FW: Testimony of Dr. Dominic Rosso - CCWG Info Bulletin - Novembe r 1, 2002

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H. Dallas, D.C.

President, Western States Chiropractic College

Phone (503) 251-5712

Fax (503) 251-5728

Testimony of Dr. Dominic

Rosso - CCWG Info Bulletin - November 1, 2002

Information

Bulletin

From the Chiropractic Communications

Working Group

Wednesday, October

30, 2002

Testimony of Dr.

Dominic Rosso Commences

Dr.

Dominic Rosso, witness for the profession, took the stand today. Dr.

Rosso's credentials were reviewed and he was accepted as an expert in

neuroradiology. He explained that such expertise gave him the ability to fully

discuss disease processes of the brain and spinal cord. Mr. Danson reviewed Dr.

Rosso's curriculum vitae

establishing the many prestigious awards and achievements Dr. Rosso has

garnered in his years of practice. It was noted, too, that he trained at CMCC,

becoming a chiropractor, before entering medical school.

Mr.

Danson began by explaining to Dr. Rosso that Dr. Norris had interpreted

Ms. ' angiogram to the jury and he asked Dr. Rosso to do the same.

Dr. Rosso described an angiogram as an invasive test, involving placing a

catheter inside the body (usually through the groin) and then moving it up

through an artery to the point of interest - in this case the left

vertebral artery. He explained that the dye injected into the artery appeared

to stop abruptly being unable to progress past a blockage in the left vertebral

artery.

Asked

whether he agreed with previous findings that there was a complete occlusion in

the left vertebral artery, he said he did. When asked whether he disagreed with

any of the assumptions made by previous witnesses he replied that he did not

agree with the presumption of dissection in the left vertebral artery. When

asked by Mr. Danson whether there was a certain tendency in his field with

regards to chiropractic neck manipulations. He replied there was often a

" knee-jerk reaction " and a leap to assume that a stroke suffered by a

patient who had received a neck manipulation was linked to the procedure

itself. He went on to say that doctors must always look for other possible

reasons for an occlusion. He said it was both significant and rare for a woman

of forty-five years of age to have such extensive atherosclerosis in both the

left and right vertebral arteries. Mr. Danson turned to the topic of the

'rat's tail' on the angiogram noted by Dr. Norris. Dr. Rosso

said he saw no evidence of this and disagreed with Dr. Norris that the

angiogram was highly suggestive of a dissection.

Dr.

Rosso explained his findings on review of the angiogram. He observed 70%

occlusion of the right vertebral artery, stating that this was one of the most

important factors in determining that Ms. died of natural causes. The

fact that she was taking anti-clotting medication yet still succumbed was also

relevant. He concluded that Ms. had been in the end stage (stage six) of

atherosclerotic disease process. When asked whether he could identify any

connection between her chiropractic adjustment and her stroke leading to death,

Dr. Rosso said he could not.

Ms.

, counsel for the College of Chiropractors of Ontario, then began

her cross-examination by asking Dr. Rosso to explain the 'rat's

tail' concept. He said that in such a case, the artery becomes so

compressed that it develops a string-like appearance that tapers at the top

end. This, he indicated, would be a typical finding in cases of arterial

dissection, but there was no evidence of a 'rat's tail' in

the angiogram of Ms. . He disagreed with Dr. Chung's suggestion (Dr.

Chung is a witness expected to be called by the family) that a 70%

occlusion in the artery was not significant, and that such a narrowing would

cause thrombosis. He said the areas affected by atherosclerosis were at

critical locations indicating the arteries were severely diseased. When

informed that Dr. Chung had said the irregularity in the artery was caused by

dissection, Dr. Rosso said this could not be seen on an angiogram. Dr. Rosso

confirmed that if plaque existed intra-cranially, that area could be

thrombogenic. Ms. asked whether an area that is healing is thrombogenic,

to which he replied this would be unusual, especially if the patient was on an

anti-coagulant.

Ms.

Oakley began her cross-examination beginning with Dr. Rosso's medical

report. She noted it was the only one he had written for this inquest and

stated that he never mentioned the angiogram. Dr. Rosso indicated that he had.

Ms. Oakley suggested he was not looking at the angiogram, but was merely

restating the position of those who had. She asked him what inquest documents

he had in his possession and whether he had read them, including the medical

reports written by other doctors who had studied the case. She noted that his

reports did not reveal what documents he had reviewed.

Ms.

Oakley then wanted to know why Dr. Rosso changed his opinion after the first

autopsy report. He said that it was due to Dr. Pollanen's reassessment of

the case. She asked him about the conditions leading up to a stroke. Firstly,

she wanted to know whether there could be several days before the onset of a

stroke that results from a dissection. He said that he was aware of this, but

that a dissection produces immediate symptoms in 70% of patients. He confirmed

that a tear can cause a " cascade effect, " wherein a clot forms and

can cause full occlusion, break, and move to the brain. He also agreed that in

some cases it might be a number of days before this happens.

Dr.

Rosso confirmed that his February

15, 2001 report stated an embolus caused Ms.

' stroke. He had now abandoned that theory based on Dr.

Pollanen's re-examination of the facts and the new pathology report. Ms.

Oakley asked him whether his report was based 100% on Dr. Pollanen's

report. He said that it was due to the fact that Dr. Pollanen was the only one

to have performed a thorough analysis.

Media Attention

The

Toronto Star in its October 31,

2002 edition carried a report on the inquest proceedings

and Dr. Rosso's testimony. The article details Dr. Rosso's

testimony and highlights his opinion that Ms. ' death was the result

of natural causes.

Thursday, October

31, 2002

Testimony of Dr. Dominic Rosso Concludes

Dr.

Dominic Rosso, witness for the profession, returned to the stand with Ms.

Oakley, Counsel for the family, conducting her cross-examination.

Ms.

Oakley first concentrated on the issue of Dr. Rosso's use of the reports

of neuropathologists Drs. Deck and Pollanen. She noted that in certain areas of

the reports atherosclerosis had been described as moderate. She indicated that

in Dr. Pollanen's November 9th

2001 report there was an observable healing process in

the left vertebral artery. Dr. Rosso acknowledged this. He also testified that

he was a neuroradiologist who diagnosed based on angiograms, CT scans and other

tests performed on living patients. Neuropathologists had access to information

that he did not. Moreover, he did not claim expertise as a neuropathologist.

Other counsel objected to the use of the earlier reports on the grounds that

later reports and subsequent testimony by Drs. Deck and Pollanen had altered

earlier versions and clarified certain issues. Mr. Danson submitted that Dr.

Rosso should give evidence on his report and observations and not on the

observations of others. The coroner ruled that these reports could be used in

the questioning but that the questions would need to be put in context and

would need to be within the limits of Dr. Rosso's expertise as a

neuroradiologist.

Ms.

Oakley then questioned Dr. Rosso regarding the progress of injury to the left

vertebral artery and the issue of a healed dissection. Dr. Rosso testified that

there was no evidence of dissection extracranially, where one would expect to

find it if there had been a dissection caused by neck manipulation. For this

reason he concluded that the cause of stroke was a natural disease process

because there was even stenosis resulting in 70% occlusion of the right

vertebral artery in addition to the complete blockage of the left vertebral

artery.

Then

Ms. Oakley addressed the issue of Dr. Pollanen's change in position in

the two different reports with two different conclusions. Dr. Rosso stated that

the first report was a theory while the second was an improvement based on new

information.

Ms.

Oakley raised the issue of Dr. Pollanen's qualifications. She noted that

Dr. Pollanen was a third-year resident who was still in a learning phase and

that his reports had not been countersigned by his supervisor, Dr. Deck. Dr.

Rosso testified that many residents could be exceptional while their

supervisors might be less than exceptional. Later in the day during

re-examination, Mr. Danson provided Dr. Rosso with a copy of Dr.

Pollanen's curriculum vitae,

which identified his PhD thesis, awards, and history of publications. Dr. Rosso

testified that he was impressed with Dr. Pollanen's qualifications.

Ms.

Oakley explored the process of the production of the neuroradiological report

of Drs. Wolinsky and Hudon. Dr. Rosso testified that it would have been written

iteratively as follows: they would have viewed test results together and

discussed initial observations agreeing on interpretation; then Dr. Hudon would

have drafted the report; then they would confer once again, revise the report

if necessary, and a final copy would be written and signed by both.

Ms.

Oakley turned to the topic of the 'rat's tail' on the

angiogram, which had been noted by Dr. Norris. She asked how neuroradiologists

Drs. Wolinsky and Hudon could have missed the 'rat's tail'.

Dr. Rosso testified that he did not use the term but understood what was meant

by it. He further testified that if there had been such a phenomenon that Drs.

Wolinsky and Hudon would have seen it and noted it in their report since Dr.

Wolinsky was a world renowned neuroradiologist with impeccable credentials and

Dr. Hudon, a resident, was already a qualified radiologist. Ms. Oakley indicated

that she anticipated that there would be contrary evidence by Dr. Gordon Chung,

a neuroradiologist appearing on behalf of the family. Dr. Rosso testified that

the 'rat's tail' even if it had been there, would not

necessarily be indicative of a dissection.

Ms.

Oakley asked about the function of anticoagulants maintaining that they were to

slow down clot formation. Dr. Rosso testified the purpose of anticoagulants was

to stop clot formation. Ms. Oakley asked if intimal damage could have been

intermittent. Dr. Rosso said this was not his area of expertise but that he did

not think so. He testified that there was no evidence in the pathology reports

of intimal disruption and no indication of a 'classic' dissection

that one would expect with insult to the artery. Dr. Rosso agreed that a small

tear could have a cascade effect leading to thrombus formation.

Ms.

Oakley concluded her cross-examination by apologizing to Dr. Rosso for comments

she had made the previous day when she implied that he had not looked at Ms.

' angiogram or CT scan before writing his reports.

On

questioning by the jury, Dr. Rosso testified that his department usually sees

approximately eight dissections per year in the posterior brainstem

circulation; while he, himself, reviews four of them. Of these four dissections

two would have been as a result of some form of trauma. He further testified

that dissection itself is rare. Mr. Danson asked a clarifying question

regarding the eight dissections a year seen by Dr. Rosso's department.

Dr. Rosso said that these dissections were from all causes.

On

re-examination from other counsel Dr. Rosso testified that Ms. '

stroke was ischemic, that is, caused by a lack of blood supply to the brain

through blockage. He further testified that a CT scan could not identify a

cause of death. Concerning the CT scan and angiogram test results that Dr.

Rosso had reviewed prior to writing his report, Mr. Danson produced a letter

and a courier waybill which showed that the CT scan and angiogram had been sent

to Dr. Rosso during January 2001, before his report was produced. Dr. Rosso was

then discharged with thanks.

Inquest schedule

The

inquest will reconvene on Tuesday, November 12, 2002.

Next Bulletin

Unless

there is new information our next bulletin will be sent Thursday November 14, 2002.

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