control that and controls volitional motor movements. Q The analysis that you just made reference to the

actors and acts, is that consistent with what you are seeing in the damage, essentially, in Grady Nelson's brain? A Yes, it is. And this is just an example of the

EEG, LORETA analysis showing the anterior singular gyrus is one of the areas that's deregulated. It's related to the frontal lobes, too.

able to -- this is the actual Z scores and the values. You can see there's four standard deviations. There's 4.7 standard deviations. You'll have this, I thin , in your

 

 

This is a bunch of numbers. I don't thin

 

 

2

controls that. It's a little bit li e what happens here in

 

 

1

It's involved in -- it's li e your wor ing memory, it

 

you'll be

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deviation from normal. Four standard deviations is very, very rare to ever see

in terms of body height, it would be somebody maybe nine or ten foot tall. Q So an analogy to someone being nine or ten feet

tall in relation to the damage that Mr. Nelson has suffered? (Omission). Q Can you analogize the results from the QEEG in

relation to the nine foot statement that you just made? A That is it's simply not normal.

(Omission). Q A What's the next analysis you did, Doctor? This is a measure of the time delay between one

part of the brain and the other. Q A Why is that important? The speed at which one part of the brain tal s to

the other part of the brain determines the efficiency. And how much information -- to another part of the brain. So the speed and the efficiency of information processing is related to how much time. When there's injury to the cables in your brain, the white matter, the fibers in your brain, then they slow down. As I mentioned, they can swell or can lose volume, the

 

 

in a normal population. It's somebody if you loo

 

1

displays to loo at. It just shows you the magnitude of

at them

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conduction velocity is reduced and things are just not as sharp. You can't allocate resources very rapidly. That's what this indicates. It's especially there's a lot of slowing in the frontal lobes and also in the temporal lobes, but the long distance and short distance connections are not conducting at a high speed. Q A What was the next one? That's the same. It's just more of the examples

that you see throughout this record. This is a measure called coherence and the blue is referred to as a disconnection syndrome. That's where there's a lac of conductivity, reduced conductivity. Q A What is conductivity? How many connections there are between one part of

the brain and another. This measure when it's blue it indicates reduced conductivity. That's seen in relatively -- it's not seen in mild head injury. Moderate to severe, you begin see this disconnection process, and it's primarily in the frontal lobes and some in the right parietal, right posterior region, but mostly it's in the frontal. The red is a hyperconductivity which happens when there's compensation. A certain amount of the brain is having to tal more to another part of the brain to do their

 

 

56

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used three words. Mild, moderate and severe head injury. Could you describe the difference and how far that is going

A

Well, traumatic brain injury is measured on a

continuum. If you were to plot the magnitude of force imparted to the s ull versus the amount of damage to the brain. If it's a small amount of force, then it's mild. That's represented primarily by either no loss of consciousness or a brief loss of consciousness. And there's a measure called the Glasgow Coma Score which shows you there's a 15, which is all this had right now would be a 14, which is a reduced awareness of your environment, but it's relatively mild. In animal studies and also some in people in autopsies, if you evaluate the tissue you'll see that there is disruption of some of the connections by an amount of energy. It slows things down. Moderate is where there is a longer period of loss of consciousness and a little bit of bleeding often. They are right at the interface of the blood that comes into the top -- the blood supply in the top of your brain called the Paya.

 

to effect the results of the wor

of the brain?

 

 

2

Q

I want to ta e a step bac for a second. You

 

1

job that normally it doesn't have to tal

that much to.

 

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And those little smaller metastasizing vessels and arteries start to bleed a little bit, and you have concussion, you can see a concussion in that patient. You can see concussion with mild, too, but it's a more

you are, you begin to lose your -- you have trouble remembering what happened. You have posttraumatic amnesia. That's moderate. And then severe is where there's a continuation, you increase the magnitude of force, then there's more bleeding, there's more stretching of the axons because one part of the brain moves faster than the other and it stretches them, and they swell. Now, the axons are actually brea ing because they stretch so much. That's when you begin to get -- and you can get that also with moderate. That's the disconnection syndrome I was mentioning where now there's a loss of the connections or a significant -- even the connections that are there, they may not be lost, but they are not operating in an efficient way. Q three? (Omission). THE WITNESS: It would be consistent with at least a moderate head injury. You said this is consistent with which part of the

 

severe concussion. You're disoriented, you don't

now where

 

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BY MR. LENAMON: Q You mentioned with moderate there may have been

some actual bleeding? (Omission).

A animals --

Well, it isn't always defined bleeding. In

(Omission). Q Could you explain your earlier testimony about how

when someone has a moderate brain injury sometimes you see bleeding? A The animal studies --

(Omission). Q What were you referring to before about the

bleeding when you were testifying before the jury? A The characteristics of traumatic brain injury. On

a continuum from mild to severe where studies have done to increase the magnitude of the force imparted to the brain, part of the s ull. Sometimes, it doesn't always happen, but you never see bleeding with mild head jury. That's the important thing. Sometimes in moderate cases you will see some bleeding. So that's one of the things that distinguishes the order between mild and moderate. You don't always see bleeding with moderate until you

 

Q

Could you describe what you tal ed about?

 

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get at the high end of moderate or it's severe, and then always you will see some bleeding. And then if it's a severe head injury, it's very common to see bleeding. Q A What was the next analysis that you did, Doctor? This is pretty much the same, just a

slightly different view of the disconnection of the frontal lobes. These are the Z scores, as I mentioned before. You can see that there's 4.71, 4.77, 4.96. The largest is 5.34 standard deviation. That's quite deviant from normal. Q A What does that mean and why is that important? That's a high level of abnormality. That would be

where you have cholesterol very high or your liver enzymes will be very high or very low. It's way outside of the normal limits.

This is the first time that people figured out that the frontal lobe -- one of the first times. This is an unfortunate individual that was wor ing on the railroad -- his name was Phineas Gage --and this is in 1844, I thin , '48 where one of the spi es that they were driving into the ground to form the trac s, I thin , and they had some type of explosive and the spi e shot up and went through his brain right here.

 

 

 

A

This is an illustration that Dr. Gluc

 

 

 

 

 

Q

O ay. Doctor, what was next? provided.

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And he had this traumatic change in his personality. Today we are not too surprised by it, but people in those

In fact, in those days a lot of people didn't thin the brain had anything to do with personality. But this was important because it was so dramatic. Let me see if I can do the next slide. He suddenly started cussing, he used to not cuss. I can see that some people may thin they have brain damage. And he became very irritable and explosive. He lost inhibition. He was impulsive. He had no respect. He had

And he essentially had no bra es and he -- these are the inds of things that tests are done, neuropsychological tests, the Wisconsin Card Sort.

15 16 17 18 19 20 21 22 23 24 25

there was a problem with the traumatic brain injury, but he became very studied because he survived, he had a family and children. His relationships with his family dramatically changed and it became a case history in neurology, in the textboo s they tal ed about this. Since then we now much more about the frontal lobes and more subtle effects than the dramatic ones you see there.

 

 

 

 

 

14

But that's when people first -- they

 

 

difficulty planning and

nowing what not to do.

new before that

 

 

 

 

days didn't

now. They new nothing about the brain.

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That was the beginning of understanding what's the function of the frontal lobe. There is stro es and tumors indicating head wounds, things li e this told us, that's what the frontal lobe is involved in, judgment, executive function, mood control, social s ills, sequential planning, speech articulation. That's what the frontal lobes do. That's just another rendition of what I just said, frontal lobes and use a variety of different functions from wor ing memory, planning.

Q A

Can you go through those for us? O ay. Problem solving is affected by deregulation

and dysfunction of the frontal lobe. Inhibition of your behavior. Your ability to plan, to ma e decisions that are in your best interests; language expression, especially expressive language; judgment, poor judgments; your understanding of the consequences of your behavior before you actually do the behavior.

outcome is not going to be good or it will be good. So that part of your brain that figures that out is your frontal lobe; spontaneity, the ability to react in social situations and to novelty and new things. If your frontal lobes are not wor ing right, then you are not very spontaneous. Sexual misconduct and social

 

 

You can plan and thin

about if I do this, then the

 

 

 

 

 

 

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behavior, again that's inhibition behavior. Planning of sequences, articulation and wor ing memory.

A

The right frontal lobe, as I mentioned before,

this is a little bit different in that it's much more involved in social understanding. The right frontal lobe gives you the big picture. Your left frontal lobe tends to want to act on things and ta e things apart. And the right frontal lobe tends to put things together. When it is not functioning right there will be inappropriate behaviors. Often a lac of control over anger. It's called low threshold frustration. A certain level of frustration drives, but then there will be an explosive angry reaction if the frontal lobes are not wor ing right. The frontal lobes are regulating and controlling our emotions. If we have drives or natural urges, the frontal lobes will -- are sensing that in the larger context and can suppress some of the urges that are not appropriate at that moment. And then wor out a plan to achieve, to meet one's needs and goals. But with reduction of the right frontal lobe, that's not done very well and people run into problems.

 

 

 

 

 

Q

Than

you, Doctor.

 

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So monitoring your social actions in situations, the ability to ta e into account the feelings of others and establishing relationships with others. We always are monitoring, we have these neurons that are referred to as mirror neurons which are in the anterior singular in the frontal lobes that react, they fire when somebody is doing something. We immediately see what the intent is to ta e these actions.

A

This is the comparison between the

neuropsychological test that you would predict just based upon Mr. Nelson's problems or deviation from normal in the frontal lobes and also these are the -- this is a slide from Dr. Gluc , showing Mr. Nelson's scores on various neuropsychological tests. He's in the fourth percentile -(Omission). THE COURT: That's all right. Are you done? MR. LENAMON: I'm done.

Doctor. (Subsequent proceedings were reported but are herein omitted at the request of the ordering party).

 

THE COURT: I'm just going to say than

 

 

 

Q

O ay. Doctor, what else did you loo at?

 

 

you,

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CERTIFICATE OF COURT REPORTER

STATE OF FLORIDA COUNTY OF MIAMI-DADE

I, BRYNN DOCKSTADER, Court Reporter for the Circuit Court of the Eleventh Judicial Circuit of the State of Florida, in and for Dade County, DO HEREBY CERTIFY, that I was authorized to, and did, report in shorthand the proceedings and evidence in the above-styled cause, as stated in the caption hereto, and that the foregoing pages constitute a true, accurate and correct computerized transcription of my report of said proceedings and evidence. IN WITNESS WHEREOF, I have hereunto set my hand in the City of Miami, Dade County, Florida, this 12th day of February, 2011.

________________________ Brynn Doc stader, RMR

 

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