1.Travis Snyder — Direct/Cross/Redirect
510 linesMay 14, 2019.
THE COURT: Are y'all ready?
BOYD YOUNG: Yes, sir.
THE COURT: I have been waiting on y'all.
BOYD YOUNG: Your Honor, the Defense would call Dr. Travis Snyder to the stand.
TRAVIS SNYDER, being first duly sworn, testified as follows:
COURT CLERK: Once you're seated, state your full name spelling your last on the record, please.
TRAVIS SNYDER: My name is Travis Snyder, S-n-y-d-e-r.
DIRECT EXAMINATION By Mr. Young:
BOYD YOUNG: Good morning, Dr. Snyder.
TRAVIS SNYDER: Good morning.
BOYD YOUNG: As you know, we're videotaping your testimony for presentation to the jury at a later time. So thank you for being here and I appreciate the Court for allowing us this opportunity. Can you tell me what you do?
TRAVIS SNYDER: So I'm a neuroradiologist. So I look at MRI's, CT's, and occasionally X-rays of the brain, the neck, sinuses and spine.
BOYD YOUNG: Can you tell me a little bit about your educational background and training as a neuroradiologist?
TRAVIS SNYDER: So I graduated from Florida State with my undergrad, and then I did, went to medical school for four years at Touro University in Nevada. And then following medical school I did a five year radiology residency. And during those five years I learned all about radiology in general including ultrasound, mammography and emergency room and of course neuroradiology as well. And then following the five years of residency I did a year of Fellowship. I went to University of Miami in Jackson Hospital. And during that I worked under only a neuroradiologist and during each month of that year I subspecialized within neuroradiology. So I would do, you know, one month of pediatric neuroradiology, one month of sinuses or head and neck and then one month of tumors or MRI. So that was that year. And then following that, I graduated from that Fellowship in neuroradiology. And then I took a test called CAQ which stands for Certificate of Added Qualifications and then I passed that test. Also I took a separate test so I'm a Board Certified radiologist. And then following that I've been in practice for the past four years now in private practice in Las Vegas.
BOYD YOUNG: And have you ever testified before?
TRAVIS SNYDER: Yes.
BOYD YOUNG: Have you been found to be an expert in neuroradiology before?
TRAVIS SNYDER: Yes.
BOYD YOUNG: Do you know about how many times?
TRAVIS SNYDER: I've probably been in probably ten trials. I'm just sort of estimating, but approximately.
BOYD YOUNG: And the nature of your practice now, can you tell us what it is that you, what do you do now?
TRAVIS SNYDER: So I work for SimonMed, which is, actually, I think it's the largest outpatient imaging company in the United States. And so I read MRI's of the brain mostly or spine from all over the Country but mostly in Nevada, Florida, Arizona and California. And so I spent about ninety percent of my time reading clinical studies for patients. And I spend about five percent of my time doing research, mostly on traumatic brain injury. We have a large database that we've created where I work with the Department of Defense to try to help understand traumatic brain injury in veterans. And I have other research projects on carbon monoxide poisoning and radiation safety and, other, other papers as well. And then I spend about five percent of my time on expert work such as, such as this. Some civil, some criminal. So about ninety percent is private practice, ten percent research, I mean, five percent research and five percent expert work.
BOYD YOUNG: I'm going to show you what's been marked as Defendant's Exhibit number one and ask, can you tell us what that is?
TRAVIS SNYDER: Yes. This is my current CV.
BOYD YOUNG: Is it accurate?
TRAVIS SNYDER: Yes. This is fairly up-to-date.
BOYD YOUNG: Your Honor, at this time I would move for admission of Defendant's Exhibit number 1 into evidence. (Whereupon, Defense Exhibit 1 was marked for identification only.)
SHAWN GRAHAM: The State would object. I've never seen a CV entered into evidence for the jury to review. If he wants to bring out all that with the jury in testimony, he can do that. So that's according to the --
BOYD YOUNG: I don't think that that's an appropriate objection.
SHAWN GRAHAM: I mean, I think, he's going to be able to testify. I think the document for the jury back there to review would be improper bolstering anyway.
BOYD YOUNG: I have always put CV's of my experts into evidence.
THE COURT: I'm not, I don't know that I've seen it done. I mean, you asked him all the questions of his background, training, medical training, practice and you offered him as a, certainly going to attempt to offer him as an expert. But why, I mean, why do we need the CV?
BOYD YOUNG: Because it goes to the qualifications and expertise. I'm happy to go through his whole CV, Your Honor.
THE COURT: Well, I mean, do that. His CV, I'm not going to admit it. That's, he can testify to it.
BOYD YOUNG: Can you tell me where all you have licenses and certifications?
TRAVIS SNYDER: Yes. I have a, as I said, I'm a Board Certified radiologist since 2015. I have a CAQ in neuroradiology. I have state licenses in Michigan, Florida, Nevada, Arizona, California, Colorado and New Mexico.
BOYD YOUNG: I think we went through most of your professional experience?
TRAVIS SNYDER: Yes.
BOYD YOUNG: Do you have any academic appointments?
TRAVIS SNYDER: Yes. I'm on faculty for a number of schools, mostly Touro University Nevada. And I take two or three medical students every month. So they come in and they work with me throughout the day and I try to teach them about radiology and neuroradiology. I'm also an instructor at Michigan State University and in Touro University in California as well as Nevada and also at the University of Nevada, Las Vegas School of Medicine. I'm a Clinical Assistant Professor of radiology. And an Adjunct Assistant Professor of radiology at the University of Nevada, Reno.
BOYD YOUNG: Are you a member of any radiological groups or affiliations?
TRAVIS SNYDER: Yes. The American Board of, American Board of Radiology, the American Society of Radiology, American Board of Osteopathic Radiology, American Osteopathic College of Radiology, the American Society of Functional Neuroradiology. And actually, I believe I'm on the American Pediatric Neuroradiology. I don't have that listed here but I'm a part of that as well.
BOYD YOUNG: Do you hold any titles or awards?
TRAVIS SNYDER: I was the Chief Radiology Resident in my Residency. I'm the Nevada Radiation Safety Officer for SimonMed and the Laboratory Director for SimonMed in Nevada. There's a few other things I'm not sure that are that relevant for what we're doing here, but.
BOYD YOUNG: Have you given a number of presentations and lectures?
TRAVIS SNYDER: Yes. Probably over 50 presentations, lectures, articles and abstracts, many of them on traumatic brain injury. The most recent one, a lecture I gave was, that's not on here, was about a month ago at Scripps in San Diego. It's a head trauma conference. It's an International head trauma conference and I was quite honored to give a lecture there on traumatic brain injury.
BOYD YOUNG: Have you published any journal articles?
TRAVIS SNYDER: Yes. I've published a, there's an article on contortionist, that's listed here. I have an abstract on IG4-related hypertrophic pachymeningitis. There's another abstract on carbon monoxide poisoning. There's an article on diffusor tensor imagining, which is just recently published, which is not listed here. It's a review of diffusion tensor imaging. And also an article on EEG in traumatic brain injury patients. And then we're working on quite a number of very exciting articles, as I mentioned, with our research group that hopefully will be coming out in the next year or so.
BOYD YOUNG: And that's listed under your previous research and current research?
TRAVIS SNYDER: Yes, under current research. I'm the principal investigator for, I'm on the lead investigator for the diffuser ten imaging research for Department of Defense. And it's called a BMA group, or H-B-O-T, HBOT grant. And also I'm involved with functional, FMRI, research. And I am the principal investigator for IRB from Touro University over, deals with 350 traumatic brain injury cases. And in those, in that research we're looking at advanced imaging and clinical findings and clinical outcomes based on the imaging. So we're looking at where the injuries are in the brain, what kind of damage that the patients have and how that manifested as far as their clinical outcome, so when they got better. Principal investigator for a volumetric software called NeuroQuant and Alzheimer's disease. And also a, I'm principal investigator on a carbon monoxide study group where we're creating a database of carbon monoxide patients.
BOYD YOUNG: Your Honor, at this time I would again offer Defendant's Exhibit number 1, a copy of Dr. Snyder's curriculum vitae into evidence.
SHAWN GRAHAM: Same objection, Your Honor.
THE COURT: He's testified to everything on there. The testimony is sufficient. The CV does not need to come into evidence, so I'm not letting it in.
SHAWN GRAHAM: Thank you, Your Honor.
BOYD YOUNG: Dr. Snyder --
BOYD YOUNG: At this time the Defense would move to declare Dr. Snyder as an expert in neuroradiology.
THE COURT: Any voir dire?
SHAWN GRAHAM: Just briefly, Your Honor. VOIR DIRE EXAMINATION
By Mr. Graham:
BOYD YOUNG: Dr. Snyder, when I'm looking at your curriculum vitae, it looks like you didn't become involved in radiology until 2009 through 2014 at your residency at Michigan State. Is that correct?
TRAVIS SNYDER: Yes.
BOYD YOUNG: And then specifically neuroradiology you had a Fellowship at the University of Miami in Jackson Hospital 2014 to '15. So one year there?
TRAVIS SNYDER: Yes. But I should say in medical school I did also learn about radiology. So that would be since, you know, 2005, I guess.
BOYD YOUNG: And then you testified to a CAQ Certification in Neuroradiology in 2015. Is that correct?
TRAVIS SNYDER: Yes.
BOYD YOUNG: Is there a Board Certification for neuroradiology?
TRAVIS SNYDER: No, it's not, I mean, the CAQ is the equivalent of a Board Certification, but it's not actually called a Board Certification. It's just, it's a test that you take. The only people eligible to sit for the test are those that have done a one year neuroradiology Fellowship. If you do that year then you have the option to sit for that, for that test. So it's sort of an equivalent but it's not technically a Board Certification. It doesn't exist.
BOYD YOUNG: There is no Board Certification for neuroradiology?
TRAVIS SNYDER: Not for neuroradiology, no.
BOYD YOUNG: And you said your practice is ninety percent clinical. Is that correct?
TRAVIS SNYDER: Yes. That means just reading cases on patients. Patients, yeah.
BOYD YOUNG: And that would be head, neck and spine, I think you said?
TRAVIS SNYDER: Yes.
BOYD YOUNG: So some of those would be neurological and some would not, for neurological purposes?
TRAVIS SNYDER: Well, they're all neuro. I mean, I do some general radiology. So if there's a stat X-ray I'll look at it, or if there's a CT pelvis, or CT abdomen or something that's urgent I can look at it. But mostly I read the neuro. I predominantly focus on neuroradiology.
BOYD YOUNG: And you testified, I think you said, maybe at ten trials as an expert. And was that radiology or neuroradiology?
TRAVIS SNYDER: Mostly neuro, neuroradiology.
SHAWN GRAHAM: Thank you, Doctor.
THE COURT: All right. Dr. Snyder will be qualified in the field of, expert in the field of neuroradiology and can offer opinions in that field. CONTINUE DIRECT EXAMINATION
By Mr. Young:
BOYD YOUNG: Dr. Snyder, we're here on the case of Tim Jones. Can you tell me how you became involved in Mr. Jones' case?
TRAVIS SNYDER: Yes. I believe someone from your office, perhaps yourself, contacted either myself or my assistant and asked me to review an MRI. And I believe I was referred by, to you by Dr. Bigler.
BOYD YOUNG: Did he send you an MRI?
TRAVIS SNYDER: Yes.
BOYD YOUNG: And how does that come to you?
TRAVIS SNYDER: I'm not sure how this particular one came to me. But a lot of times they're just sent in the mail. The CD with the images are sent in the mail. Sometimes people use Dropbox or some file sharing program to get it to us. So, but in any event it came to me and I reviewed the images. And then I believe we had a phone conversation and I just discussed my findings with you. And then I said if it would be helpful I could make a power point and a report to further explain the imaging findings. So that's what I, that's what I did.
BOYD YOUNG: Let me show you what's been marked as Defendant's Exhibit number 2. I'll ask you, do you recognize that?
TRAVIS SNYDER: Yes.
BOYD YOUNG: What is that?
TRAVIS SNYDER: So this is the report that I did for following review of the imaging findings. And this contains summaries of my opinions on the, on the scan and some literature backing. Some literature references. Peer reviewed literature to support my opinions.
BOYD YOUNG: Your Honor, at this time Defense would offer Defendant's Exhibit number 2, a copy of Dr. Snyder's report, into evidence.
SHAWN GRAHAM: I'm assuming that's the same one that you sent us earlier?
BOYD YOUNG: It is.
SHAWN GRAHAM: No objection, Your Honor.
THE COURT: Defendant's 2 is admitted without objection. (Whereupon, Defendant's Exhibit number 2 was admitted into evidence.)
BOYD YOUNG: And, Your Honor, I need to ask that Defendant's Exhibit Number 1 be made a Court's Exhibit.
THE COURT: Okay. It will be numbered sequentially after the other. It might be 76, I believe.
COURT REPORTER: Judge, we're at 78.
THE COURT: 78?
COURT REPORTER: Yes, sir. I had already marked number 1 for the Defense, but I can just change that, I guess. I mean, the CV had already been marked as Defendant's number 1, so I'll just put a Court's Exhibit on there.
THE COURT: Also?
COURT REPORTER: Yeah. And that will be number 78. (Whereupon, Court's Exhibit number 78 was marked for identification.)
BOYD YOUNG: Dr. Snyder, I'm going to show you what's been marked as Defendant's Exhibit number 3 and ask you if you recognize those.
TRAVIS SNYDER: Yes. This is my presentation. And in this presentation I've saved key images from Mr. Jones' scan and with arrows to annotate them and there's also some literature references in this.
BOYD YOUNG: And there's ten slides. Are those the slides that go with your report?
TRAVIS SNYDER: Yes.
BOYD YOUNG: Your Honor, at this time I'd offer these ten slides and Defendant's Exhibit number 3.
SHAWN GRAHAM: No objection, Your Honor.
THE COURT: Defendant's 3 without objection. (Whereupon, Defendant's Exhibit number 3 was admitted into evidence.)
BOYD YOUNG: So, Dr. Snyder, you got the CD of Mr. Jones' MRI. Do you know where that MRI was done or when it was done?
TRAVIS SNYDER: It was dated 4/20/18. And as far as where it was done, it looks like it says Palmetto Richland.
BOYD YOUNG: Palmetto Richland?
TRAVIS SNYDER: Yes.
BOYD YOUNG: Thank you. So you opened it up and what did you see?
TRAVIS SNYDER: So, yeah, I can go through all the findings. It was a, first of all, it was a high quality MRI. It was, the technical, the first thing I look at as a neuroradiologist, to make sure the quality of the exam is appropriate. And I think this was a very good quality exam. It was well done with the proper sequences. So MRI's have many different sequences. It's not like a X-ray where you have just one image. There's probably 15 different sequences that were performed on Mr. Jones. And the first finding, and the most striking finding that, and I can show this on slide one, is that he has a depressed, yeah, there it is. The jury can see that, or --
BOYD YOUNG: Yes.
TRAVIS SNYDER: Oh, okay. There's a large left frontal depressed skull fracture. And the yellow arrows are pointing to that. And the image on the left is an actual image. So that's taken sort of starting at the top of my head going down. These, these slices are acquired this way. And so, that is kind of through the mid-portion of the brain on the left.
BOYD YOUNG: So this is sort of looking down?
TRAVIS SNYDER: Well, it's looking up actually. It's looking up at the patient. So the, is this a pointer? I can use this?
THE COURT: There's a pointer right there. Right here. Here, Doctor, there's a pointer. A Oh, yes. So this, this is the front and the back, and this is actually the right and the left. So it's, we're looking up at the patient and this is flipped. And this is taken through the mid-part of the brain. And this whole area here on the left frontal, this is depressed skull fracture. So it's pretty large, and you don't have to be a neuroradiologist to see that it's abnormal. And I very rarely see something like this when I review images. So it is a large, and this is from old trauma. There's no question that that's the, that's the left frontal fracture. And so the image on the right, this is a frontal view. And so, instead of going, instead of slicing up to down, we're basically slicing front to back. So it's looking at the patient from the front. So this is the right eye, that's the left eye. You can kind of see them there. And then there also is the depressed skull fracture on the left frontal lobe.
And here's the normal one on the right. So this is a nice curved linear skull. This one is normal. And then that one is a depressed skull fracture. So that's the first finding. Now, on slide two, the second finding. So these are, again, axial images. So these are taken up to down going through the brain. And this is the right side of the brain, and there's that skull fracture we saw before. And this sequence is different than the previous sequence and this sequence is a special sequence. It's actually quite an expensive sequence to run. I don't know what the, what they, how they do this at their center. But at our center this is expensive to run. And it's the best sequence available for hemorrhage and it's very sensitive for hemorrhage. And the only purpose of this sequence is for hemorrhage. And these, and hemorrhage looks like decreased signal on, on this MRI. And so, the arrow is pointing to that black dot and that's the area of hemorrhage. And there's another one here and there's a third one here. There's at least three areas of hemorrhage. So, and this is not, sort of expected because he has the skull fracture and then he has these hemorrhages which are under the skull fracture which are well seen on this, on this sequence.
BOYD YOUNG: So the fact that the hemorrhages are visible in an old injury, what's the significance of that?
TRAVIS SNYDER: Well, this is, these hemorrhages are consistent with diffuse axonal injury. So that's where there is, there is disruption of the axons, there's disruption of the fiber tracts in the brain, basically the telephone wires of the brain are messed up. And a hemorrhagic diffuse axonal injury, as we see here in Mr. Jones, is very unusual. Most patients that have had trauma do not have this. It's associated with poor prognosis. And, for example, there was a study that was done on one-hundred boxers and boxers are in the ring, you know, in the ring fairly constantly getting hit very hard, knocked out, constantly having head trauma. And in that study of one-hundred boxers not a single boxer had any hemorrhage like, like this. So you have to have a severe trauma which we know he did because he has a large fracture there. And also, these hemorrhages do overtime, they, about thirty percent of them resolve. So it's likely that at the time that this, this trauma occurred that he had more of these. So he probably had more and then they, they, a few of them likely resolved.
BOYD YOUNG: Now, let's go on to your third finding.
TRAVIS SNYDER: Well, so that's, that's where the, that's where the hemorrhage is. So he has a skull fracture and underlying scattered hemorrhages in the left frontal lobe.
BOYD YOUNG: I know what I was going to ask you about. The technology to find these hemorrhages, did that exist 20 years ago or has it gotten better?
TRAVIS SNYDER: No, it did not. Twenty years ago this sequence, called susceptibility weighted sequence did not exist. This is a fairly new sequence and we do it at our centers. And we're, you know, quite proud we have it at our centers. But most places do not even have this sequence so, it's, because of it's so expensive. You have to pay the manufacturers to unlock the key. You have to pay GE or Phillips or whoever to get that sequence. So this would not have existed 20 years ago. And this sequence is about four to six times more sensitive than the next best sequence, which is called gradient echo, or GRE. And there's a study by Tong, 2013, which showed how much better the sequence was than the previous one.
BOYD YOUNG: Let's go to your third finding.
TRAVIS SNYDER: So the next slide, slide three shows another finding here. This is showing an area of cortical thinning and scarring. And so the cortex is the, is the outside of the brain. The brain is made up of the gray matter which is the outside of the brain. And then the white matter which is the inside of the brain. And the gray matter, or the cortex, is where electrical signals are generated. And then the white matter is where the basically telephone wire. So it's where the signals kind of go through. It's how the brain is connected. And so, Mr. Jones has an area, this is right under the skull fracture and it's right around all those areas of hemorrhage. And in the image in the upper left you can see the, it should look like this where you have the gray matter outside and the white matter on the inside with the smooth, with smooth transition, whereas here it's very irregular and the cortex is thin. So this cortex is normal up here. It shows a nice gray cortex.
But here the cortex is sort of absent and it's all kind of blurred. So that's where he has cortical thinning and scarring. And you can see it as well on the image on the left. This is a coronal image facing us where you see the arrow pointing to it as well there. And I think it's probably best seen on this middle image which is another coronal image, which is in a sequence called FLAIR, F-L-A-I-R, and it's quite a good sequence to look for that sort of pathology. And the cortex should look like this, this gray matter coming all the way around lobulated. This is how the cortex should look normally, whereas here it becomes blurred and it becomes sort of thin. And so that is also likely posttraumatic. It can also be seen, the cortex thinning can also be seen in schizophrenia or schizoaffective disorders. But, I mean, this is right under where he was hit. So I think, you know, posttraumatic etiology would be probably favored.
BOYD YOUNG: And were there any other findings?
TRAVIS SNYDER: Yes. So the next slide we're looking at coronal images of the brain through the mid-portion. So this is right about through going, slicing front to back right about through the mid-portion of the brain at the level almost of the ears. And so, this image on the right, this is the right, this is the left, this is up, this is down. These are the ventricles, which are fluid filled spaces in the middle of the brain. This is normal. And what we're looking at is an area called the hippocampus. And hippocampus is part of the, the medial or the middle aspect of the temporal lobe and the temporal lobe is this area. I'm outlining the whole temporal lobe. So this is the middle, medial part of the temporal lobe. And the hippocampus is this region. And this is the left hippocampus and this is the right hippocampus. And you can see that the right hippocampus is smaller than the left. And this, and the image on the right also shows it in a different sequence, shows that, how the right hippocampus is smaller than the left. And this is secondary, this is an abnormal finding. It's not very common to see this. And hippocampus is an area that's, there's many articles that talk about how it's affected from head trauma. And so certainly that would be consistent with the history of head trauma, especially given all those other findings for head trauma.
BOYD YOUNG: Did you put Mr. Jones' MRI showing the hippocampus compared to a normal hippocampus?
TRAVIS SNYDER: Yes. That's the next slide. And this was, this was for the, for the jury to see the, this is Mr. Jones' brain on the left side of the screen. And this is the same image as before showing how that right hippocampus is decreased. And you can argue the left is a little decreased too. But it's a little tough to say, but the right we can definitely go with as being decreased. And this is a normal patient. So this is just a normal patient that I, you know, see every day reading MRI's. And this is what it should look like. The hippocampus, I'm outlining it with my tracer right here on the right, and that's the left one. And so these are our normal hippocampus and Mr. Jones has that atrophy. And if I could move to the next slide.
BOYD YOUNG: Yes, sir.
TRAVIS SNYDER: So that hippocampus connects to other parts of the brain through this tract called the fornix. And the fornix is a fiber tract that extends from the hippocampus. And it's a little tough to see on imaging but I tried to get some images of it here where the arrow is pointing to it. And you can see how the right one is smaller than the left one. This one's a nice, pretty big left one and this one is slightly smaller. And it's a subtle finding but I think it's real, it's seen on two slices. This one is smaller than this one. And the fornix atrophy is, again, is associated with hippocampal atrophy. So if the hippocampus is atrophied the fornix is also often atrophied because they're connected. And so this, I think, shows it. And also atrophy means injury. So when the brain is injured, first of all it swells, just like when you get a bruise on your, on your hand or anywhere. You get swelling and then following that it shrinks. But the difference is the brain does not heal like, you know, the hand or the foot. It doesn't grow back. So it remains, it remains decreased in size because it was injured.
BOYD YOUNG: Did you do a slide about the hippocampus and its effects?
TRAVIS SNYDER: Yes. The next slide, and this is just to show how prevalent it is that the hippocampus is injured following brain trauma. There's many articles on it and these are some of the articles on it. Let me see. Dr. Bigler, who will be speaking later, is, actually was very instrumental in discovering some of this and many other authors as well. And so, the hippocampus is, it's not, you know my opinion, it's a neurologic fact that the hippocampus is very sensitive to traumatic, from trauma.
BOYD YOUNG: Any other associations with hippocampal atrophy?
TRAVIS SNYDER: Yes. There's, they are a little more than usual. But you can have hippocampal atrophy if you have a seizure disorder. That can cause hippocampal atrophy from seizures. It has been described in, well the temporal horns which are spaces adjacent to the hippocampus have been described as larger in patients with schizophrenia, or schizoaffective disorder. So that would be also a possibility. Patients with carbon monoxide poisoning are very prone to hippocampal atrophy. There's many articles on that. So yeah, head trauma is not the only cause.
BOYD YOUNG: I think you said something about there was a positive correlation between temporal horn enlargement and hippocampal atrophy and schizophrenia. Can you tell us what that means?
TRAVIS SNYDER: So there's a few findings on Mr. Jones that sort of suggest that are, it's a positive correlation with schizophrenia or schizophrenic spectrum. And those are his, he has a thinning of the, of the corpus callosum, which okay, this is the next slide. And this sort of shows it, so let's talk about this. So on the image on the left, this is a, so this is a view we haven't seen before. We've seen the axial view and we've seen the frontal view and now we're seeing a side view. So this is the, this is the front, this is the back, this is up, this is down and this is right through the center. So this is the midline. So this is right between the eyes in the center of the brain. And this is the corpus callosum. This structure where the arrows are pointing to. And this structure, the corpus callosum is the, is really the only structure, there's a few smaller ones, but essentially it's the only structure that connects the right brain to the left brain.
And it's made up of a bunch of telephone wires, if you will. Electrical connectors that the right and left brain communicate. So it's a very important structure because without it the two sides of the brain would not communicate. And Mr. Jones shows, see, it's kind of thinned here in the front and in the back and there's a little lump there. And this is more of what a normal one would look like on the right. So in this finding it's not that well described in traumatic brain injury. You can have injuries to the corpus callosum in traumatic brain injury but it potentially could relate to a schizophrenia or schizoaffective type disorder. It's a positive correlation. It's very difficult to diagnose schizophrenia or schizoaffective disorder from an MRI. But I want to be clear to the jury that, that to diagnose schizophrenia or schizoaffective disorder from an MRI is very difficult. But you can suggest that there's a positive correlation. And so, it's possible that he may, he may have one of those conditions but it's not diagnostic on MRI. So the findings of, on MRI are the temporal horn which we've discussed, the corpus callosum thinning, cortical thinning and also frontal and temporal lobe atrophy, all can be seen in schizophrenic or schizoaffective type disorders. And he has, he has many of those findings. So it's possible that it's consistent with, if he has that, but it requires a clinician to make the diagnosis not, not the imaging.
BOYD YOUNG: Got you.
TRAVIS SNYDER: Yeah.
BOYD YOUNG: Dr. Snyder, the nature of Tim's brain injury, is that, I think you talked about there are different classifications, mild, medium, severe, or mild, moderate, severe. How does that work?
TRAVIS SNYDER: Yes. The tract range is classified as mild, moderate or severe. And it's mostly a clinical diagnosis based on how long consciousness was lost for. But there are some imaging correlates such as the hemorrhage and the fracture. And so this is certainly not a mild traumatic brain injury. As we mentioned, this is, this is on the more severe spectrum. And so whether this is moderate or severe would require, you know, his, his clinicians or review of medical records, how, how long he lost consciousness and what his Glasgow Coma Scale was, which is a way to measure neurologic function in someone who has a brain injury. But based on the imaging, this is not a mild brain injury. This is either moderate or, you know, perhaps severe depending on, on those other factors.
BOYD YOUNG: Did you do a slide sort of summarizing your findings?
TRAVIS SNYDER: Yes. So yeah, there's just, they are almost done. This is, I just have basically two summary slides. And this slide just sums up all the findings that we've discussed today for the jury to review or have on hand of the imaging findings. And so the first finding is the, the first thing we saw was the large left frontal anterior depressed skull fracture. We saw left frontal hemorrhagic diffuse axonal injury. Those are all those little areas of decreased signal on SWI. You know, at least three or four of those. Then he has left frontal focal cortical thinning and scarring. And that might be secondary to, probably secondary to a brain contusion from the trauma. And that cortical thinning and scarring is right next to the hemorrhagic diffuse axonal injury. And then he's also, he has right hippocampal atrophy and he has right fornix atrophy. And that is the medial area of the right temporal lobe which is, which is atrophic. And so taken all -- and the fornix attaches to the hippocampus. And so taken altogether, these findings are consistent with a traumatic brain injury or they're not consistent with, they are, I mean this is a certainty that they're related to traumatic brain injury and it's a fairly advanced traumatic brain injury. And then also we talked about the findings which are not diagnostic of but there's a positive correlation between the thinning and irregularity of the corpus callosum, prominence of the right temporal horn, and right hippocampal atrophy, and left frontal lobe atrophy as well. And these findings have been described in schizophrenia and schizophrenic type disorders, clinician requires a clinical correlation.
BOYD YOUNG: You were talking about the damage to these areas of the brain. Can you tell us a little bit about what the significance of those areas are and damage to them?
TRAVIS SNYDER: Yes. So this, the last slide talks about some of this. And this is what's been described for the frontal lobe injuries. There's been many research articles on they've studied patients that have had frontal lobe injuries and what those, the deficits of those patients are. And first of all, the frontal lobe is the most commonly, common area for traumatic brain injury. So that fits with Mr. Jones as well. And some of the symptoms that have been described following frontal lobe injury includes cognitive problems, lower intelligence, lower IQ. And then also problems with executive functions, with personality changes, risk taking, disinhibition and behavior spontaneity. So those are all possible deficits that could occur from someone with a frontal lobe injury. And the hippocampal injury that we saw on the right, that has been, that is associated with emotional centers as part of the limbic system. And that, that also has a pretty high function for memory. So memory is involved in hippocampus. So it certainly would not be surprising if Mr. Jones had some of these symptoms or, I mean I would be surprised if he had no symptoms. I mean I think that someone that has this degree of a traumatic brain injury would have some sort of symptoms and these are the ones that we might expect. And this would require his doctors, you know, to examine him or someone to review the medical records to make that determination of which ones of these, if any, that he had.
BOYD YOUNG: Like, for instance, low IQ. If he doesn't have low IQ, does that mean he doesn't have poor executive functioning? Are they, are the effects related or can they be completely separate?
TRAVIS SNYDER: Well, they can be completely separate. And you can have someone that, for example, has severe memory problems but is very high functioning, or you can have someone who has severe emotional problems but is able to do many things that are, that are considered high functioning. And you, the reverse, you could, there could be someone that is completely cognitively impaired but they're emotionally stable, personalities are fine. So how traumatic brain injury manifests can be very different in different patients. And it, it's hard to predict based on imaging.
SHAWN GRAHAM: Your Honor, I'm going to object to the question and answer. I'm not sure that we're in the Doctor's field anymore. He's a neuroradiologist who reads images. He doesn't actually deal with testing and other types of areas that would actually determine if any deficits that exist or not.
BOYD YOUNG: I think he's made it clear that he's not saying if, that he did or not. And his opinion as an expert, is it possible that someone has strengths in one area and weaknesses in another.
THE COURT: And his expertise in the field of neuroradiology, so he'll limit his opinions to that. So rephrase your question and make certain that's what he does.
BOYD YOUNG: Sure. With somebody with these injuries that we've seen here, could they go to college, is that possible?
TRAVIS SNYDER: Yes.
BOYD YOUNG: And get a degree in computer engineering?
TRAVIS SNYDER: Yes. Based on the frontal, on imagine findings of frontal lobe injury there's, there's a wide variety of symptoms that have been reported, that can be reported, and the same with the hippocampus based on imaging findings. And someone can be, the range that's been reported in the neuro-imaging literature is quite broad in terms of what the problems would be. But I think it's, it's very highly probable that someone with this type of injury will have some sort of deficits and have some sort of symptoms. But I can't say what those might be. But these are the likely possibilities.
BOYD YOUNG: And I understand. I just want to be clear for the jury. You're not saying that based on this imaging you're, that Tim's diagnosed as schizophrenic?
TRAVIS SNYDER: No, I'm not.
BOYD YOUNG: You're saying that based on these images he has a brain injury and other brain changes that are consistent or positively correlated with people who have schizophrenia?
TRAVIS SNYDER: Yes.
BOYD YOUNG: Is it possible for people to have schizophrenia and get a brain injury?
TRAVIS SNYDER: Yes.
BOYD YOUNG: Thank you. One second. Thank you, Dr. Snyder. Please answer questions the State may have.
SHAWN GRAHAM: Your Honor, can we take a short break?
THE COURT: We may. We'll take a short break and be back on the, you can stand down for a few minutes.
(Whereupon, a short break was taken.)
THE COURT: Your witness.
CROSS-EXAMINATION By Mr. Graham:
SHAWN GRAHAM: Good morning, Dr. Snyder, how are you?
TRAVIS SNYDER: Good morning. Thanks.
SHAWN GRAHAM: I just want to go through your findings and some of your testimony. You were sent these MRI's in the mail, I'm assuming?
TRAVIS SNYDER: I believe so.
SHAWN GRAHAM: And what were you asked to do?
TRAVIS SNYDER: To review them to see if there were any positive findings or any abnormalities.
SHAWN GRAHAM: Were you asked specifically to look for traumatic brain injury?
TRAVIS SNYDER: I don't believe so.
SHAWN GRAHAM: Were you asked specifically to look for schizophrenia or schizoaffective disorder type findings?
SHAWN GRAHAM: The film you said was taken on April 20th of 2018. Is that correct?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: He would have been a 36-year-old at the time of the MRI. Are you aware of that?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: Now, at the time his children were killed, the time he killed his, when he killed his children, that was four years before. You understand that?
TRAVIS SNYDER: I didn't know the timeframe, no.
SHAWN GRAHAM: Assuming the four year lapse between the time he killed his children and the time that these MRI's were taken, do you understand my question so far?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: All right. As far as your findings to the TBI, do you have any idea when that occurred?
SHAWN GRAHAM: From your reading of the MRI it could have been before or after?
TRAVIS SNYDER: Yes, but I, I don't think there's any question when it occurred, because it was such a devastating injury there should be no debate over when it, I mean, I can't image that it's not known when that injury occurred, so.
SHAWN GRAHAM: You were not provided any information about when the injury occurred?
SHAWN GRAHAM: And would it surprise you to know that that frontal lobe fracture of the skull occurred when he was 15 years old?
TRAVIS SNYDER: No, that would not surprise me.
SHAWN GRAHAM: As far as the findings that go with your discussion about schizophrenia and schizoaffective disorder, those are the thinning and some other abnormalities, correct?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: You don't know what his brain looked like in those regards back on August 28th of 2014, do you?
SHAWN GRAHAM: And you don't know whether those change, whether they were present at the time, or they could have, in fact, happened in those four years since, couldn't they?
TRAVIS SNYDER: I think it would be unlikely that, I mean, the thinning of the corpus callosum, that's, I'm not sure I've seen that sort of develop in a short time period like that. Most of the time it's something that people have had for, you know, most of their lives, if not all of their lives.
SHAWN GRAHAM: So they're born with it?
TRAVIS SNYDER: I'm not sure if born with it. But potentially, or it develops sort of early. I don't, yeah, I don't know that I've seen that where you have a scan of someone and then four years later there's another scan and then it shows this, these abnormalities. I mean, most, most of this is something that is, that they've had for a long time.
SHAWN GRAHAM: Well, you talk about three particular things. The thinning and irregularity of the corpus, and I may pronounce it wrong, callosum?
TRAVIS SNYDER: You're right, yes.
SHAWN GRAHAM: The prominence of the right temporal horn and the right temporal atrophy, correct? Those are the three findings that you say may correlate to schizophrenia or schizoaffective disorder?
TRAVIS SNYDER: Yes and there's two others. There's cortical thinning and there's also the left frontal atrophy. And those also have been described in schizophrenic or schizophrenic type disorder. But given that those are in the same location as the trauma, that I think those are likely from the trauma, not from--
SHAWN GRAHAM: -- from what I've read of your report, you actually attribute those to being consistent with traumatic brain injury?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: Okay. So the only ones that your report talked about being related to schizophrenia or schizophrenic spectrum disorders are the thinning and irregularity of the corpus callosum. Could that be caused by the TBI?
TRAVIS SNYDER: It's possible, but pretty unusual in TBI to have, to have that, especially when there's no, if there's hemorrhages in the corpus callosum, you know, then we might, or shearing injuries in the corpus callosum then maybe it's from that. But it's possible it's from the trauma.
SHAWN GRAHAM: So as far as the corpus callosum, you don't know whether it's from the TBI or not. Is that fair to say? Could be?
TRAVIS SNYDER: Right. It may not, it may not, I mean, it may not be from schizophrenia, schizoaffective disorder either because, because MRI cannot diagnose reliably schizophrenic or schizoaffective disorder. There's some loose correlations and a lot of it's in the research phase. So there's findings that are suggestive of it or there's a positive correlation. But, but you can't, I'm not saying he has that based on the imaging.
SHAWN GRAHAM: Right.
TRAVIS SNYDER: Yeah.
SHAWN GRAHAM: That is one of the questions I was going to ask you. Looking at an MRI you cannot diagnose somebody with schizophrenia or schizoaffective disorder. Isn't that correct?
TRAVIS SNYDER: Not without the, the clinical correlation.
SHAWN GRAHAM: And that would come from a psychiatrist or some other person?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: The prominence of the right temporal horn, that could have been caused by a TBI as well?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: The right temporal atrophy, that could have been caused by the TBI as well?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: So your testimony is not that he has schizophrenia or schizoaffective disorder?
TRAVIS SNYDER: No, but that there are some findings on MRI that are possibly related to it. There's a positive correlation between the findings on the MRI and schizophrenia or schizophrenic spectrum type disorder. So, I mean, I think it's worth mentioning that if he has that, that it's supported by the MRI. But, but it's, it's not, I can't say that it's more likely than not he has schizophrenia or schizophrenic disorder based on the MRI. There's a few findings that are, that are concordant with that in the right setting.
SHAWN GRAHAM: But all of those could have been caused by a TBI that he had, correct? That's what you testified to.
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: You don't know when those came about?
SHAWN GRAHAM: And just because he has them doesn't mean he has schizophrenia or schizoaffective disorder, isn't that correct?
TRAVIS SNYDER: Yes, you are correct.
SHAWN GRAHAM: He could actually have the same findings that you have that you're saying there's a correlation to and not have schizophrenia or schizoaffective disorder or any mental health issues. Isn't that true?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: You do know, or do you know that he was on Geodon and other antipsychotic medications since the time of his arrest in 2014?
TRAVIS SNYDER: No, I did not know that.
SHAWN GRAHAM: And you would agree with me that the taking of the medication itself, are you familiar with Geodon?
TRAVIS SNYDER: Not, not well, not very familiar.
SHAWN GRAHAM: My understanding from the review of his records is if he was taking --
BOYD YOUNG: I'm going to object. It's outside of the scope.
SHAWN GRAHAM: If he was taking maximum doses --
BOYD YOUNG: Your Honor, I objected.
THE COURT: Wait. He's changed his question. So I'm going to sustain your objection outside the scope but he may be rephrasing his question.
BOYD YOUNG: He's not a toxicologist, Your Honor.
THE COURT: He's an expert in neuroradiology so he can ask the question. If it's outside the scope, it is, but I've already questioned that.
SHAWN GRAHAM: Doctor, wasn't, wasn't one of your studies or papers or abstracts have to do with medication and thinning of brain matter?
TRAVIS SNYDER: Which one? Sorry.
SHAWN GRAHAM: I don't remember the name. But wasn't one of your, on your curriculum vitae one of them, didn't you have some experience in looking at the effects of medication on, occurring?
TRAVIS SNYDER: Oh, well, maybe you're talking, it was, yes. Yes, that was in, yeah, that was when I was, before I was in medical school I worked with a doctor on looking at, on looking at brain voxels and the effect of medication on, on that, yes.
SHAWN GRAHAM: Correct. And isn't it true that medication can actually cause the effects that you said that you saw?
TRAVIS SNYDER: No, not, not, not to my knowledge. There's some research. And the research that we were doing was looking, it was looking at microscopic voxels. So it was looking at very small voxels. And it was, frankly, that was, it was a little bit discorded, what we were finding and what the literature said. And there are some articles that may talk about how atrophy can occur. But mostly what's, atrophy can occur in the cerebellum, which is in the back of the brain. And that's the most common area that people on antipsychotics such as Haldol specifically, and alcoholism. Alcohol and Haldol can cause cerebellar atrophy and he doesn't have cerebellar atrophy. So I don't think that, the findings that we've described, that I described, are not related to, to medications.
SHAWN GRAHAM: Not from anything that you've seen?
TRAVIS SNYDER: No, not that, I've never seen these findings. I mean the findings that are related to medication atrophy are in the cerebellum, not in the areas that, that we discussed. And if there are some articles on it, it was, it's more researched based. And, you know, when I was involved in that, that was, you know, like 10, 10 or 15 years ago, so.
SHAWN GRAHAM: What you can say from a review of Mr. Jones' MRI is that he had a traumatic brain injury. I heard you say that and that's correct?
TRAVIS SNYDER: Yes, a hundred percent.
SHAWN GRAHAM: What you don't know is what those effects are on Mr. Jones, correct?
TRAVIS SNYDER: Yes. I don't know what those are, but I would, I would, I would suspect he would have some sort of symptoms given how severe his injury was.
SHAWN GRAHAM: But you never met with him?
SHAWN GRAHAM: And you never reviewed any records to determine what, if any, effects he had because of the TBI. Is that correct?
TRAVIS SNYDER: Correct.
SHAWN GRAHAM: He could have suffered cognitive defects like a coma, confusion, shortened attention span, memory problems and amnesia, true?
TRAVIS SNYDER: Those are symptoms that can occur from traumatic brain injury, yes.
SHAWN GRAHAM: Problem solving deficits, problems with judgment, inability to understand abstract concepts, loss of sense of time and space, decreased awareness of self and others, inability to accept more than one or two step commands simultaneously. Those are other effects that a TBI could show. Is that true?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: He could have motor deficits, paralysis or weakness in his limbs, correct?
TRAVIS SNYDER: Those are a little more unusual, the motor, motor deficits from traumatic brain injury. But it's, for example, there's Parkinson's from traumatic brain injury. That's been described. But as far as paralysis it would be very unusual unless there was a direct injury to the motor cortex which is in the front and the back of the brain.
SHAWN GRAHAM: But I think you said that you've described him as either moderate or severe traumatic brain injury based on your readings of the MRI?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: So it is possible that for somebody who suffered the injuries that you say you saw, there could have been motor deficits, correct?
TRAVIS SNYDER: Yeah. The frontal lobes are not as, I mean, motor is not a great deficit for the frontal lobes. There may be some involvement but it's, it's more in the back in the primary motor cortex.
SHAWN GRAHAM: How about perceptual or sensory deficits?
TRAVIS SNYDER: Well, the visual is in the occipital lobes. So that's above the cerebellum in the back so that would be visual. And then a sensory is mostly considered parietal, so that would be more in the back above. So it's in the back higher. That's parietal. That's where sensory is typically. Frontal lobes may have some effect on that but I don't think as much as the other things we discussed.
SHAWN GRAHAM: So looking, if I'm beginning to understand now. Looking at his MRI and the TBI that he suffered in which you see, the only area that you would see he would have deficits in is cognition?
TRAVIS SNYDER: No. I mean, I think we have a list of all the things that the frontal lobes are associated. They're with personality, they're with risk, inhibition, judgment, memory. And then also there's, there's emotional problems which are actually more involving the hippocampus. So, but yeah, cognitive is, would be one thing that could, that he may have.
SHAWN GRAHAM: Well, if I'm looking at, that's a copy of your presentation, I believe, correct?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: That's that last slide?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: And of all of them, I think this is the only slide that talks about potential damages that you would expect to see from the TBI that you reviewed, correct?
TRAVIS SNYDER: Well, for the frontal lobe. And then hippocampus we kind of talked about separately.
SHAWN GRAHAM: You just didn't bother to produce a slide for that?
TRAVIS SNYDER: Well, the frontal lobe was the worst, I mean, because he has that skull fracture and the, he has all those hemorrhages in the front. So that's why I made it for the frontal lobe. I mean, I could have made one for the hippocampus as well. But I, in my report I discussed it, but I just didn't make a slide for it.
SHAWN GRAHAM: The frontal lobe is what you saw as being the worst damage? Fair to say?
TRAVIS SNYDER: Yes, I think it is. But not to minimize the hippocampal damage however.
SHAWN GRAHAM: The frontal lobe injury could involve motor function?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: Memory?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: Executive function and personality, risk taking, disinhibition and behavioral sponta --
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: -- spontaneity --
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: -- is that correct?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: So those would be some symptoms that you would expect the psychiatrist or psychologist to go look at, based on your findings, and see if they existed or not?
TRAVIS SNYDER: Yes. They could evaluate for those. And as we discussed some are probably more likely than others.
SHAWN GRAHAM: So some or none of those could exist, correct?
TRAVIS SNYDER: Yeah. I'd be, I'd be very surprised if none of those existed.
SHAWN GRAHAM: It's possible they don't, isn't it?
TRAVIS SNYDER: It's possible, just very unlikely as, very unlikely, in my opinion.
SHAWN GRAHAM: On page nine of your report under five, at the very bottom, it says, If Mr. Jones demonstrates low IQ, disinhibition, risk taking, difficulties with executive functions, behavioral spontaneity, memory problems or motor deficits it would be consistent with his injuries. However, clinical correlation is recommended. So you're saying somebody else needs to look at those areas --
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: -- correct?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: So is it a true or false statement if I say that after a traumatic brain injury that you have immediate swelling of the brain?
TRAVIS SNYDER: Yes. If the brain is damaged in a macroscopic sort of way, yes.
SHAWN GRAHAM: Which Mr. Jones was --
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: -- is that correct?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: At what point, is it a year, 18 months, that you would expect whatever symptoms that Mr. Jones was going to have, that he would have them?
TRAVIS SNYDER: I'm not sure --
BOYD YOUNG: Objection. That's outside the scope of radiology. A I mean, I can answer generally.
THE COURT: If it's in the scope, he can generally answer since he knows. A Well, yeah. I mean, a lot of symptoms will manifest immediately. But some take, some will manifest later. There is a inflammatory cascade that occurs following traumatic brain injury, if there's injury, and which can occur, which can, which can continue. In fact, there is a risk of patients with, so there's a recent study, 2018, by Barnes, B-a-r-n-e-s, which looked at patients with traumatic brain injury. Mild traumatic brain injury. So not like Mr. Jones, but just mild traumatic brain injury where they did not lose consciousness. And that study looked at, it was a large number of veterans over, over many years and they found that there's a twofold risk in dementia. So that shows that symptoms can occur decades following a mild traumatic brain injury even without loss of consciousness. So it's tough to say, you know, when symptoms could develop. Some certainly would be expected immediately. And many symptoms actually get better. So a lot of times patients will have most symptoms in the beginning and then they'll just kind of start to generally improve. But some of them, some symptoms never get better, some people are permanently damaged and then some people, they also develop symptoms later, including sometimes decades later.
SHAWN GRAHAM: So when you talk about symptoms that open decades later, what are you talking about?
TRAVIS SNYDER: Well, I'm talking about dementia from that study or such as, we talked about Parkinson's related to traumatic brain injury. Often that does not occur right away. So things sometimes take longer to manifest.
SHAWN GRAHAM: As far as what you described in your frontal lobe injury, if it involved motor functions you would expect to see it immediately, yes?
TRAVIS SNYDER: Regarding specific symptoms I'm not sure. I would rather speak generally because I just don't know.
SHAWN GRAHAM: So you reported that deficits could occur, but you don't know when the deficits might show up?
TRAVIS SNYDER: Right. I mean, individual deficits, I don't know when they would show up. But a lot of them probably more immediately and then some may take, may take longer. And some might be permanent but I don't know which ones would or not. It's a lot of --
SHAWN GRAHAM: As an expert, you wrote in your report and you're testifying to the jury that these deficits had occurred. But you're now telling me that you don't know when they could occur or when they would go away?
TRAVIS SNYDER: Well, I said that those are deficits associated with frontal lobe injury. And the articles describe the studies done. So that's accurate. And then as far as when they occur, yeah, I don't think that that, I don't know that that's really known.
SHAWN GRAHAM: So the studies that you read to describe when motor functions occurred, there was nothing in there about when they occurred or when they resolved?
TRAVIS SNYDER: I mean, I studied a lot of papers. Some of them may have talked about that, but I just, I don't know.
SHAWN GRAHAM: Memory you don't know when that might happen or when it might resolve?
TRAVIS SNYDER: Well, I think all these, a lot of them probably occur at the time of the injury. But some may not, and some may manifest later. And, and, yeah, I don't know.
SHAWN GRAHAM: Besides Parkinson's and dementia, what else might manifest later?
TRAVIS SNYDER: Any of those symptoms.
SHAWN GRAHAM: So you're saying that somebody can have a traumatic brain injury and 20 years later begin to have memory problems and you're going to say it's associated with a TBI?
TRAVIS SNYDER: Well, that was what the study from Barnes 2018 found. They found that people that had traumatic brain injury, 20 or 30 years later they developed dementia from that injury and they had a twofold, twofold risk of dementia.
SHAWN GRAHAM: So when you're talking about memory here, you're talking about not memory. You're talking about dementia and Parkinson's that happens 20 years later?
TRAVIS SNYDER: Well, no. I mean, but a dementia is a form of memory loss. So it's, but it's under, I mean, there's memory and then dementia is one form of that.
SHAWN GRAHAM: Sure.
TRAVIS SNYDER: So it's not equivalent.
SHAWN GRAHAM: How about other types of memory? Is there anything that you know of or are aware of that says that if you have a memory problem related to a TBI, that it doesn't occur almost immediately and reach whatever its best or worst is going to be in about 18 months to two years?
TRAVIS SNYDER: Yes. There is, I mean, symptoms do not have to develop immediately from the traumatic brain injury. And, in fact, there's many cases, and I've worked with neurologists who specialize in head trauma who see the patients and they say sometimes the patients, for example, will have a traumatic brain injury. And then they'll go home and they'll rest, or they'll take it easy for a few months, or they'll be, you know, kind of incapacitated. And they think they're okay and then about six months later they go back to work and they start trying to work and they find they can't work, or they find they can't do things they used to do. And so, they don't even realize that they had the deficit. So it's how you measure this can be a little bit, it's not straightforward.
SHAWN GRAHAM: Right. So it would be common for any deficits that were going to show up to show up in about six months, wouldn't it? That's what you just said, isn't it?
TRAVIS SNYDER: Well, I was giving an example. But yes, as far as when symptoms manifest from brain injury, mostly it would be more immediately. But, I mean, there can be long-term deficits like we discussed which are, which are not uncommon.
SHAWN GRAHAM: Which is the dementia and Parkinson's that you discussed?
TRAVIS SNYDER: And other ones, too.
SHAWN GRAHAM: Like what?
TRAVIS SNYDER: Well, everything that's on that slide. I mean, someone could have a traumatic brain injury and could have permanent deficits from those, from those injuries. So someone could have permanent memory loss based on a traumatic brain injury. They could have permanent personality disorder. They could be, have emotional problems that are permanent, so.
SHAWN GRAHAM: Right. But I guess my question is, and those are may, not must?
TRAVIS SNYDER: Correct, might.
SHAWN GRAHAM: But if they were going to show up, they would show up shortly after the traumatic brain injury, within six months, a year, 18 months or two years. Isn't that true? Except for the two that you mentioned, Parkinson's and dementia, they would show up early, wouldn't they?
TRAVIS SNYDER: I think typically they would, but maybe not in every case.
SHAWN GRAHAM: So you would agree with me that if, short of dementia or Parkinson's, if Mr. Jones was going to have cognitive issues, is it fair to say that it would have shown up six months to a year later? It would have developed during that time and gotten as best or as worst as it's going to be during that time?
TRAVIS SNYDER: I'm not sure we can say that with certainty. But it would be, yes, most likely that would occur. But, I mean, also, how was it measured. I mean, when he, if he was 15 when he had this, I mean, how was, was he evaluated appropriately or was he tested. I mean, those are all the questions that are kind of out of my, my scope.
SHAWN GRAHAM: Sure. Would it surprise you to know that approximately 11 months afterwards he had Illinois Goal Assessment Program and that he ranked in the 71st percentile of application decision-making? Would that surprise you?
TRAVIS SNYDER: What was it? It was test or is a --
SHAWN GRAHAM: Some of the school testing during high school.
BOYD YOUNG: Your Honor, I'd like to see a copy of it before tendering to the witness.
TRAVIS SNYDER: I'm sorry. The question was, oh, I'm sorry.
SHAWN GRAHAM: So, Doctor, what I'm asking you to look at is some testing that came out of the state of Illinois approximately two years, I believe, after his head injury.
TRAVIS SNYDER: Okay.
SHAWN GRAHAM: Now, I know you don't know what his testing was before. But looking at these scores, you would agree with me that at least in application of decision-making he had a 71 percentile related to everybody else?
BOYD YOUNG: Objection, beyond the scope.
TRAVIS SNYDER: Yes, that's what it says there. And yes, we don't know what he was before. And also, as we said, not all of the, I mean, not all of the symptoms from frontal lobe injuries will occur in ever, in every patient. So he, maybe he was doing pretty good in that, in that area, and maybe he was --
THE COURT: Okay. I think we're getting beyond the scope. So sustained as to a follow-up question on that.
SHAWN GRAHAM: Are you aware that he attended a community college for two years and had a 4.0 GPA?
BOYD YOUNG: Objection, beyond the scope.
THE COURT: I think we're getting beyond the scope of his expertise in neurology, radiology.
SHAWN GRAHAM: Without going into them specifically, you would agree with me, Doctor, wouldn't you, that if I have college transcripts showing what his grades were in high school, transcripts and things like that, that would deal directly on his cognition, correct? One of the possible areas that you describe that may have happened because of his TBI?
TRAVIS SNYDER: Yes. I mean, cognition can be tested in different ways and it can be different manifestations. But if he was doing okay in school, then I guess it did not impact the cognitive, or may not impacted the cognitive processes involved with those activities.
SHAWN GRAHAM: So regardless of having a TBI, he could have done well in school, possibly?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: You don't know? It wouldn't surprise you?
TRAVIS SNYDER: It's possible.
SHAWN GRAHAM: He could have graduated from college and got a good job with a good company, couldn't he?
TRAVIS SNYDER: It's possible.
SHAWN GRAHAM: And you're not here today to say because he had a TBI that that's the reason he killed his children, are you?
SHAWN GRAHAM: You testified in a case in Texas with Billy Joel Tracy back in 2017, I think. Is that correct?
TRAVIS SNYDER: Yes.
SHAWN GRAHAM: And in that case didn't you testify that just because someone has brain abnormalities --
BOYD YOUNG: Objection, relevance.
THE COURT: I haven't heard the question yet, so let me hear it.
SHAWN GRAHAM: Didn't you testify that just because someone has brain abnormalities it does not mean there is a problem and that the patient can be relatively normal? Aren't those words that you used during that trial?
TRAVIS SNYDER: That's--
THE COURT: I'm going to sustain as to relevance. He has got to testify about this case. I don't think that's relevant to his opinion here. I think you can ask that question, but not --
SHAWN GRAHAM: You would agree --
SHAWN GRAHAM: I think I understand Your Honor's ruling.
SHAWN GRAHAM: You would agree with me that just because someone has a brain abnormality it does not mean that there's a problem and that the patient can be relatively normal? Isn't that a true statement?
TRAVIS SNYDER: Yes, it's possible for someone that has brain abnormalities to, to be relatively normal.
SHAWN GRAHAM: And you would agree with me that not all people with abnormal brain scans are violent criminals who kill their children?
TRAVIS SNYDER: I would agree.
SHAWN GRAHAM: How much did you get paid to come here and testify and review these, Doctor?
TRAVIS SNYDER: Well, my, my billing records, so far I think I've been paid $4,200.00, $4,270.00 so far.
SHAWN GRAHAM: And you're a clinician from Las Vegas?
TRAVIS SNYDER: Yes. And also I should add that I don't take any of that money personally. That money goes to our research, I have a research company. And so, I don't get paid from that company either. So this, the money I do for expert witness, I mean, activities, they go to fund our research.
SHAWN GRAHAM: Which is, you said five percent of your practice is research, I guess?
TRAVIS SNYDER: Yes. Yes.
SHAWN GRAHAM: Thank you, Doctor.
THE COURT: Any redirect?
BOYD YOUNG: Yes, sir.
REDIRECT EXAMINATION By Mr. Young:
BOYD YOUNG: Your research is set up to benefit who?
TRAVIS SNYDER: Well, patients with traumatic brain injury is the goal, yes.
BOYD YOUNG: And are veterans most of the people that you're dealing with in that?
TRAVIS SNYDER: Well, the veterans, the research I'm doing with the veterans is separate from, I don't fund that personally. That's funded by --
SHAWN GRAHAM: Objection, Your Honor. I don't understand the relevance and it's beyond the scope of what I went into on direct or cross.
BOYD YOUNG: He went into the money, Judge.
THE COURT: No, I don't think that's relevant. I mean, everybody's entitled to be paid for what they do. He's answered your question. I don't think we need to go delve into any further. How about that.
BOYD YOUNG: Sure.
BOYD YOUNG: Did the fact that you got paid affect, is there a number to get paid and say, Tim doesn't have a traumatic brain injury?
TRAVIS SNYDER: No, there's not.
SHAWN GRAHAM: Objection, Your Honor, bolstering.
THE COURT: Sustained as to bolstering.
BOYD YOUNG: Bolstering would be me asking him --
THE COURT: I know what bolstering is. Just rephrase your question.
BOYD YOUNG: Did the fact that you got paid in any way affect any of your opinions in this case?
TRAVIS SNYDER: No, not a bit.
THE COURT: He can answer that.
BOYD YOUNG: I don't think we've talked about this. And I know that Mr. Graham covered this a little bit. If somebody had an initial injury to their brain and then had a subsequent injury in the same area, what does that do?
TRAVIS SNYDER: Well, if someone has a traumatic brain injury and then they have a second traumatic brain injury then they have worst outcome than someone without the first traumatic brain injury. So someone that has multiple concussions, they have, each one is sort of, they have a worst outcome if they have multiple traumatic brain injuries. And there's many studies that talk about that. And the theory is that their functional reserve of the brain is sort of decreased. So there's, you know, if you damage it at first then, you know, you're damaged, and then you have less of an ability to compensate or the plasticity, neuroplasticity, the brain cannot compensate as much because it's already been damaged from the first traumatic brain injury. So people that have multiple traumatic injuries especially tend to have poor outcomes.
BOYD YOUNG: Is there any question in your mind about whether or not this is an old injury versus an injury that is somewhere less than four years old?
TRAVIS SNYDER: I think it would be very well known when this occurred. I cannot imagine that there is any debate on when this occurred, other, counsel was saying that it was when he was 15, so.
BOYD YOUNG: Would, the skull fracture had refused. Is that right?
TRAVIS SNYDER: Sorry?
BOYD YOUNG: The skull fracture that was pushed into the front lobe had sort of refused. Is that right?
TRAVIS SNYDER: Well, it's healed but it's still depressed. It's, it healed but it's pushed in kind of on the brain.
BOYD YOUNG: Could that have been treated? I mean, could, if it had been treated at the time could it have been pulled off the brain to prevent further damage?
TRAVIS SNYDER: I don't, I don't, no, I don't think that would have made a difference.
BOYD YOUNG: Okay. You were asked a lot of questions about schizophrenia and traumatic brain injury. Schizophrenia is, your understanding is schizophrenia is a brain disease?
SHAWN GRAHAM: Objection, Your Honor, he's a neuroradiologist.
THE COURT: Sustained.
BOYD YOUNG: Is it your understanding that schizophrenia can cause changes in the brain?
SHAWN GRAHAM: Objection, leading.
THE COURT: Sustained as to the lead.
BOYD YOUNG: Can schizophrenia cause changes in the brain?
SHAWN GRAHAM: Your Honor, he's not a schizophrenic expert. He's a neuroradiologist that reads MRI's.
THE COURT: I think he, if he knows subject to his expertise which he testified to earlier were correlations to, such as that, but not treating that. But if it's correlated he can answer.
TRAVIS SNYDER: Yes. There are neuro-imaging research articles and, and peer reviewed literature that talks about the neuro-imaging findings for schizophrenia as we've, and schizophrenic disorder as we've, as we've discussed. And Mr. Jones has some of those findings on his imaging.
BOYD YOUNG: Are you familiar with a term called, frontotemporal dementia?
TRAVIS SNYDER: Yes.
BOYD YOUNG: And is, can you tell us what that is?
TRAVIS SNYDER: Frontotemporal dementia is, it's a type of dementia and it's, on imaging you --
SHAWN GRAHAM: Your Honor, I'm going to object to the leading, beyond the scope of anything that anybody's gone into at this point.
BOYD YOUNG: He talked about dementia. That was a large part of the questions --
THE COURT: That's not part of this case.
BOYD YOUNG: No. It's part of the questions from the State as to what is dementia and people being at risk for dementia, is this a specific type of dementia which he's familiar with and caused by brain damage.
THE COURT: All right. But he's testified that that was not relevant here. Not present here. So why do we need to go into it? I thought that was other things, the dementia and the Parkinson's. Both of those issues are not present and other causes related to the injury he's seen, why go into --
BOYD YOUNG: The testimony was that Mr. Jones was at risk for later dementia.
THE COURT: That's not relevant today.
BOYD YOUNG: It is relevant today, Your Honor.
THE COURT: All right. Then for purposes of this, I want a short break here. So that now we're in-camera I want to hear your question now. That way the jury won't be presented that if I rule otherwise.
BOYD YOUNG: Sure.
THE COURT: That's the only way I can figure to do it.
BOYD YOUNG: Understood.
THE COURT: With a long pause.
BOYD YOUNG: Understood.
THE COURT: All right. Now ask your question, proffer your question. IN-CAMERA TESTIMONY
BOYD YOUNG: What is frontotemporal dementia?
TRAVIS SNYDER: It's a type of dementia which is, it's different than Alzheimer's dementia or other dementias. And it's, on imaging it's manifested as atrophy of the frontal lobes and the temporal lobes.
BOYD YOUNG: And is that a progressive illness?
TRAVIS SNYDER: Yes.
BOYD YOUNG: Does it all happen at one time or do you get worse over time?
TRAVIS SNYDER: No, it is a, it's progressive. And it's, yes. I don't, I don't think that Mr. Jones has frontotemporal dementia.
THE COURT: Your objection is sustained.
BOYD YOUNG: Is he at risk of developing frontotemporal dementia?
TRAVIS SNYDER: Not specifically frontotemporal dementia. He's at risk more for general dementia. But that specific type of frontotemporal dementia is, is, I mean, I would like, it's more accurate to say he's, he's at risk for a general dementia.
SHAWN GRAHAM: Your Honor, I would object to relevance.
THE COURT: I sustain as to relevance. It appears to the Court that those questions, the Doctor's been very clear on that, that that's not a, present in his imaging review. And therefore I don't find it relevant in his opinion for this case. I just don't think any of that's relevant. I think we're going outside the scope of the direct and the cross.
BOYD YOUNG: So the Court's ruling is that I can't ask him about the dementia, that Mr. Jones is at risk of developing dementia from his brain injury?
THE COURT: All right. I'm going to make my ruling and we'll take another pause and I'll allow you to ask is he at risk for developing, if he knows. But the last three questions I think I want redacted for the, I'm ruling that that can't be presented to the jury.
BOYD YOUNG: Yes, sir.
THE COURT: All right. Ask your question.
BOYD YOUNG: Is Mr. Jones at risk for developing dementia?
TRAVIS SNYDER: Yes. And the study we talked about is a twofold risk in patients with mild traumatic brain injury. And Mr. Jones has a, at least a moderate traumatic brain injury, if not severe. And so he would be definitely at risk for developing dementia secondary to his traumatic brain injury.
BOYD YOUNG: If you heard evidence that he had a significant drop in his grades, began using drugs and alcohol and other sort of risk taking behavior, would that stuff be consistent with somebody who has a traumatic brain injury?
TRAVIS SNYDER: It's possible that, given his injuries that the electrical function of his brain was, was, was not working properly. Areas of the brain were overactive or underactive and, therefore, he was perhaps trying to treat that with drugs or alcohol. That's, I don't think that is that uncommon. But, I mean, I can't say based on imaging that that would occur with more likely than not, but it's possible.
BOYD YOUNG: Finally, is it possible for somebody who has a traumatic brain, can traumatic brain injury cause schizophrenia?
SHAWN GRAHAM: I'm sorry, Your Honor. I didn't hear the question.
THE COURT: Can traumatic brain injury cause schizophrenia.
TRAVIS SNYDER: I don't believe there's a very high correlation between that. There may be some theories, but I don't think it's accepted medical fact that traumatic brain injury causes schizophrenia. There may be some research that, that talks about it. But yeah, it's, schizophrenia does not have a known cause. It's multifactorial. Means it could be some genetic. It could be some environmental. It could be some factors. Potentially, I guess, it could be trauma. But I don't think that's an accepted fact.
BOYD YOUNG: And are there any studies that show when somebody had a traumatic brain injury at a young age schizophrenia develops later in life. Is that your understanding?
TRAVIS SNYDER: I'm sorry?
BOYD YOUNG: Schizophrenia sort of, positive symptoms of schizophrenia develop later in life?
THE COURT: I think that's outside the scope. The Solicitor's standing up. That's basically rephrasing your last question. That's, he answered your question. I don't believe that's a proper follow-up.
BOYD YOUNG: I'll rephrase.
BOYD YOUNG: Is it possible for somebody to have a traumatic brain injury early in life and then later develop schizophrenia later in life?
SHAWN GRAHAM: Objection, Your Honor. Scope, Your Honor.
THE COURT: Sustained as beyond the scope.
BOYD YOUNG: Are the images that you saw and the damage that you noted consistent with somebody who had a traumatic brain injury early in life and then later went on to develop schizophrenia?
SHAWN GRAHAM: Objection, Your Honor. He doesn't know whether that's a, it's calling for a conclusion that's not in evidence.
THE COURT: Sustained. You've gone through that enough. He testified he didn't know anything about his other condition. He hadn't reviewed any of his other records. He reviewed the images, wrote his report.
BOYD YOUNG: Yes, sir. I'm just asking about --
THE COURT: Okay. You've delved into it enough, I mean.
BOYD YOUNG: So I'm not allowed to ask that question?
THE COURT: I sustained his objection. Ask you another question. I'm kind of ready for a break, so I'll tip my hat to that.
BOYD YOUNG: Thank you. That's all I have.
THE COURT: All right. You can stop the video. All right. We'll stand down for a few minutes. You can step down.
RICK HUBBARD: Judge, can I ask for a clarification on the exhibits but I was not clear how many Defense exhibits we would have because I think one was premarked.
THE COURT: Three were marked, 1, 2 and 3 were all marked. 2 and 3 were admitted without objection, the CV was not admitted but it was marked as Court's exhibit 78.
RICK HUBBARD: So right now it is just two, 2 and 3.
THE COURT: Right. The first one, the first 2 is the report and 3 are the slide images.
RICK HUBBARD: Thank you, Your Honor.
(Whereupon, a short break was taken.)
THE COURT: We have got two more issues to deal with this morning before we recess for the lunch meal. Solicitor, you had an issue with a search warrant. I am told it needs to be resolved before we get any further. It looks like Ms. Mayes is about to stand.
RICK HUBBARD: That's right.
THE COURT: Ms. Mayes, tell me the issue you have. There was some mention to me yesterday, there were two search warrants. One on the phone itself and one on the extraction of the information off the phone I believe. Is that right?
SUZANNE MAYES: Well, Your Honor, the phone was originally seized in 2014 and went to SLED. There was an original extraction which was a logical extraction. Later in 2018, in November of 2018 a search warrant to obtain both the physical and a logical from the phone. That is the search warrant that was done by Lieutenant Jesse Laintz and executed by Mike Phipps. That is the extraction that we are going to be using as evidence in this case. So that is the search warrant that is being challenged.
THE COURT: Mr. Secor, you are handling that issue, the search issue and all of this ties back to the safety checkpoint, does it not?
CASEY SECOR: Certainly would be through the poisonous tree under our argument but then we would challenge the actual abrogated as well under State and Federal grounds.
THE COURT: Okay. Well, as to the fruit of the poisonous tree, we have heard that and I have ruled that it was a constitutional traffic safety checkpoint. The Defense is protected on those issues, that that was done properly, within the bounds of the Constitution. Do you now want to be heard on the sufficiency of the affidavit?
CASEY SECOR: If that is what the State would like. Whatever Your Honor says.
THE COURT: Okay. Let's do that.
SUZANNE MAYES: The State calls Lieutenant Jessie Laintz.