1 STATE OF ILLINOIS 2 IN THE CIRCUIT OF THE ELEVENTH...

PAUL KALOOSTAIN, M.D., AUGUST 16, 2019

Huntington Court Reporters & Transcription, Inc. 1600 S. Lake Avenue, Suite 102, Pasadena, CA 91106 1-626-792-6777

1 STATE OF ILLINOIS

2 IN THE CIRCUIT OF THE ELEVENTH JUDICIAL CIRCUIT

3 COUNTY OF MCLEAN

4

5 MARY JO DAVIS, ) )

6 Plaintiff, ) )

7 v. )Case No. 15 L 157 )

8 EMILIO M. NARDONE, M.D., and ) CENTRAL ILLINOIS NEURO HEALTH )

9 SCIENCE, LTD., a corporation, ) )

10 Defendants. ) ________________________________)

11

12

13

14

15 DEPOSITION OF PAUL KALOOSTIAN, M.D., taken on behalf

16 of Defendants, at 600 South Lake Avenue, Suite 102,

17 Pasadena, California 91109, commencing at 8:11 a.m.,

18 on Friday, August 16, 2019, before DONNA BALL,

19 Certified Shorthand Reporter, License No. 11191

20

21

22

23

24

25



1 APPEARANCES OF COUNSEL:

2

3

4 FOR PLAINTIFF:

5 CLIFFORD LAW OFFICES BY: SARAH F. KING, ESQ.

6 120 North LaSalle Street 31st Floor

7 Chicago, Illinois 60602 (312) 899-9090

8 [email protected]

9

10 FOR DEFENDANT:

11 LIVINGSTON, BARGER, BRANDT & SCHROEDER, LLP BY: PETER W. BRANDT, ESQ.

12 115 West Jefferson Street Suite 400

13 Bloomington, Illinois 61701 (309) 828-5281

14 [email protected]

15

16 ALSO PRESENT:

17 EMILIO M. NARDONE, M.D.

18

19

20

21

22

23

24

25



1 I N D E X

2 WITNESS

3 PAUL KALOOSTIAN, M.D.

4

5 EXAMINATION BY PAGE

6 MR. BRANDT 5, 80

7 MS. KING 65

8 EXHIBITS

9 (Retained by Counsel) DEFENDANTS' DESCRIPTION PAGE

10 1 Amended Motion of Discovery 85

11 Deposition (With Notice to Produce Rider)

12 2 Plaintiff's Rule 213(f)(3) 85

13 Disclosure of Paul Kaloostian, M.D.

14 3 Production dated August 12th, 85

15 2019, from Sarah King to Peter Brandt which lists e-mail, case

16 list, invoices, curriculum vitae and 213 (f)(3)opinions Letter

17 dated August 12, 2019

18 4 Complaint At Law Conti-Medical 85 Negligence Emilio M. Nardone, M.D.

19

20

21 QUESTIONS NOT ANSWERED

22 (NONE)

23

24 INFORMATION REQUESTED

25 (NONE)



1 PASADENA, CALIFORNIA; FRIDAY, AUGUST 16, 2019

2 8:11 A.M.

3 -oOo-

4

5 PAUL KALOOSTIAN, M.D.,

6 the deponent herein, after having

7 been first duly sworn, was deposed

8 and testified as follows:

9

10 EXAMINATION

11 BY MR. BRANDT:

12 Q Let the record reflect this is a discovery

13 deposition taken of Dr. Paul Kaloostian.

14 Am I pronouncing it right?

15 A Yes, sir.

16 Q Okay. Taken pursuant to notice in the applicable

17 Illinois Supreme Court rules. And just let the record

18 show that my client is here, Dr. Nardone.

19 Doctor, I'm going to hand you some exhibits. The

20 first is -- here -- the notice of the deposition, and it

21 has on there what we call a rider that has information

22 that we ask that you bring to the deposition.

23 Okay?

24 A Yes, sir.

25 Q All right. Did you see that document before I



1 just handed it to you?

2 A I don't know if I saw it word for word like this,

3 but something similar, yes.

4 Q Okay. All right. And we have marked as Exhibit

5 3 what has been produced to us kind of in response to that

6 request that you produce. There's some other, I think,

7 some bills that came through yesterday or the day before

8 that aren't attached.

9 But my question is, do you think that Exhibit 3

10 is a complete response to the rider?

11 A Let's see. I do.

12 Q Okay. We have a listing in the disclosure which

13 we've marked as Exhibit 2 of the documents that you

14 reviewed in order to come to your opinions in this case.

15 Okay?

16 MS. KING: You're talking about the 213.

17 MR. BRANDT: His 213.

18 MS. KING: There you go.

19 THE WITNESS: Yes.

20 BY MR. BRANDT:

21 Q Okay. And so my first question, I guess, is did

22 you review all those materials listed?

23 A Yes, sir.

24 Q And did you write on any of those materials?

25 A No, sir.



1 Q The notes that you took, if any, are contained in

2 Exhibit No. 3?

3 A Yes.

4 Q Okay. You have no other notes that you've

5 written anywhere that are not contained in this Exhibit

6 3?

7 A Not that I'm aware of, no.

8 Q Okay.

9 (A discussion was held off the record.)

10 BY MR. BRANDT:

11 Q Have you reviewed other cases for Sarah's

12 office?

13 A I may have. I'm not sure exactly.

14 Q Okay. How could we find out? What would be a

15 way for you to find out for us?

16 A We would ask the law office.

17 Q Okay. All right. Do you know if you've

18 testified in court for their firm?

19 A I believe no.

20 Q Given depositions for their firm?

21 A I would say probably no to that.

22 Q Okay. Looked at some cases maybe?

23 A Possible. I don't remember.

24 Q You just don't remember?

25 A Don't remember.



1 Q How many cases do you have in your file drawer or

2 do you have currently that you're working on for

3 litigation?

4 A I would estimate maybe ten.

5 Q Okay.

6 A That's an estimate. I don't know an exact

7 number. But maybe ten.

8 Q What was your income -- what's your income from

9 testifying like last year, two years ago?

10 A I don't know. Honestly, I really don't know that

11 answer.

12 Q What would be the percentage of your income?

13 A Perhaps maybe 20 percent.

14 Q Okay. And do you advertise your services as an

15 expert?

16 A Yes, sir.

17 Q Okay. Where?

18 A Expert Institute.

19 Q Okay.

20 A And Cal Med Medical Evaluators. That's an old

21 company. Haven't done much with them for a while. That's

22 all I can remember right now.

23 Q Okay. Do you think there might be others out

24 there if I look?

25 A Possibly.



1 Q Okay.

2 A Yeah.

3 Q How many cases do you get from those individual

4 services a year?

5 A It varies. I just started medical/legal work

6 about a year and a half ago. So hard to really give a

7 long-term estimate. But just within that year and a half

8 or less, I would say somewhere maybe 50.

9 Q Okay.

10 A Yeah.

11 Q Fifty cases, you think?

12 A Yeah.

13 Q Okay. All right. Do you --

14 A That's an estimate. I don't know. It could be

15 more or less. That's all I can really say.

16 Q I appreciate you giving us an estimate. That's

17 fine.

18 Do you have a corporation through which fees are

19 funneled for expert work?

20 A No.

21 Q Okay. If you're paid, let's say, by Sarah for

22 your work here today, does that go to you or does it go to

23 the university or where does it go?

24 A It goes to me.

25 Q All right. You said you've been doing it for



1 about a year and a half; is that what you said?

2 A About that, yeah.

3 Q Have you reviewed other cases involving

4 meningioma?

5 A Not that I can recall.

6 Q And have you reviewed cases that involve

7 meningioma -- I'm sorry. Let me ask a better question.

8 Do you treat meningioma?

9 A Yes, sir.

10 Q All right. I looked through your CV, and we'll

11 get into that in a minute, but it seemed to me that the

12 focus of your practice seemed to be spine.

13 Would that be a fair statement?

14 A Yes, sir.

15 Q What percentage of your practice would be brain

16 tumors?

17 A I would say -- an estimate would be maybe 10 to

18 15 percent or less.

19 Q Okay. And what percentage would be meningioma?

20 A Meningiomas, I would say maybe less than five

21 percent.

22 Q Okay. And do you perform surgery to remove

23 meningioma?

24 A Yes, sir.

25 Q Okay. Craniotomy to remove meningioma?



1 A Yes, sir.

2 Q And what percentage of the meningioma that you

3 see do you perform surgery for? In other words, those

4 patients that present to you with a meningioma, what

5 percentage of those are going to go to surgery? And then

6 you can break it out what percentage of those you are

7 going to watch and what percentage of those are going to

8 go to stereotactic radio treatment?

9 A In my practice -- I have to think about that a

10 little bit. I haven't really looked at that.

11 Q Okay.

12 A But I would say maybe, by far, the majority are

13 nonoperative.

14 Q Okay.

15 A So I would say 90 to 95 percent are nonoperative.

16 And you get these rare cases, maybe the five percents,

17 that are operative. In terms of radiosurgery, I would say

18 the vast, you know, the vast majority of the 5 percent --

19 maybe 3 percent or so, I guess, I'm estimating -- would

20 probably need radiosurgery.

21 Q Okay.

22 A If they are small. So the size would be very

23 important in determining what -- what to do. So it would

24 be based on size and -- and other characteristics of the

25 imaging and patient presentation.



1 Q Okay. So sounds to me, from what you're saying,

2 that you have to individualize treatment for each patient;

3 true?

4 A Yes, sir.

5 Q Some patients are going to go to surgery and some

6 are going to go -- can we say SRS? Is that okay to use

7 that acronym?

8 A Yes, sir.

9 Q Some are going to go to SRS; true?

10 A Yes.

11 Q And some are going to have surgery and then

12 followed by SRS; true?

13 A Yes, sir.

14 Q And then some you are just going to watch?

15 A Yes.

16 Q Is that right?

17 A Yes, sir.

18 Q And you have to individualize those treatment

19 decisions, right, for each patient; right?

20 A Yes, sir.

21 Q You talked a minute ago about small tumors.

22 Where is your line? What's the definition?

23 A I mean, I don't know if there is an exact

24 definition, but the standard of care would be about three

25 centimeters or less would be more on the smaller end,



1 which would be more amenable to radiosurgery. That's in

2 my mind and I think most people's minds how they would

3 characterize, quote, "Small."

4 Q Okay. Is it true that some patients who have a

5 meningioma that are that size that are small, as you've

6 defined it, would nonetheless go to surgery?

7 A It's possible, yes, sir.

8 Q And it's possible that those patients can go to

9 surgery and that surgery be within the standard of care;

10 true?

11 A That hypothetical is possible, yes, sir.

12 Q Have you performed surgery on a meningioma and

13 had complications of bleeding?

14 A I don't recall a case where that happened.

15 Q Okay.

16 A But I've had colleagues where that's happened.

17 Q Sure. It's a known complication; true?

18 A Bleeding is a complication of any surgery, yes,

19 sir.

20 Q And have your colleagues had situations where

21 there's been bleeding that has caused devitalization of

22 brain tissue?

23 A Yes, sir.

24 Q Okay. And is it the standard of care once that

25 devitalization takes place that the brain tissue be



1 removed? Is that proper care?

2 A It can be proper. It just depends on the

3 situation.

4 Q Okay. I guess I'll ask this before I forget.

5 What are your rates for looking at this case?

6 A Honestly, I don't remember. But I would say

7 maybe an estimate maybe $700 an hour perhaps. I can't

8 remember.

9 MR. KAPLAN: Okay. Do you know Sarah?

10 MS. KING: It might be on the bill. I was going

11 to --

12 MR. BRANDT: Okay. If it's on the bill, that's

13 fine.

14 THE WITNESS: Yes, it should be on the bill.

15 MS. KING: Yeah, the rate on the bill is $700 an

16 hour.

17 MR. BRANDT: Okay. Sorry.

18 Q And you are coming to Bloomington, Illinois to

19 testify or am I coming back here?

20 A Whatever you want me to do.

21 Q I don't think it's my call.

22 A I'm happy to oblige.

23 Q Okay. Have you testified in court before as an

24 expert?

25 A I have, sir.



1 Q About how many times?

2 A I would estimate probably six, five or six times.

3 Q Okay. And given how many depositions, do you

4 think, since you've been doing expert work?

5 A I would roughly say maybe 10 to 13.

6 Q Okay. All right. And it seems -- sounds to me

7 from what you said earlier that the cases in which you've

8 given both depositions in testimony have been involved --

9 I'm sorry, have involved cases other than meningioma or

10 brain tumor?

11 A Yes, sir.

12 Q Have those been mostly spine surgery cases?

13 A Yeah. The majority would be spine surgery, yes,

14 sir.

15 Q Any other area that you've testified in?

16 A I've had cases of traumatic brain injury --

17 Q Okay.

18 A -- which is not a tumor, it's more traumatic

19 injury.

20 Q Okay.

21 A I've had a couple cases of carpal tunnel problems

22 that have happened. And I've had a couple cases of

23 chiropractic injury of the neck that have injured some

24 vessels going up to the brain. So I think, from my

25 recollection, those would be the others.



1 Q Okay. Do you testify more for Plaintiff or

2 Defendant?

3 A I try to make it 50-50. So it's probably not

4 exactly 50-50, but it's close to that.

5 Q Have you testified in disability cases?

6 A I don't believe so.

7 Q Okay. Have you got a rate that you charge to

8 come testify at trial that's different than your hourly

9 rate here?

10 A Yes, it is different.

11 Q What is it?

12 A Honestly, I don't remember the exact number, but

13 we can get you that information.

14 Q Okay. Do you charge a per diem?

15 A What's a per diem?

16 Q Like if you traveled from here to Chicago to

17 Bloomington and it took you an entire day, do you charge

18 us a daily rate as opposed to an hourly rate?

19 A Yes, sir.

20 Q Okay. You don't know what that is?

21 A I don't know.

22 Q Can you tell Sarah and let her know?

23 A Yes, sir.

24 Q Okay. Have you testified in states other than

25 California?



1 A Yes, sir.

2 Q Okay. Have you -- how did you charge in those

3 circumstances? Did you charge by the hour for your travel

4 or --

5 A No. I believe for full-day trial cases with

6 traveling, it's a per diem, as you called it.

7 Q Okay. And you think that's $10,000 or $5,000?

8 A Honestly, I will get you an exact number. I

9 don't -- I just -- I can't remember all this data, you

10 know. A lot of other things to remember. But -- so I

11 will get you that information.

12 Q Okay. I lied. I have four exhibits. There is a

13 document that's attached to the complaint, the lawsuit

14 papers. Okay? And we refer to it as a 2622?

15 Huh?

16 MS. KING: I was just -- go ahead. Every time

17 numbers come up that we refer to, the expert always looks

18 at me. They go what are you talking about.

19 MR. BRANDT: We just like numbers.

20 MS. KING: Yeah.

21 MR. BRANDT: We're number focused. I'm going to

22 mark this as Exhibit No. 4.

23 Q I just have a simple question here, and that is

24 did you prepare this report that's attached to the

25 complaint?



1 A May I see it?

2 Q Oh, yeah. I won't make you not see it. Okay?

3 I'm just turning it to -- so I'm turning to -- to that

4 page of the report that's attached to the lawsuit papers.

5 A Your question was did I write this?

6 Q Is that your work product?

7 MS. KING: They are -- they are not the same.

8 THE WITNESS: Yeah, they are not the same. This

9 is my work product.

10 BY MR. BRANDT:

11 Q I'm sorry. This would have been -- the document

12 that you're looking at, the lawsuit papers with the report

13 attached, would have been prepared three, four years ago.

14 A No. Then this would not be my product.

15 Q Okay. I have attached as Exhibit No. 2 a CV of

16 yours that -- I'm trying to -- it's not dated. And I'm

17 going to hand it to you, and just ask if you have a more

18 up-to-date one. This is -- I mean, this was provided to

19 me a couple months ago, so it can't be too old.

20 A I mean, it looks roughly -- I mean, this is my

21 CV, and it looks roughly accurate here. I don't know

22 about it being up to date.

23 Q All right. Let me ask you a more pertinent

24 question. Anything that you've written about treatment

25 for brain tumors since that particular CV was prepared?



1 A No.

2 Q Okay. Have you written anything on brain -- I'm

3 sorry -- on brain tumor surgery at all?

4 A I have to look at my resume, but there may be a

5 case report or two, but I don't know if it relates to a

6 meningioma.

7 Q Okay. Do you think there's anything that you've

8 written about or that you've authored, co-authored, had

9 published or peer reviewed that deals with the topics that

10 we're going to discuss today, which is treatment of the

11 meningioma?

12 A I don't believe so.

13 Q All right. Have you provided to Sarah, or

14 anybody at her office, literature related to the treatment

15 of meningioma?

16 A I have not provided, no.

17 Q How about citations, any citations that you've

18 provided to her?

19 A No, sir.

20 Q Did you do any research in this case --

21 A Not --

22 Q -- on that topic?

23 A I'm sorry.

24 Q It's all right.

25 A No, not other than just general knowledge and my



1 training and experience.

2 Q So what you're saying to me is you try to keep

3 current on the current literature; is that right?

4 A Yes, sir.

5 Q You didn't do any specific research relative to

6 the Davis case?

7 A Correct.

8 Q All right. I looked at your CV, and it looks

9 like you were on the editorial board of a number of

10 publications?

11 A Yes, sir.

12 Q Okay. So the JSN Neurosurgery and Spine would be

13 one; is that right?

14 A Yes, sir.

15 Q Are these that are listed in your -- in your CV,

16 are those reasonably reliable publications?

17 A Yes, sir.

18 Q How about the National Institute of Health? Do

19 they publish reasonably reliable information?

20 A Yes, sir.

21 Q How about the Journal of Neurosurgery?

22 A Yes, sir.

23 Q How about Neurosurgery?

24 A Yes, sir.

25 Q Do you take those two last journals, Journal of



1 Neurosurgery -- do you take these two journals that I've

2 discussed, the Journal of Neurosurgery and Neurosurgery?

3 Do you take those, receive those?

4 A Yes, sir.

5 Q Do you read those?

6 A Yes, sir.

7 Q Let me ask you if you agree with some of these

8 statements. "Embolization with polyvinyl alcohol

9 particles can result in brain and cranial nerve injury,

10 vision loss or poor wound healing and stroke."

11 Is that a true statement?

12 A That statement in itself can be true, yes.

13 Q How about this, "Polyvinyl alcohol particles is

14 the most commonly used substance for pre-op embolization

15 of meningiomas as opposed to other products, if you will,

16 for pre-embolization."

17 Is that a true statement? If you know?

18 A I'm not exactly sure what's the most common.

19 Q Okay.

20 A I know it's one that can be used. I don't know

21 if it's the most common.

22 Q Okay. Do you agree with this statement, "High

23 rates of failure to achieve active hemorrhage arrest occur

24 with particulate embolic materials?"

25 A High rates of what?



1 Q "High rates of failure to achieve active

2 hemorrhage arrest occur with particulate embolic

3 materials."

4 Is that a true statement?

5 A I guess hypothetically that could be true.

6 Q Is it -- have you read, "Polyvinyl alcohol

7 particles used for pre-op embolization from meningiomas

8 can actually make it more difficult to stop the bleeding

9 intraoperatively."

10 Have you read that?

11 A That may have been documented, but I don't know

12 that as a standard of care in my teaching practice.

13 Q Okay. But you have read that that's certainly

14 been the experience of some authors that have investigated

15 this particular product?

16 A That may be possible.

17 Q Okay. Do you agree the most common neurocranial

18 tumor associated with post-operative hemorrhage is a

19 meningioma?

20 MS. KING: Can you repeat that? I'm sorry.

21 MR. BRANDT: Sure.

22 Q The most common neurocranial tumor associated

23 with post-operative hemorrhage is a meningioma?

24 A I'm not aware of that fact.

25 Q Okay. Can certainly post-operative or



1 intraoperative hemorrhage occur during surgery to resect a

2 meningioma without a breach in the standard of care?

3 A That is hypothetically possible, yes, sir.

4 Q Okay. And the pre-op embolization risk relative

5 to benefit is something you need to discuss with the

6 patient; true?

7 A Yes, sir.

8 Q All right. Because there is a risk of pre-op

9 embolization; true?

10 A Yes.

11 Q We just discussed some of those; right?

12 A Yes, sir.

13 Q Those are recognized risks, the ones I just

14 discussed with you; right?

15 A I believe so.

16 Q Okay. And so that's something that has to be

17 taken into consideration if the patient is going to go

18 through pre-embolization; right?

19 A Yes, sir.

20 Q Have you read, Dr. Kaloostian, that the

21 pre-embolization has actually caused more injury in some

22 cases than it's helped?

23 A That can happen.

24 Q Okay. All right. Let me switch gears a little

25 bit.



1 The symptoms associated with a meningioma and the

2 occipital lobe, would those include loss of visual

3 field?

4 A Yes, sir.

5 Q Seizures?

6 A Yes, sir.

7 Q Memory impairment?

8 A It's possible.

9 Q Okay. Motor disturbances?

10 A It's possible, if there's extension into a motor

11 area.

12 Q Okay. And sensory disturbances?

13 A Yes.

14 Q Headache?

15 A Yes, sir.

16 MR. BRANDT: I'm sorry. Did you get his answer

17 there?

18 THE REPORTER: Yes.

19 BY MR. BRANDT:

20 Q Disorientation or loss of focus?

21 A Possible.

22 Q Okay. Muscle weakness?

23 A It's possible.

24 Q Speech problems?

25 A Possible.



1 Q Ataxia?

2 A Possible.

3 Q Loss of olfactory?

4 A More on the -- on the unlikely side.

5 Q Okay. A loss of initiation to become active? In

6 other words, the patient has a loss of initiation.

7 A Possible.

8 Q How about confusion?

9 A That could happen.

10 Q Okay. And altered mental status?


12 Q How about behavioral changes in personality? In

13 other words, changes in both behavioral and -- behavior

14 and personality?


16 Q And so we know in this case, Ms. Davis, when she

17 presented to the emergency department, that she did have

18 headache; right?

19 A Yes, sir.

20 Q She did have some disorientation; right?

21 A Yes, sir.

22 Q She had had some speech problems, I think, at

23 that time? Correct me if I'm wrong.

24 A May I take a look at my notes, sir?

25 Q You can take a look at anything you'd like.



1 A Yes, sir.

2 Q She had confusion; right?

3 A Yes, sir.

4 Q Her sister described that she was having some

5 personality or behavioral changes, too; is that right?

6 A Yes, sir.

7 Q All of those things were associated with the

8 meningioma, would you say? Would you agree with that?

9 A That's possible, yes.

10 Q They weren't -- there wasn't any other diagnosis

11 for that problem; true?

12 A Correct.

13 Q Okay. She was having, I think, what they

14 described as seizures at that time; is that true?

15 A Yes, sir.

16 Q So she's symptomatic at the time that she comes

17 to the ED; is that right?

18 A Yes, sir.

19 Q Her meningioma is causing symptoms for her; is

20 that right?

21 A Yes, sir.

22 Q You also looked at the images, right, in this

23 case?

24 A Yes, sir.

25 Q And you found that there was swelling, brain



1 swelling, going on at that time; true?

2 Let me put it better. I'm sorry. That wasn't a

3 fair question.

4 The reports, anyway, the imaging that was taking

5 place, she had CT, MRI, CTA, pre-operatively; true?

6 A Yes, sir.

7 Q And MRA, too; is that right?

8 A Yes, sir.

9 Q The reports indicate that she had brain swelling

10 as a result of the meningioma; true?

11 A Yes, there was edema.

12 Q There's edema. Okay. So when she presents to my

13 client, Dr. Nardone, she has not only -- or at least

14 presents to the emergency department, she has symptoms;

15 true?

16 A Yes, sir.

17 Q And she has some brain edema; is that right?

18 A Brain swelling, yes, sir.

19 Q And the standard of care would include surgery,

20 in other words, craniotomy to remove a meningioma in a

21 patient who has those -- that presentation; true?

22 A That is one option, yes, sir.

23 Q Okay. Can pre-op embolization also lead to

24 swelling?

25 A Hypothetically, yes.



1 Q Okay. And can it also lead to ensuing

2 neurological deficits?

3 A Yes.

4 Q Okay. This was written. I wrote it down. You

5 can tell me if you agree with it. "Pre-op embolization

6 can present an unnecessary risk for the patient because

7 the surgery already involves extensive devascularization

8 and achieves the same result as embolization."

9 Do you agree with that?

10 A I think I would disagree with that.

11 Q It sounds to me, from what we have talked about

12 so far, that there are differences in surgical management

13 for meningioma in a patient like Davis. In other words,

14 that can vary from surgeon to surgeon as to how they

15 approach the patient; true?

16 A Yes, sir.

17 Q And that can still be within the standard of

18 care; true?

19 A That is possible.

20 Q Okay. Well, in other words, so some

21 neurosurgeons might approach this patient with surgery;

22 right?

23 A Yes, sir.

24 Q Some might approach a wait and see approach for

25 Ms. Davis; right?



1 A Yes, sir.

2 Q In other words, monitor her with imaging of her

3 routine imaging over time; right?

4 A Yes, sir.

5 Q Some might include pre-op embolization if they

6 are going to surgery; right?

7 A Yes, sir.

8 Q Some may not; right?

9 A Yes, sir.

10 Q And it's also true that some patients -- some

11 surgeons would use SRS and some would not; true?

12 A Correct.

13 Q And all of those approaches would be within the

14 standard of care; true?

15 A Depends on the case, obviously.

16 Q I'm talking about the Davis case. In the Davis

17 case, all of those approaches would be within the standard

18 of care; right?

19 A Well, my thought is different than -- in terms of

20 this case. I think that in this particular case,

21 preoperative embolization would have been helpful, would

22 have prevented bleeding from occurring. And actually, I

23 didn't see a clear emergency to operate on this patient

24 within three or four days of seeing the patient.

25 So if you're asking about this particular case,



1 then no, I would not say it's the standard of care. But

2 if you're talking about in general for treating patients

3 with brain tumors, then that could be the case, yes.

4 Q How about, would it be -- in your understanding

5 of both your practice, your experience, your education and

6 training that different neurosurgeons are going to

7 approach a patient like Davis differently. In other

8 words, some might take her to surgery without

9 pre-embolization; true?

10 A That's true.

11 Q Okay. And would those surgeons, if they did

12 that, like, say, Dr. Nardone, would that be within the

13 standard of care?

14 A When I'm giving my opinion, it's within a

15 reasonable degree of medical certainty, what the majority

16 of surgeons would do. So I would say no is the answer to

17 that question.

18 Q Okay. But maybe a minority of the surgeons might

19 take the patient to surgery?

20 A Yes, sir.

21 Q Okay. And that would be within the standard of

22 care; true?

23 MS. KING: Objection. Form, foundation and asked

24 and answered.

25 THE WITNESS: If it's a minority of surgeons that



1 would take the patient to surgery rather than the

2 majority, I would say, no, that's not the standard of

3 care.

4 BY MR. BRANDT:

5 Q What makes -- let me ask a better question.

6 The patient presents with symptoms, has some

7 brain edema, has a what we've discussed as a small tumor,

8 meningioma, in the location where Ms. Davis has. What

9 makes Ms. Davis different, if anything?

10 MS. KING: Objection. Form. From who?

11 MR. BRANDT: From other patients.

12 Q Does she stick out in some ways? Is there

13 something unique about Ms. Davis and her presentation?

14 A Well, everyone is unique in their own way; right?

15 Q Absolutely.

16 A But I think, in answering the particular question

17 you're asking, her symptoms were recent. I believe

18 starting September 14th, if I'm not mistaken.

19 Q Right.

20 A And prior to that, she was pretty healthy and had

21 no other symptoms. And -- and then surgery was done a few

22 days later without really exhausting standard conservative

23 treatments that are present to be used. That could

24 mitigate symptoms in such a patient. So I think that's

25 one way that her care -- her care and presentation was



1 different than the kind of the standard of care approach.

2 And then, obviously, the whole issue of

3 discussing alternatives with the patient and documenting

4 alternatives such as nonoperative treatments, with

5 steroids and anti-epileptics and following the patient

6 symptomatically along with another imaging study over time

7 to see if there's any integral change. Potentially, this

8 could have been a tumor that was present since birth. So

9 technically 62 -- or 63 years, and may not have been

10 causing her much trouble.

11 So I think these are ways in how this case is

12 different than others.

13 Q Anything else that you can think of that

14 distinguishes Ms. Davis from somebody else?

15 A Not at this time.

16 Q You saw from the imaging that this patient's

17 tumor itself was calcified.

18 Did you see that?

19 A There's some small areas of calcification, yes,

20 sir.

21 Q That does affect the efficacy of embolization;

22 true?

23 A In this case, no.

24 Q Why not?

25 A Because the whole tumor wasn't calcified



1 completely and embolization would have obviously been very

2 helpful because preoperative imaging showed a bunch of big

3 vessels inside and outside of the tumor that I would have

4 been nervous to have approached, personally. And

5 embolization would have helped, at least, to close off

6 those vessels, if it would have been possible.

7 Sometimes you talk to an interventional

8 specialist, and when I talk to them and they say, "You

9 know, Dr. Kaloostian, we're not able to get into those

10 vessels to embolize them." So at least they tried, you

11 know, and sometimes you can't embolize somebody's vessels.

12 But the vast majority of cases that I've seen, it's very

13 helpful in terms of decreasing blood loss and makes the

14 surgeries much quicker. I believe -- most people believe

15 it's safer for the patient to do it that way. Only

16 because these tumors get so much blood flow from the

17 external carotid circulation that -- that it's quite

18 beneficial to at least discuss it or trial embolization.

19 Q Embolization carries risk, though, that we've

20 talked about; right?

21 A Hypothetically, yes, sir.

22 Q Large vessel dissection would be wrong?

23 A Yes, sir.

24 Q Microcatheterization of the microfracture of the

25 vessel, that's a risk; true?



1 A Yes, sir.

2 Q Unintended arterial or venous occlusion can

3 happen; right?

4 A That's possible.

5 Q And that can result in hemorrhagic or ischemic

6 infarct; true?

7 A Yes, sir.

8 Q You've mentioned, I think you referred to the

9 proposition that the tumor anatomy might not be suitable

10 for embolization; true?

11 A I'm sorry. Repeat the question.

12 Q The tumor anatomy may not be suitable for

13 embolization; true?

14 A It's possible some tumors may not be amenable,

15 sure.

16 Q Is stroke also a risk of embolization?

17 A Yes, sir.

18 Q Okay. Facial nerve palsy?

19 A That's more the lower end of things, but that's

20 possible.

21 Q Have you seen -- sorry if I've asked you this.

22 But there are studies that I've looked at that show the

23 estimated blood loss of surgery was actually larger in

24 patients who were embolized.

25 Have you seen those studies?



1 A That is extremely rare.

2 Q Okay. But it can happen?

3 A Have I seen that? Possibly.

4 Q Okay. There were some studies that showed no

5 significant differences in operative complications between

6 tumors that did and did not receive embolization

7 preoperatively. In other words, no significant difference

8 in the outcomes.

9 Have you seen that literature?

10 A Possibly, but it's not something that's the

11 standard of care.

12 Q Well, I'm just asking -- I'm not really talking

13 about it in terms of the standard of care. I'm just

14 talking about in terms of outcome. You've seen that

15 literature; true?

16 A It's possible.

17 Q Okay. Tumors that are calcified typically not

18 candidates for embolization. I know you've given me your

19 opinions about this one, but just generally speaking?

20 A No, sir.

21 Q They aren't or they are? I'm sorry.

22 A They're not contraindicated for embolization.

23 Q So let me ask you a better question so we get a

24 better answer. Sorry.

25 So are tumors with calcification typically not



1 candidates for embolization?

2 A No.

3 Q You disagree with that?

4 A I disagree.

5 Q Do you perform the embolization yourself?

6 A No, sir.

7 Q Who -- who do you have do that? In other words,

8 what group do you use to do that?

9 A Usually it's interventional radiologists. Or it

10 could be someone who's a neurologist, a radiologist, or a

11 neurosurgeon.

12 Q Okay.

13 A In my practice, it's a radiologist.

14 Q And you're at which hospital?

15 A In Riverside Community Hospital and Corona

16 Regional.

17 Q Okay. Are those groups employed by the hospital,

18 if you know, those two hospitals?


20 Q Do you know? If you don't know, that's fine.

21 A They are likely employed by the hospital.

22 Q Okay. Is it true that embolization of the middle

23 meningeal artery, which is what we're going to talk about

24 here today, can result in embolization of branches of that

25 artery that supply the cranial nerves?




2 Q Okay. Sounds like what we've talked about here,

3 that you should agree with this, hopefully, embolization

4 should be considered on a case-by-case basis depending

5 upon imaging, characteristics, anatomic location and

6 patient's specific factors.

7 Would that be a true statement?

8 A Yes, sir.

9 Q Okay. In your report -- I'm sorry. We call

10 these 213. Okay. Because we like the numbers. Exhibit

11 No. 2. Okay? I'm going to hand this back to you. You've

12 got it. And I want to ask you about the proposition of

13 not taking this patient to surgery but just kind of

14 waiting and watching.

15 Okay?

16 A Okay.

17 Q So it wasn't particularly clear to me what the

18 time frame was that you were suggesting, because in the

19 report it talks about two months and then you talk about

20 several months. So is there a -- is there a time frame in

21 your mind or are you just continuing to watch these

22 patients?

23 A In this particular case, which we'll talk

24 about -- you're not talking generally, are you? You're

25 talking --



1 Q I'm sorry. We're talking about Ms. Davis.

2 A Okay. So in this particular case, she presents

3 on September 14th with symptoms. She improved with

4 steroids and seizure medicine and was sent home, I think,

5 a day or two later.

6 I would have -- and I think most people would

7 have done a repeat study, such as an MRI or a CAT scan,

8 but probably an MRI in a few months. It could be anywhere

9 from three to six months, I would say, and see if there's

10 a change. If this tumor has tripled in size, then it's

11 pretty active. It's alive. It needs to be removed and

12 treated. If it's stable and maybe it's been stable for 63

13 years, and she's stable symptomatically, then we just

14 continue to follow it.

15 Q Is there a concern if the tumor is malignant that

16 you haven't done a biopsy?

17 A A malignant tumor would have grown in size quite

18 significantly on repeat study. And so I think the option

19 is to really do a repeat study over the next couple

20 months, and if it's actively growing and she's

21 neurologically worsening, then a biopsy would be indicated

22 because you would think it's -- that the pathology is more

23 in line with something more aggressive like a grade 2 or a

24 grade 3 meningioma. But to go straight to a resection, I

25 think in this case, I think was not the standard of



1 care.

2 Q Surgery is the most common treatment for

3 meningioma; true? Back in 2014, surgery was the most

4 common treatment for meningioma; true?

5 A I think that is possible. But I think there are

6 adjunctive treatments, as well, that go along with it. So

7 it's hard to really study that. Oftentimes, there's

8 surgery done followed by radiation as well as preoperative

9 embolization. So it's hard to really give an answer to

10 that question.

11 Q Okay. So within the realm of the standard of

12 care in 2014, September of 2014, the most common approach

13 to a meningioma was craniotomy with surgery; true? Maybe

14 followed with SRS? It may include embolization, may not.

15 But the most common approach was surgery; true?

16 A I'm not sure -- I'm not a hundred percent sure if

17 that's true because there's a lot that goes into it

18 depending on what type of meningioma, where the meningioma

19 is located.

20 Q Okay. Sure.

21 A Patient presentation. It's hard to really give

22 an accurate number. I don't know.

23 Q It's true that surgical approach, craniotomy to

24 meningioma, was within the panoply, if we can call it

25 that, of approaches; true?



1 A Absolutely.

2 Q Okay. Did she have a World Health Organization

3 grade 1 meningioma? Or does it -- let me ask it. Does

4 that matter to you?

5 A The pathology does matter, yes, sir.

6 Q So do you have an opinion about what grade World

7 Health Organization tumor she had?

8 A To be honest, I don't remember.

9 Q Okay. So I guess it doesn't matter to you.

10 A Well, if you told me what it was, it would

11 matter. I don't remember what it was off the top of my

12 head.

13 Q Okay. But I'm just saying in terms of your

14 opinions about the approach that should have been taken

15 here, whether she was WHO 1 or 2, that's not affecting

16 your opinions in this case?

17 A No.

18 Q You didn't see it; is that true?

19 A The answer to that question is no.

20 Q And we talked about -- well, certainly WHO grade

21 2 meningioma, the management of that would include the

22 things that we've talked about, surgery, craniotomy;

23 right?

24 A Yes, sir.

25 Q Surgery with radiation therapy or radiation SRS



1 alone; right?

2 A Yes, sir.

3 Q And waiting and watching; correct?

4 A Yes, sir.

5 Q All appropriate approaches?

6 MS. KING: In general, you mean?

7 THE WITNESS: Generally speaking, yes.

8 BY MR. BRANDT:

9 Q For WHO grade 1 --

10 A Yes, sir.

11 Q -- meningioma; yes?

12 A Yes, sir.

13 Q Do you know who John Park is from

14 Santa Barbara?

15 A I don't.

16 Q He's a neurosurgeon in Santa Barbara. He wrote

17 this. "Surgery is the preferred treatment for most

18 meningiomas, especially for tumors that are large, growing

19 quickly or causing symptoms."

20 True? Do you agree with that statement?

21 A No.

22 Q Okay. Certainly, this patient's meningioma was

23 causing symptoms; true?

24 A Yes, sir.

25 Q So I understand you disagree with it, but within



1 the statement itself, his position is that surgery is

2 preferred for treatment for meningiomas, especially for

3 tumors that are causing symptoms. Okay? And my question

4 is, have you seen that elsewhere in literature?

5 A That type of statement is -- is noted in

6 literature, of course.

7 Q All right. Active surveillance -- tell me if you

8 agree with this. "Active surveillance may be an option if

9 a meningioma is small, not causing symptoms and is

10 presumed to be benign."

11 A That's true.

12 Q Okay. Is the -- I think I asked you this.

13 National Institute of Health, is their publication

14 reasonably reliable?

15 A I would probably say the vast majority are,

16 yes.

17 Q Okay. I read this about what we're talking about

18 here. "Surgical resection is recommended for patients

19 with increasing neurological deficit. Patients with

20 pretreatment edema should also undergo surgery because the

21 risk of worsening edema and permanent neurological

22 sequelae are greater in those patients who undergo SRS

23 than with primary surgical resection."

24 Now, that was a long statement.

25 A Yeah. I think in general I would disagree with



1 that statement.

2 Q Okay. And if this was published in the Journal

3 of Neurosurgery, you would disagree with that?

4 A I would disagree with that sentences that you

5 said. And there are other articles that say contrary to

6 that.

7 Q So would it be a fair statement that maybe

8 reasonable minds disagree on this topic?

9 A Yes, sir.

10 Q I want to talk to you about SRS for a moment.

11 Okay?

12 A Yes, sir.

13 Q We talked a little bit about the risks of SRS

14 include seizures, brain swelling and injury to adjacent

15 brain tissue; true?


17 Q And certainly something that's a concern with SRS

18 is that a number of -- or some of the radiation is going

19 to affect adjacent tissue. That's one of the biggest

20 worries with SRS; true? If you know.

21 A I would say with SRS, the outcome of that

22 happening is extremely low. With whole brain radiation,

23 you would see that more so, as was done in the old days.

24 But with the stereotactic radiosurgery, you have over 100

25 different beams going on one particular area of the brain,



1 which should limit the adjacent tissue from being

2 radiated. That's the whole purpose of radiosurgery.

3 Q If you're going to watch a patient like

4 Ms. Davis, she's going to have routine imaging performed;

5 is that right?

6 A Yes, sir.

7 Q And so, just hypothetically, let's assume that

8 transpired with her, how often would she be imaged?

9 A Well, I would say the initial study should be

10 relatively sooner. So given that she had one MRI, I

11 believe on the 14th of September, I would do another one

12 in a couple months.

13 Q Okay.

14 A Maybe three months.

15 Q Let's -- let's assume that there's no change at

16 that time period, at the time period of the couple months

17 after the initial presentation to the ER, how often are

18 you going to image her, or what would be your

19 recommendation at that point?

20 A In terms of how often I would image her, I would

21 say probably yearly.

22 Q Okay. And do you -- would she would she have MR?

23 How would you image her? What -- what would you order?

24 A I would say MRI would probably be best for the

25 first year or two. And then if they're stable by that



1 point, I would just stop imaging and follow her

2 conservatively, unless she worsens in some way.

3 Q In other words, if her -- if she's -- we know

4 she's having symptoms; right?

5 A Yes, sir.

6 Q She comes to the emergency department and they

7 provide her some steroid, I think you said; is that

8 right?

9 A Yes, sir.

10 Q That improved her symptoms during the time period

11 she was in the ED; true?

12 A Yes, sir.

13 Q She can't stay on steroids forever; true?

14 A Yes, sir.

15 Q Is that right? You wouldn't want to do that;

16 correct?

17 A Correct.

18 Q So how -- how would you then treat her if her

19 symptoms returned? If her symptoms returned, are you

20 going to take her to SRS or surgery, or what would you

21 do?

22 A Well, first of all, I think the -- it is correct

23 that you can't keep someone on steroids for years.

24 Q Right.

25 A Typically, the inflammation calms down after you



1 give the initial doses of steroids. So the swelling

2 wouldn't typically be a big issue over time. But it can

3 come -- it can return. I think in her case, the seizure

4 treatment really helped her significantly, and I think

5 that really can be continued over time and be followed by

6 a neurologist. And I'm trying to think of the question.

7 MS. KING: Me, too.

8 MR. BRANDT: That's fine. I'll ask another

9 question.

10 Q So let's assume, hypothetically, that her

11 symptoms return in a year. Okay? She's off steroids,

12 she's still continue with the Keppra for her seizures,

13 okay, but she's starting to have symptoms again.

14 At that point in time, is it appropriate at that

15 time to take the patient either to craniotomy, SRS,

16 surgery with pre-embolization or not. One of the two.

17 Are those kind of your options at that point?

18 A Yes, sir.

19 Q Okay. So once she starts to develop symptoms

20 again, she's going to have some treatment for her tumor at

21 that point; true?

22 A If she so desires, yes, sir. Those are

23 options.

24 Q Okay. Have you ever had a patient with symptoms

25 say I don't want any treatment for that?



1 A Yes, sir.

2 Q Okay. How do you treat them? Would you put her

3 back on -- I'm sorry. Assuming that's Ms. Davis, in my

4 hypothetical, she comes back in a year and she starts to

5 have symptoms again, and she's having the headaches. Her

6 seizures may be, you know, covered by the Keppra, but

7 she's also having some other of the symptoms that we

8 talked about that patients present with with a meningioma.

9 Okay? That's my hypothetical. She's back after a year,

10 those symptoms are coming back, except for the seizures,

11 so at that point in time, if that patient declined

12 surgery, are you going to treat her with steroids? What

13 are you going to do?

14 A If she declined surgery, then you treat her

15 medically with steroids and seizure medication.

16 Q Okay.

17 A And if she declines any -- any other treatments,

18 those would be the options.

19 Q Do you treat those patients or do you send them

20 over to neurology for treatment?

21 A Neurology.

22 Q Is it true, Dr. Kaloostian, that with any

23 craniotomy, patients can develop seizures

24 post-operatively?

25 A Yes.



1 Q Neurologic problems such as weakness, speech,

2 problems with memory, coordination?


4 Q Those are all known complications from just

5 having a craniotomy, true, recognized complications?

6 A They could happen in rare cases, yes, sir.

7 Q That's what I'm saying. They are recognized

8 complications; is that true? In other words, patients can

9 develop these problems just from having craniotomy?


11 Q Okay. The problems that I discussed earlier,

12 seizures, neurologic problems, speech problems, memory

13 problems, just having a craniotomy, those problems are

14 within the realm of sequelae that can occur; true?

15 A Yes, sir.

16 Q True, also, with SRS; right? You can have all

17 those complications with SRS; true? Those are known

18 complications of SRS?


20 Q And so, if I'm a medical student working with you

21 and I said, are those known complications of SRS, those

22 ones we just talked about, seizures, neurological

23 problems, weakness, problems with memory, coordination

24 problems, would you tell me, yes, those are known

25 complications of SRS?



1 A By "Known," do you just mean they have been

2 reported once or twice?

3 Q Yes.

4 A Yes, that's possible.

5 Q Okay. So "Yes"?

6 A Yes, sir.

7 Q Do all patients who have a meningioma get a

8 pre-op angiogram?

9 A The key phrase there is "All," and I would say no

10 to that.

11 Q Okay. Is there a certain percentage that don't

12 or certain percentage that do, if you know?

13 A I don't know the numbers on that. But I would

14 just say that the majority of patients that have a

15 specific tumor that looks vascular, like a meningioma,

16 would at least have a trial or discussion about

17 pre-operative embolization. I don't have a percentage on

18 that.

19 MR. BRANDT: All right. It's really hot in here.

20 Is it hot for you guys?

21 THE WITNESS: I'm okay. I'm okay.

22 MS. KING: I think we can go off the record.

23 MR. BRANDT: I'm sorry. Let's take a break.

24 Let's go off record.

25 (A break was taken.)



1 BY MR. BRANDT:

2 Q Just a couple other things I want to cover with

3 you. I think you told me that you have had the

4 complication of bleeding with the resection of a

5 meningioma? Or not?

6 A I have not. Personally, no.

7 Q I'm sorry. You did say that. I apologize. I'm

8 not trying to play games with you.

9 So is it your belief, after looking at this case,

10 that the transverse sinus was ligated, injured, something

11 like that during this procedure?


13 Q Okay. Do you have an opinion whether it was or

14 not?

15 A Likely.

16 Q What's the -- what's the evidence of that?

17 A The evidence was that the tumor had involved the

18 transverse sinus and so there was an opening into the

19 transverse sinus. You're essentially are opening into

20 the -- to get the tumor out, you have to enter into the

21 sinus, which is already entered into.

22 Q So Dr. Nardone described in his operative note

23 that the tumor pulled off the sinus easily, or words to

24 that effect.

25 Do you remember that?



1 A Yes, sir.

2 Q And so we also know that Dr. Gordhan, Gordhan,

3 G-o-r-d-h-a-n, was involved later on in the procedure.

4 I'm going to say towards the end of the procedure.

5 A Yes, sir.

6 Q Do you remember that?

7 A Yes, sir.

8 Q And do you recall that there was -- he came in

9 and actually glued the middle meningeal artery; is that

10 right?

11 A I think it was the posterior meningeal branch of

12 the middle meningeal artery -- I'm sorry. I think it was

13 the posterior meningeal artery that was glued.

14 Q Okay. Was there any treatment that he provided

15 to the -- to the transverse sinus?

16 A No, sir.

17 Q Was there any other evidence that you have that

18 the transverse sinus was involved as causing bleeding for

19 this patient other than what you've just said?

20 A Other than that and the loss of over two liters

21 of blood, no.

22 Q Okay.

23 A Losing that much blood would have to involve

24 something more than a smaller arterial bleeder.

25 Q Okay. You've reviewed the images in the case. I



1 think we've already covered this, the MRI, the CT. I

2 apologize. Let me just say this. Sometimes we repeat

3 things, and I probably am going to do that, so if you've

4 already answered it, just say, "I've already answered it."

5 A No problem.

6 Q MRI, we've looked at the MRI, CT, CTA, MRA that

7 were all performed pre-operatively; is that right?

8 A Yes, sir.

9 Q Okay. And I think we've established that there

10 was brain edema demonstrated --

11 A Yes, sir.

12 Q -- on some of those; right?

13 Can we agree that the CTA and the MRA do not

14 demonstrate total occlusion of the transverse sinus, if

15 you remember?

16 A From my review, it looked like the sinus was

17 essentially occluded from -- on the right side. And the

18 reason I say that is because I can see definite cutoff

19 points on those studies.

20 Q Okay. So would my statement be wrong? You would

21 disagree with my statement?

22 A Please repeat it.

23 Q Sure. Agree -- do you agree that the CTA and the

24 MRA do not demonstrate total occlusion of the transverse

25 sinus?



1 A I would disagree.

2 Q Okay. And have you talked to Ms. King about

3 demonstrative aids at trial? Do you know what I'm talking

4 about?

5 A I'm sorry. What is a demonstrative aid?

6 Q Drawings.

7 A No, we have not discussed that.

8 Q Okay. My anticipation would be that you would

9 testify using the images that I just described, the MRA,

10 CTA, CT and MRI at trial?

11 A I would believe so, but obviously, if we, you

12 know -- if I need to use an aid for myself to convey what

13 my thoughts are, I would have to use it.

14 Q Okay. All right. I guess -- I'm sorry. I

15 probably didn't ask a very good question. Would it be

16 your anticipation that given -- that in giving testimony

17 at trial that you would use those images, those radiologic

18 images to discuss your testimony?

19 A It's likely.

20 Q There's an issue in the -- in the disclosure that

21 we have here as Exhibit No. -- can you just read that off

22 at the bottom. Exhibit No. 2 that talks about informed

23 consent.

24 Okay?

25 A Yes, sir.



1 Q Okay. And take a look at whatever you need to

2 look at, because I'm -- I just want to ask you about that.

3 I got your opinions, so I'm not going to spend a lot of

4 time on this issue because I understand what your opinions

5 are because they are well written in the disclosure.

6 Okay?

7 MS. KING: I think it's paragraph 14 and 15.

8 BY MR. BRANDT:

9 Q Take your time to look at those, and then I'll

10 ask you some questions. How is that?

11 A Okay.

12 MS. KING: And they continue on to paragraph

13 16.

14 THE WITNESS: Yes, sir.

15 BY MR. BRANDT:

16 Q Okay. I guess I should ask a basic question.

17 The document that you're looking at, did you prepare that

18 or did you -- or did somebody else prepare it?

19 A I prepared it.

20 Q Okay. And are there drafts of that document that

21 you have that you've not provided to me?

22 A There may be one in this packet that you've

23 presented to me.

24 Q Exhibit No. 3, for the record?

25 A Yes, sir.



1 Q Okay. Any others?

2 A Not that I'm aware of, no.

3 Q Did you pass the document by Sarah or --

4 Sarah King or somebody else in her office before it was

5 finalized?

6 A I believe so, yes.

7 Q And do you think all those versions have been

8 provided to me?

9 A Yes, sir.

10 Q Okay. All right. And so I'm not going to have

11 you read what you've written because, as I've said, I

12 understand it and I can read it.

13 What do you understand transpired with respect to

14 informed consent in this case?

15 A Well, as noted in the disclosure, I believe there

16 was a lack of informed consent provided. So that's --

17 that's the general issue, I think, in this particular

18 case.

19 Q Have you been presented with patients like

20 Ms. Davis that present very similarly to her? I

21 understand every patient is different. I got that. But

22 have you had patients that present similarly to her?

23 A Yes, sir.

24 Q And what do you typically talk about in that

25 context in terms of informed consent?



1 A In the context of informed consent, I would

2 discuss the treatment options including conservative

3 management with medications and serial imaging, as well as

4 consideration of other possible options, such as

5 embolization of the tumor, radiation treatment to the

6 tumor, and then surgical treatment to the tumor.

7 But my recommendation, in this particular case,

8 would have been to -- the patient to have followed this

9 conservatively, the serial imaging. I would have also

10 discussed all the risks and benefits of each of those

11 procedures.

12 Q Okay. Can you tell me what those are? In other

13 words, tell me what you would say to the patient.

14 A In addition to what I already said, I would state

15 that there are risks and benefits to any of the above

16 options that we discussed. For example, risks of surgery

17 would include the incomplete resection of the tumor, need

18 for more surgery, bleeding, infection, stroke. I would

19 also discuss the risks of embolization to include risks of

20 stroke, bleeding, and then the risks of embolization

21 possibly being increased swelling around the tumor site

22 and need for surgery to be done if the radiosurgery does

23 not decrease the size of the tumor over time.

24 And then, obviously, I would discuss the benefits

25 of each of those. For example, benefits of conservative



1 management would be avoiding brain surgery and -- and

2 treating the symptoms with medications rather than having

3 any sort of interventions. Benefits of surgery could

4 include removal of the tumor so it's not a problem for

5 her. A benefit of embolization prior to surgery could be

6 that it would make surgery less intense, less bloody and

7 potentially a shorter operation, which would be beneficial

8 for her. And then the benefit of radiosurgery would

9 include, obviously, avoiding brain surgery and the

10 potential of -- of a stagnation of growth of this tumor.

11 Q Okay. Does that pretty much cover what you would

12 discuss?

13 A Yes, sir.

14 Q Do you have an opinion about Ms. Davis' ability

15 to comprehend such a discussion at the time that she's

16 seen by neurosurgeons in this case?

17 A No, sir.

18 Q Okay. Fine. Okay. I want to just switch gears

19 a little bit.

20 You're a -- going back to your CV. Okay? You're

21 a locums neurosurgery. Do you continue to do that

22 today?

23 A No, sir.

24 Q Okay. When you're a locums, what does that

25 entail?



1 A Locums is a really great opportunity for doctors

2 to travel and provide their services at hospitals that are

3 underserved.

4 Q Okay.

5 A In other words, I went to Maine, I went to

6 Maryland, Northern California. These hospitals, believe

7 it or not, are just not able to cover the neurosurgical

8 services appropriately. So patients are being

9 underserved, they are not being treated well, they're

10 being shipped to hospitals that are far away, and not --

11 and having poor outcomes because of that. So that's why

12 locums is really a nice opportunity, in my opinion, to

13 travel and perform these services to really help people

14 that are underserved.

15 Q Okay. In 2017, you were an assistant professor

16 Roman numeral 3.

17 What does that mean, the Roman numeral part of

18 it?

19 A I think that was at John Hopkins Hospital in

20 Baltimore, Maryland. Yeah, that's -- that's what they

21 gave me as my title. I don't know why.

22 Q Okay.

23 A I think there's different levels of that.

24 Q Okay. I was just curious.

25 A I think it's just based on -- just as you move on



1 in your career, you get advanced to different stages

2 arbitrarily.

3 Q If you look at page 20 of your CV. Okay? Now,

4 I'm going to your CV, which should be attached there.

5 Okay? There's this cracking series that you were --

6 authored or co-authored?

7 A Yes, sir.

8 Q Is this kind of like a how-to for medical

9 students or residents or what it's for?

10 A Yes. These are for the USMLE, which is the --

11 USMLE, United States Medical Licensing Exam.

12 Q Okay.

13 A So these are textbooks on that, on how to pass

14 the exam.

15 Q Got it. Is there anything in there regarding

16 meningioma, to your knowledge? Look at -- look at No. 2

17 and No. 22? Just as a --

18 A I don't believe there would be a section that

19 would pertain to this particular case of a meningioma.

20 Q Okay. So look at page -- let me -- let me back

21 up there.

22 Do you do bedside teaching and classroom teaching

23 both currently?

24 A Yes.

25 Q Okay. And do you give materials or do you have



1 reference materials for neurosurgeons to be on

2 treatment -- treatment of brain surgery -- I'm sorry,

3 brain tumors?

4 A I don't have any reference material. I just

5 lecture because I like to speak and give talks.

6 Q I appreciate that. I just -- I just didn't know

7 if you said, "Here's a reference that you should read

8 relative to brain tumors."

9 A No, I don't give any particular references.

10 Q Look at page 30-C, letter C on your CV.

11 MS. KING: You said 30, the last part C?

12 THE WITNESS: C.

13 BY MR. BRANDT:

14 Q Part C. So these are neurosurgical presentations

15 that you've made; true?

16 A Yes, sir.

17 Q So we're on the same page. No. 21 talks about

18 spinal meningiomas; is that right?

19 A Yes, sir.

20 Q So what type of presentations are these?

21 A This is for, actually, during medical school. So

22 this is way back in the day.

23 Q Okay.

24 A But this was on spinal meningioma. So you could

25 have meningiomas in the brain and in the spine.



1 Q Right.

2 A So this particular talk was on spinal

3 meningiomas.

4 Q Right. Did you -- when you gave these talks back

5 in medical school, did you have published materials?

6 A No, sir.

7 Q Okay. Well, then that's probably going to save a

8 lot of time.

9 You were involved with a lot of M&M cases?

10 A Yes.

11 Q Case presentations throughout your training. Any

12 of those deal with brain tumor. I think number -- if you

13 look at page 34, there was one that dealt with a wing

14 meningioma?

15 A Yes. That is a M&M presentation back in 2010, it

16 looks like.

17 Q Okay.

18 A I don't recall it, but that is an intracranial

19 meningioma case.

20 Q Do you have any materials?

21 A No, sir.

22 Q Okay. Look at page -- I kind of knew the answer

23 to that, but I got to ask. Page 39. Okay? No. 220.

24 This is "The road to neurosurgery is a marathon, not a

25 sprint"; is that right?



1 A Very true, yes.

2 Q And so what you're -- is this a book? I can't

3 remember.

4 A No. This is a -- I guess a -- a lecture that I

5 gave to -- to the students who I think were coming on

6 board to join UCLA School of Medicine. Because I

7 graduated from there --

8 Q Right.

9 A -- so I think they wanted me to give a lecture.

10 Q The point of this is with neurosurgery, it's both

11 time consuming and meticulous; true?

12 A Absolutely.

13 Q And it's important for the neurosurgeon to hang

14 in there as long as it takes to get the procedure

15 completed; true?

16 A Yes, sir.

17 Q Is that really what you were talking about to

18 them?

19 A Yes, sir.

20 Q In other words, this isn't something to be

21 rushed?

22 A Correct.

23 Q And then there was -- if you look at page 40.

24 Nos. 28 -- 228, I apologize. Nos. 228, 229 and 235 are

25 lecture series of primary brain tumors. I think I know



1 the answer to this, but do you have any of those

2 materials?

3 A No, sir.

4 Q Okay. Bear with me just a second. This will

5 help shorten it up.

6 A Take your time.

7 Q Do you have any opinions about Ms. Davis'

8 condition today? Are you going to -- there's a -- there's

9 a neurologist who is going to testify in this case. Are

10 you deferring to that person or do you have some opinions

11 other than what's contained in Exhibit No. 2?

12 A No, I do have opinions.

13 Q Okay. Why don't you tell me what they are.

14 A That the outcomes, such as cognitive decline, and

15 other deficits as noted in the report were related to the

16 complications from the surgery.

17 Q I understand that. I'm just talking about how

18 she is today versus as of, let's say, last week or last

19 month. There's a neurologist who is going to talk about

20 her day-to-day, her ADLs, all those things that she has.

21 Are you going to testify about those things, too?

22 A I can only testify up until when I receive the

23 last set of records.

24 Q Okay.

25 A Up until then, that what I just said is my



1 viewpoint on it.

2 Q Okay.

3 A I wouldn't have any other information as to how

4 she's doing today or yesterday. I just don't have any

5 information on that.

6 Q Whether she's doing worse or better, you can't

7 say?

8 A Correct.

9 MR. BRANDT: Let's take a break, and I'm going to

10 talk to Dr. Nardone, and I won't have a whole lot left.

11 THE WITNESS: Okay.

12 MR. BRANDT: Only two questions or something like

13 that.


15 BY MR. BRANDT:

16 Q Help me out just on one issue, if you can. SRS

17 will stop the growth of the tumor; is that true?

18 A Yes, sir.

19 Q Okay. And it may reduce the size of the tumor;

20 is that right?

21 A It can.

22 Q Okay. It won't eliminate the tumor; true?

23 A It probably won't eliminate this tumor, no.

24 Q Okay. All right. The -- you talked about -- and

25 this is probably repeating a little bit, so I apologize to



1 you. You talked about conservative management being with

2 medications, and I think you said, we talked -- you said

3 medications, so I just want to go back and make sure I

4 have an understanding what your opinions are.

5 You talked about short-term steroid; true?

6 A Yes, sir.

7 Q And then long-term Keppra; right?

8 A Yes, sir.

9 Q Anything else? Are those the two medications

10 that you're going to treat this patient with?

11 A Yeah, I think those two would help her, yes.

12 Q Okay. Anything else that you've seen in the

13 record -- I mean, you've looked at her records. You know

14 what medications she's taking. I guess my question is,

15 are those medications helping her? Or do you have an

16 opinion?

17 MS. KING: Today, or are you saying would they

18 have it, her medication with medical management?

19 MR. BRANDT: That's a good objection.

20 Q So my question is, if she's continuing to take

21 those medications today, are they helping her or does she

22 really just need the Keppra?

23 A I think --

24 Q Or do you defer? If you defer, that's fine, too.

25 I just want to know.



1 A I think they would help her, honestly. I really

2 do, because these are -- both the steroid and the seizure

3 medicine are very strong medications that work well in my

4 experience with patients with this problem. So I think

5 they would help the patient.

6 MR. BRANDT: All right. We're done. Thank you.

7 MS. KING: I do have a couple questions, then

8 we'll be all done with it.

9 THE WITNESS: Yes, ma'am.

10

11 EXAMINATION

12 BY MS. KING:

13 Q I'm going to go backwards. So you mentioned that

14 you reviewed all the imaging studies in the case and that

15 would include post-operative CT scans and the MRI that was

16 done after both surgeries were performed by Dr. Nardone;

17 correct?

18 A Yes, ma'am.

19 Q And on those post-operative scans, did you see

20 evidence of permanent brain damage?

21 A Yes, ma'am.

22 Q Can you describe that for me. And if you need

23 the phone, I can bring it up. And can you specifically

24 talk about frontal lobe damage that Ms. Davis sustained?

25 A The -- looking at the CT scans after surgery, and



1 the MRI scans, there was clear bleeding, you know, in the

2 brain, pretty significant. Not just around the site of

3 the tumor, but inside the ventricles of the brain as well

4 as in the temporal lobe and the frontal lobe, especially

5 on the right side.

6 So -- and looking at the MRI, I think that was

7 done December of 2015. There was continued residual

8 post-surgical pathology affecting the occipital lobe,

9 parietal lobe, temporal lobe and frontal lobe. So then

10 those sites are away from where the tumor was. So in that

11 sense, involving -- there was different areas of the brain

12 that caused permanent injury.

13 Q And in your executive or executive functioning as

14 a person mostly controlled by your frontal lobe?

15 A Yes, ma'am.

16 Q You mentioned that the other areas of Ms. Davis'

17 brain that are injured were away from the tumor?

18 A Yes, ma'am.

19 Q Okay. And that was caused by bleeding;

20 correct?

21 A Yes, ma'am.

22 Q And at some point, Ms. Davis' brain herniated

23 after the complications occurred; correct?

24 A Yes, ma'am.

25 Q What is the brain herniation and how did that



1 lead to permanent injury in Ms. Davis?

2 A Yeah, and I could show it on the films, as well,

3 but basically, herniation is when an area of the brain

4 becomes very angry and upset, and it's when it becomes

5 angry and upset, it becomes swollen. And because there's

6 a defect in the area where the tumor was resected, the

7 brain was herniating out through that -- that hole that

8 was created from the surgery. And so that's demonstrating

9 that the brain is upset and not happy. And so that's

10 what -- that's what herniation is.

11 Q Without a complication, so a meningioma

12 resection, that involves pre-embolization, am I correct

13 that it would be very, very rare to have injury to your

14 temporal lobe, your frontal lobe, your occipital lobe, and

15 I may have missed one lobe.

16 A Parietal lobe.

17 Q Parietal lobe.

18 MR. BRANDT: Let me just object to the form.

19 But you can answer.

20 THE WITNESS: Yes, that would be very unlikely.

21 BY MS. KING:

22 Q Okay. So I'm going to ask my question again in a

23 little better form. Would you agree with me that if a

24 meningioma that is in the occipital lobe is partially

25 resected within the standard of care, which would include



1 pre-embolization, it would be very, very rare to ever have

2 a situation where your temporal lobe, your frontal lobe,

3 your occipital lobe and parietal lobe are all injured?

4 A That's correct. That's extremely rare.

5 MR. BRANDT: Same objection.

6 It's okay. You've answered it.

7 BY MS. KING:

8 Q Your report mentioned a concept called debulking,

9 I believe?

10 A Yes, ma'am.

11 Q Can you explain to us what that term means and

12 how that plays into the standard of care with respect to a

13 meningioma like Ms. Davis', which is small and in the

14 occipital lobe?

15 A Absolutely. Debulking is a fancy term for

16 essentially chopping off some amount of tumor and not

17 taking out everything. So when you debulk something,

18 you're getting rid of some of the tumor in a safe manner

19 and leaving the rest of the tumor behind that you feel is

20 unsafe to remove, but yet would be okay for the patient to

21 still have it present and left in or potentially treated

22 with alternative treatments.

23 So in this particular case for this patient, if

24 surgery was to be done, I wouldn't have done a complete

25 resection of this tumor. I don't think most people would



1 have, just because of the sinus issue. You know, it's a

2 dangerous area. It scares me, you know, to have tumors in

3 that area. And, you know, you have to be very careful

4 because these tumors are very vascular and they get

5 significant blood supply and blood drainage out from these

6 particular arteries and veins, respectively.

7 So debulking in this case, if we're going to plan

8 surgery, I think, would have been a really good option. I

9 know in the deposition, it was mentioned that he tried for

10 a gross total, but I think debulking would have been more

11 appropriate rather than a gross total resection.

12 Q And meningiomas are slow-growing tumors, correct,

13 in general?

14 A Yes, ma'am.

15 Q And you mentioned that if they're not

16 slow-growing the way that you figured that out is to

17 follow a patient with serial imaging; correct?

18 A Yes, ma'am.

19 Q In -- meningiomas in women, specifically, are

20 generally benign; true?

21 A That's true.

22 Q Okay. Specifically in women; true?

23 A Yes, ma'am.

24 Q Why in the sense of a slow-growing meningioma is

25 debulking in a 63-year-old woman especially appropriate?



1 A I believe that, in this particular case, given

2 she's a woman, 63 years old, with a relatively small

3 meningioma in a difficult location adjacent to the

4 vascular structures, debulking would have been much more

5 appropriate to resect it as much as you can safely, and

6 then just to treat the rest either with watchful waiting

7 or with serial imaging studies or with radiation. I think

8 that being aggressive here can -- can cause, you know,

9 potentially problems.

10 Q Is it your opinion that a plan for a gross total

11 resection in Ms. Davis' case was below the standard of

12 care?

13 A Yes, ma'am.

14 Q Okay. You touched a little bit on the content of

15 a brain edema today, and I want to talk about that the two

16 different senses. Post-operatively, after Ms. Davis'

17 experience in -- since bleeding during surgery, she had

18 edema all over the brain; correct?

19 A Yes, ma'am.

20 Q Okay. Prior to surgery, when she presented to

21 the emergency room on the initial scans in this case, am I

22 correct that the edema was localized around the tumor?

23 A That's true.

24 Q And so am I correct that Ms. Davis did not have

25 mass effect or full brain swelling when she presented to



1 the emergency room?

2 A That's correct. It was localized to the area

3 around the tumor.

4 Q Okay. And how -- first of all, how does that

5 happen? How does the tumor cause localized swelling?

6 A Anytime there's a foreign body in the brain or

7 the spinal cord, those areas become upset. It's like a

8 bad neighbor, or something like that. You don't want that

9 person there, you know. So, basically, the brain is

10 reacting to this foreign body by having a lot of different

11 inflammatory markers around it, and you can see this edema

12 called vasogenic edema on imaging studies. And that's

13 what the patient had on the pre-operative CAT scans and

14 MRIs that were done.

15 Q How do steroids treat localized edema from a

16 meningioma?

17 A Yeah. Steroids are amazing at really decreasing

18 the inflammatory markers around the foreign body region,

19 which is causing this edema. And it really essentially

20 almost completely removes the vasogenic edema. I've seen

21 that happen so many times. And so the steroids just work

22 by decreasing the inflammation and essentially tricking

23 the brain to allow this foreign body to remain there, but

24 without causing the normal -- you know, unwanted changes

25 that would occur around that foreign body.



1 Q And in this case, we know that the steroids did

2 their job, for lack of a better term, with Ms. Davis

3 because of, one, that her symptoms went away, and two, she

4 did have a scan on the 19th that was compared to the 15th

5 and found to have less edema; correct?

6 A Yes, ma'am.

7 Q You listed a couple of things that you, as a

8 reasonably careful neurosurgeon, take into account when

9 they're weighing the risks and benefits of surgery. For

10 Ms. Davis, you mentioned her symptoms, her age.

11 Would the location of her tumor also be one of

12 those factors you take into account?

13 A Yes, ma'am.

14 Q The size of the meningioma?

15 A Yes, ma'am.

16 Q And then all of the information that you, as a

17 neurosurgeon can gather from her pre-operative imaging;

18 correct?

19 A Yes, ma'am.

20 Q And would one of those factors or pieces of

21 information you can gather from pre-operative imaging be

22 the vascular area of the tumor?

23 A Yes, ma'am.

24 Q On the pre-operative imaging that was done in

25 this case, can you see the meningeal arteries that are



1 feeding this tumor?

2 A Yes, ma'am.

3 Q And is that one of the bases for your opinion

4 that if surgery was going to be pursued at any point,

5 Ms. Davis -- the standard of care required Ms. Davis to be

6 referred for a consultation regarding pre-operative

7 embolization?

8 A Absolutely.

9 Q And why is it that pre-operative embolization for

10 Ms. Davis, given that we could see the arterial supply for

11 surgery, would have made surgery safer?

12 A Yeah. Well, the whole point of pre-operative

13 embolization is to identify any major feeders. We're not

14 talking about small feeders, but major feeders that can be

15 entered into and just closed off so that the surgeons can

16 have an easier time in surgery, which would, therefore,

17 correlate with the patient having a better outcome.

18 By closing off these big vessels, it decreases

19 the risk significantly of having any unwanted arterial or

20 venous vessels bleeding in surgery. So then, technically,

21 by this happening, it makes the resection of the tumor

22 safer and classically decreases the operative time, as

23 well.

24 Q And in this case, given the arterial feeders that

25 we can see on pre-operative imaging, it is your opinion



1 that the standard of care required pre-operative

2 embolization if this tumor was, in fact, going to be

3 operated on?

4 A Yes, ma'am.

5 Q You talked a little bit about your presentation

6 regarding the risks and benefits of the options for

7 treatment that you yourself have with your patients?

8 A Yes, ma'am.

9 Q Am I correct that part of your job as a

10 reasonably careful neurosurgeon is not only to present

11 those risks and benefits to the patient, but to weigh the

12 risks and benefits to yourself when making treatment

13 recommendations?

14 A That's correct.

15 Q I want to go through that a little bit with the

16 options that we have discussed in this case.

17 A Yes, ma'am.

18 Q You answered a lot of questions about the

19 possibility of risks for a number of different options

20 early on in this deposition; correct?

21 A Yes, ma'am.

22 Q So let's first talk about medical management.

23 Can you explain to me how, for Ms. Davis, the benefit of

24 medical management outweighed the risk of a gross total

25 resection?



1 A The benefit of medical management is clearly that

2 you're avoiding a major brain surgery. And in this

3 particular case, she had demonstrated really quick

4 improvement in her symptoms to the point where she was

5 able to be discharged home. And so following that trend,

6 I think she would have actually done quite well over the

7 long haul with medical management in this case, just based

8 on her response to the medications that were provided.

9 I think by seeing her response, I mean, that's

10 the best objective data to really utilize in this case.

11 Some people don't respond to those initial steroids and

12 seizure medicines that continue to seize and get worse

13 while in the hospital. And in that case, maybe a

14 different treatment would have been necessary, but I think

15 in this particular case, she really showed quite

16 significant improvement, which is pretty interesting to

17 see.

18 So I think -- I think she could have done quite

19 well with medical management over time. And then clearly,

20 the -- you know, the risks of surgery, especially with a

21 tumor in this particular region, the risks were higher

22 than the standard meningioma in the brain just given the

23 location and proximity to such important vascular

24 structures.

25 Q Am I correct that there was very low risk from



1 Ms. Davis with medical management?

2 A That's right. Correct.

3 Q And there was a very high risk of complications

4 with a gross total resection given the location of this

5 tumor?

6 A Yes, ma'am.

7 Q I want to turn then to radiosurgery. How did the

8 benefits of radiosurgery outweigh the risks of gross total

9 resection?

10 A The benefit of radiosurgery as compared to tumor

11 resection would be clearly the lack of needing a brain

12 surgery and its inherent risks. Also, stereotactic

13 radiosurgery, another benefit would be that tumors of this

14 size, typically three centimeters or less, these tumors

15 have shown a really good result in terms of stagnating

16 growth and often decreasing growth over time.

17 Radiation treatment works by sclerosing off the

18 vessels within the tumor bed. In other words, the

19 radiation shrinks down these arteries inside the tumor.

20 And so, therefore, by shrinking down those vessels, you're

21 shrinking blood supply to those tumors, which would,

22 therefore, cause the tumor to -- to, I guess, kill itself

23 in some way.

24 Q And am I correct that the radiosurgery for this

25 tumor carried a lower risk of complication to Ms. Davis



1 than a gross total resection?

2 A That's correct.

3 Q I might want to turn to the option of

4 pre-embolization of this tumor versus surgery without

5 pre-embolization. Okay? We talked about already some of

6 the benefits of pre-embolization. Am I correct that the

7 major benefits are decreasing the risk of intraoperative

8 bleeding and making the surgery all-over safer and

9 potentially shorter?

10 A Yes, ma'am.

11 Q And is it your opinion in this case that the

12 benefits of surgery with pre-embolization outweighed the

13 benefits of attempting a gross total resection?

14 A Absolutely.

15 Q And am I correct that if surgery was going to be

16 attempted, a partial resection with pre-embolization was a

17 lower risk option for Ms. Davis than attempting a gross

18 total resection?

19 A Absolutely.

20 Q And is it your understanding in this case that

21 instead of any of those other lower risk options,

22 Dr. Nardone's plan was to attempt a gross total

23 resection?

24 A That was my impression from the deposition.

25 Q You were asked a number of questions regarding



1 publications, some of which you were involved in and some

2 of which I don't think you are. Just generally speaking,

3 if you are going to state that an article is reasonable,

4 reliable or authoritative, you would have to review the

5 article itself; right?

6 A Absolutely.

7 Q And not all articles published by every journal

8 or even the NIH are reasonably reliable; correct?

9 A That is absolutely correct.

10 Q Before you would state here today or to one of

11 your students or to one of your colleagues that an article

12 was reasonable or reliable or authoritative, you would

13 read it, note who the author was; correct?

14 A Absolutely.

15 Q You were asked some questions about your

16 experience with tumors and meningiomas. But as it breaks

17 down overall between spine and brain, without getting into

18 the specifics of each, what is the percentage breakdown of

19 your practice currently?

20 A I would say roughly on an estimate basis 80

21 percent spine and 20 percent tumor. Or 20 percent brain,

22 not tumor.

23 MR. BRANDT: I'm sorry. I don't mean to

24 interrupt you, but your question really left it unclear to

25 me. Do you mind if I just ask a question real quick about



1 this?

2 MS. KING: Yeah, I'm going to get to it, I think,

3 because I'm clearing it up.

4 MR. BRANDT: I'm sorry. I just was -- maybe I

5 just lost your question.

6 MS. KING: No, it's all right.

7 MR. BRANDT: Thanks.

8 BY MS. KING:

9 Q You, as a neurosurgeon, you operate on spines and

10 treat pathology of the spine and you also treat pathology

11 of the brain; correct?

12 A Yes, ma'am.

13 Q And as we sit here today, your practice is about

14 80 percent spine and, you think, about 20 percent

15 brain?

16 A Yes, ma'am.

17 Q And then within your percentage of your practice

18 that is brain, you treat various pathologies including

19 meningioma?

20 A That is correct.

21 MS. KING: Did that clear that up?

22 MR. BRANDT: It did. Thank you. I apologize.

23 THE WITNESS: I'm sorry if I wasn't clear.

24 MR. BRANDT: No, no, no. I'm the one who should

25 apologize.



1 BY MS. KING:

2 Q And in your training and experience when it's

3 comes to meningiomas, you yourself have performed

4 radiosurgery on them; correct?

5 A I have.

6 Q And would that be with both CyberKnifing and

7 Gamma Knifing?

8 A Yes.

9 Q You trained in both of those radiosurgical

10 techniques?

11 A Yes, ma'am.

12 Q And have all the opinions you've given us here

13 today, unless you stated otherwise, been to a reasonable

14 degree of medical certainty?

15 A Yes, ma'am.

16 MS. KING: Thank you. I have no more questions.

17 THE WITNESS: Thank you.

18 MR. BRANDT: I have a few follow-ups.

19 Okay?

20 THE WITNESS: Yes, sir.

21

22 FURTHER EXAMINATION

23 BY MR. BRANDT:

24 Q Dr. Nardone's surgery involved some removal of

25 devitalized brain tissue.



1 Do you have any understanding or opinion as to

2 how much brain tissue was removed as a part of this

3 surgery in September of 2014?

4 A That's difficult to quantify.

5 Q Yeah. I'm going to offer up to you that there's

6 nothing charted about that.

7 Would that be true?

8 A Yeah. There's -- it is hard to quantify that

9 because, you know, you either have to weigh it or measure

10 the dimensions of the tissue removed and sometimes some

11 brain get suctioned up into the suction. You don't really

12 account for that.

13 Q The -- I think Dr. Nardone's operative note talks

14 about the proposition that he was able to -- he wrote

15 this. I'll just read this so it will be fair to

16 everybody. This is on page 2 of his operative note. "A

17 nice border was identified superiorly and laterally, and

18 then was detaching the tumor from the tentorial attachment

19 as well as the attachment to the transverse sinus."

20 Do you read that to believe that he was able to

21 pull the tumor off the transverse sinus? Am I reading

22 that correctly?

23 A My interpretation, yes, is that there was a nice

24 border between the tumor and the various attachment sites.

25 Q Okay. The -- you talked about the -- sorry. I'm



1 just having trouble reading my writing. You were asked

2 questions about the location of her meningioma. And you

3 said this: "There was a higher risk than a standard

4 meningioma." And I didn't know what you meant by that.

5 A What I --

6 Q How are you differentiating?

7 A I should have been more clear. I apologize.

8 Q It's all right. That's why we're asking

9 questions.

10 A All I meant was the location of it.

11 Q Okay.

12 A So the location of this tumor was near and on

13 the -- and below the transverse sinus. So -- and that's a

14 major drainage pipeline of all of our veins of our brain.

15 They all go through the transverse sinus down into our

16 neck veins. So that's what I meant by that.

17 MR. BRANDT: Okay. Let's take a break. I'm

18 going to have to meet with Dr. Nardone for a minute.

19 Probably pretty close to being done.

20 THE WITNESS: Thank you, sir.


22 BY MR. BRANDT:

23 Q I want to clarify. You were going to -- you were

24 being asked to testify today that got continued or

25 canceled or something?



1 A Yes, sir.

2 Q And you were going to testify as an expert

3 witness?

4 A Yes, sir.

5 Q Was it a medical negligence claim, a malpractice

6 claim?

7 A I can't recall the details of it.

8 Q Okay. Was it a brain tumor case?

9 A No.

10 Q Have you ever been sued? Did I ask you that?

11 A No. Let's keep it that way.

12 Q Okay. Appreciate that. I appreciate from your

13 testimony today that steroids are given pre-operatively to

14 a patient who presents like Ms. Davis does to the

15 emergency department; correct?

16 A Yes, sir.

17 Q Regardless of what treatment she's going to have,

18 whether it's conservative management, medical management,

19 SRS or surgery or a combination of all three, she's going

20 the get steroids; right?

21 A Yes, sir.

22 Q Once those steroids are stopped, however, the

23 edema is likely to return; true?

24 A That's not always the case. Sometimes it

25 doesn't.



1 Q Sometimes it does, though. It is a risk?

2 A Yes, sir.

3 MR. BRANDT: Those are all the questions I have.

4 THE WITNESS: The pleasure is all mine.

5 MR. BRANDT: Thank you.

6 Do you want to tell him about signature?

7 MS. KING: Yeah, we went over that.

8 MR. BRANDT: Okay.

9 MS. KING: We reserve signature.

10 MR. BRANDT: Okay. Thanks for your time. It's

11 nice to meet you.

12 THE WITNESS: Pleasure meeting you both.

13 MR. BRANDT: I am going to make a record that I'm

14 not going to attach any of this.

15 Okay?

16 MS. KING: Okay. Do you want to give her the

17 copy?

18 MR. BRANDT: She can have it. I'm just not going

19 to --

20 MS. KING: Are we on the record for this?

21 MR. BRANDT: Yeah, we're on the record.

22 Okay?

23 So, for the record, I am going to give you the

24 exhibits that we made reference to.

25 MS. KING: I'll put it in there.



1 MR. BRANDT: Thank you.

2 Exhibit 1 was the notice for the deposition

3 today, and the rider. No. 2 was the plaintiff's rule

4 213(f)(3) disclosure for Dr. Kaloostian with his CV

5 attached. No. 3 was a production dated August 12th, 2019,

6 from Sarah King to me which listed his e-mail, case list,

7 invoices, curriculum vitae and 213 opinions. No. 4 was a

8 copy of the complaint at law filed November 5, 2015, with

9 the attached health care professionals report. I'm not

10 going to attach those, unless somebody wants them. Except

11 I am going to give those to the court reporter so that she

12 can use those for whatever purposes. I just don't need

13 another copy back.

14 Okay?

15 MS. KING: Okay.

16 MR. BRANDT: Does that sound good?

17 MS. KING: Sounds good.

18 MR. BRANDT: All right. Here you go.

19 (Defendants' Exhibits 1 - 4 were marked

20 for identification and Retained by Counsel.)

21 THE REPORTER: Ms. King, did you want a copy of

22 the transcript?

23 MS. KING: Plaintiff will order an e-tran,

24 regular delivery.

25 MR. BRANDT: And so in Illinois -- I'm just going



1 to tell you this.

2 THE REPORTER: We're off the record, though;

3 right?

4 MR. BRANDT: You can put it on the record. I

5 don't care.

6 In Illinois, he -- you have to send him the

7 original for review and signing and an errata sheet.

8 Okay?

9 And then we'll get copies. And I'll pay -- I

10 paid for the original. Okay? But I don't get charged for

11 a copy.

12 THE REPORTER: Correct. So an original and one,

13 just to make sure. So you're doing it where you're

14 sending the original -- not the original. You're

15 sending -- I mean, you're sending the original to --

16 MR. BRANDT: Original goes to him.

17 THE REPORTER: Original goes to him, and then a

18 copy to you?

19 MR. BRANDT: Copy to me. That's it.

20 THE REPORTER: And that's it.

21 MR. BRANDT: And she wants a copy.

22 THE REPORTER: And you want a copy in addition to

23 that.

24 MR. BRANDT: So you need to get his e-mail

25 address, or whatever it is, however he'd like it, if you



1 would, please, Donna. And, Donna, I would like a PDF,

2 four to a page, four to a page.

3 THE REPORTER: Got it.

4 MR. BRANDT: Mini script.

5 (The deposition proceedings

6 were concluded at 10:24 a.m.)

7 -oOo-

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25



1 PENALTY OF PERJURY CERTIFICATE

2

3

4 I hereby declare I am the deponent in the

5 matter within, that I have read the foregoing transcript

6 and know the contents thereof; that I declare that the

7 same is true of my knowledge, except as to the matters

8 which are therein stated upon my information or belief,

9 and as to those matters, I believe them to be true.

10 I declare being aware of the penalties of

11 perjury; that the foregoing answers are true and correct.

12

13

14

15 Executed on the ____ day of _____________,

16 2019, at _____________________________________ California.

17

18

19 _________________________

20 Paul Kaloostian, M.D.

21

22

23

24

25



1 REPORTER'S CERTIFICATE

2 STATE OF CALIFORNIA ) ) ss.

3 COUNTY OF LOS ANGELES )

4 I, DONNA BALL, CSR 11191, Certified

5 Shorthand Reporter No. 11191, in and for State of

6 California, do hereby certify;

7 That the deponent, PAUL KALOOSTIAN, M.D.,

8 named in the foregoing deposition, prior to being

9 examined, was by me first duly sworn to testify to the

10 truth, the whole truth and nothing but the truth;

11 That said deposition was taken before me at

12 the time and place herein stated and was thereafter

13 transcribed into print under my direction and supervision,

14 and I hereby certify the foregoing deposition is a full,

15 true and correct transcript of my shorthand notes so

16 taken.

17 I further certify that I am not of counsel

18 nor attorney for either of the parties hereto or in any

19 way interested in the events of this case and that I am

20 not related to either of the parties hereto.

21

22 Witness my hand this 6th day of September,

23 2019.

24 ______________________________ DONNA BALL, CSR NO. 11191

25

CORRECTION SHEET

PAGE/LINE FROM TO


Huntington Court Reporters & Transcription, Inc.600 S. Lake Avenue, Suite 102, Pasadena, CA 91106 1-626-792-6777

90

CORRECTION SHEET

PAGE/LINE FROM TO


Huntington Court Reporters & Transcription, Inc.600 S. Lake Avenue, Suite 102, Pasadena, CA 91106 1-626-792-6777

91



WORD INDEX

< $ >$10,000 16:7$5,000 16:7$700 13:7, 15

< 1 >1 3:9 39:3, 15 40:9 85:2, 1910 9:17 14:510:24 87:6100 42:24102 1:1611191 1:19 89:4,5, 24115 2:1212 3:17120 2:612th 3:13 85:513 14:514 53:714th 30:18 37:3 43:1115 1:7 9:18 53:7157 1:715th 72:416 1:18 4:1 53:1319th 72:4

< 2 >2 3:11 5:13 17:15 36:11 37:23 39:15, 21 52:22 58:16 62:11 81:16 85:320 7:13 58:3 78:21, 21 79:142010 60:152014 38:3, 12, 12 81:32015 66:7 85:82017 57:152019 1:18 3:15,17 4:1 85:5 88:16 89:2321 59:17213 3:11, 16 5:16,17 36:10 85:4, 722 58:17220 60:23228 61:24, 24229 61:24235 61:242622 16:1428 61:24

< 3 >3 3:11, 13, 16 5:5,9 6:2, 6 10:19

37:24 53:24 57:16 85:4, 530 59:11309 2:1330-C 59:10312 2:731st 2:634 60:1339 60:23

< 4 >4 3:18 16:22 85:7, 1940 61:23400 2:12

< 5 >5 3:6 10:18 85:850 8:850-50 15:3, 4

< 6 >600 1:1660602 2:761701 2:1362 31:963 31:9 37:12 70:263-year-old 69:2565 3:76th 89:22

< 8 >8:11 1:17 4:280 3:6 78:20 79:14828-5281 2:1385 3:9, 11, 13, 18899-9090 2:7

< 9 >90 10:1591109 1:1795 10:15

< A >a.m 1:17 4:2 87:6ability 56:14able 32:9 57:7 75:5 81:14, 20Absolutely 30:15 39:1 61:12 68:15 73:8 77:14, 19 78:6, 9, 14account 72:8, 12 81:12accurate 17:21 38:22achieve 20:23

21:1achieves 27:8acronym 11:7active 20:23 21:1 24:5 37:11 41:7, 8actively 37:20addition 55:14 86:22address 86:25adjacent 42:14, 19 43:1 70:3adjunctive 38:6ADLs 62:20advanced 58:1advertise 7:14affect 31:21 42:19age 72:10aggressive 37:23 70:8ago 7:9 8:6 11:21 17:13, 19agree 20:7, 22 21:17 25:8 27:5,9 36:3 40:20 41:8 51:13, 23, 23 67:23ahead 16:16aid 52:5, 12aids 52:3alcohol 20:8, 13 21:6alive 37:11All, 48:9all-over 77:8allow 71:23altered 24:10alternative 68:22alternatives 31:3, 4amazing 71:17amenable 12:1 33:14Amended 3:9amount 68:16anatomic 36:5anatomy 33:9, 12ANGELES 89:3angiogram 48:8angry 67:4, 5answer 7:11 23:16 29:16 34:24 38:9 39:19 60:22 62:1 67:19ANSWERED 3:21 29:24 51:4, 4 68:6 74:18answering 30:16answers 88:11anticipation 52:8,16anti-epileptics 31:5

anybody 18:14Anytime 71:6anyway 26:4apologize 49:7 51:2 61:24 63:25 79:22, 25 82:7APPEARANCES 2:1applicable 4:16appreciate 8:16 59:6 83:12, 12approach 27:15,21, 24, 24 29:7 31:1 38:12, 15, 23 39:14approached 32:4approaches 28:13,17 38:25 40:5appropriate 40:5 45:14 69:11, 25 70:5appropriately 57:8arbitrarily 58:2area 14:15 23:11 42:25 67:3, 6 69:2, 3 71:2 72:22areas 31:19 66:11,16 71:7arrest 20:23 21:2arterial 33:2 50:24 73:10, 19, 24arteries 69:6 72:25 76:19artery 35:23, 25 50:9, 12, 13article 78:3, 5, 11articles 42:5 78:7asked 29:23 33:21 41:12 77:25 78:15 82:1,24asking 28:25 30:17 34:12 82:8assistant 57:15associated 21:18,22 23:1 25:7assume 43:7, 15 45:10Assuming 46:3Ataxia 24:1attach 84:14 85:10attached 5:8 16:13, 24 17:4, 13,15 58:4 85:5, 9attachment 81:18,19, 24attempt 77:22attempted 77:16attempting 77:13,

17attorney 89:18August 1:18 3:13,17 4:1 85:5author 78:13authored 18:8 58:6authoritative 78:4,12authors 21:14Avenue 1:16avoiding 56:1, 9 75:2aware 6:7 21:24 54:2 88:10

< B >back 13:19 36:11 38:3 46:3, 4, 9, 10 56:20 58:20 59:22 60:4, 15 64:3 85:13backwards 65:13bad 71:8BALL 1:18 89:4,24Baltimore 57:20Barbara 40:14, 16BARGER 2:11based 10:24 57:25 75:7bases 73:3basic 53:16basically 67:3 71:9basis 36:4 78:20beams 42:25Bear 62:4bed 76:18bedside 58:22behalf 1:15behavior 24:13behavioral 24:12,13 25:5belief 49:9 88:8believe 6:19 15:6 16:5 18:12 22:15 30:17 32:14, 14 43:11 52:11 54:6,15 57:6 58:18 68:9 70:1 81:20 88:9beneficial 32:18 56:7benefit 22:5 56:5,8 74:23 75:1 76:10, 13benefits 55:10, 15,24, 25 56:3 72:9 74:6, 11, 12 76:8 77:6, 7, 12, 13



benign 41:10 69:20best 43:24 75:10better 9:7 26:2 30:5 34:23, 24 63:6 67:23 72:2 73:17big 32:2 45:2 73:18biggest 42:19bill 13:10, 12, 14,15bills 5:7biopsy 37:16, 21birth 31:8bit 10:10 22:25 42:13 56:19 63:25 70:14 74:5,15bleeder 50:24bleeding 12:13, 18,21 21:8 28:22 49:4 50:18 55:18,20 66:1, 19 70:17 73:20 77:8blood 32:13, 16 33:23 50:21, 23 69:5, 5 76:21bloody 56:6Bloomington 2:13 13:18 15:17board 19:9 61:6body 71:6, 10, 18,23, 25book 61:2border 81:17, 24bottom 52:22brain 9:15 12:22,25 14:10, 16, 24 17:25 18:2, 3 20:9 25:25 26:9,17, 18 29:3 30:7 42:14, 15, 22, 25 51:10 56:1, 9 59:2, 3, 8, 25 60:12 61:25 65:20 66:2, 3, 11,17, 22, 25 67:3, 7,9 70:15, 18, 25 71:6, 9, 23 75:2,22 76:11 78:17,21 79:11, 15, 18 80:25 81:2, 11 82:14 83:8branch 50:11branches 35:24BRANDT 2:11, 11 3:6, 15 4:11 5:17,20 6:10 13:12, 17 16:19, 21 17:10 21:21 23:16, 19

30:4, 11 40:8 45:8 48:19, 23 49:1 53:8, 15 59:13 63:9, 12, 15 64:19 65:6 67:18 68:5 78:23 79:4,7, 22, 24 80:18, 23 82:17, 22 84:3, 5,8, 10, 13, 18, 21 85:1, 16, 18, 25 86:4, 16, 19, 21, 24 87:4breach 22:2break 10:6 48:23,25 63:9, 14 82:17,21breakdown 78:18breaks 78:16bring 4:22 65:23bunch 32:2

< C >Cal 7:20calcification 31:19 34:25calcified 31:17, 25 34:17California 1:17 4:1 15:25 57:6 88:16 89:2, 6call 4:21 13:21 36:9 38:24called 16:6 68:8 71:12calms 44:25canceled 82:25candidates 34:18 35:1care 11:24 12:9,24 13:1 21:12 22:2 26:19 27:18 28:14, 18 29:1, 13,22 30:3, 25, 25 31:1 34:11, 13 38:1, 12 67:25 68:12 70:12 73:5 74:1 85:9 86:5career 58:1careful 69:3 72:8 74:10carotid 32:17carpal 14:21carried 76:25carries 32:19Case 1:7 3:15 5:14 12:14 13:5 18:5, 20 19:6 24:16 25:23 28:15, 16, 17, 20,20, 25 29:3 31:11,23 36:23 37:2, 25

39:16 45:3 49:9 50:25 54:14, 18 55:7 56:16 58:19 60:11, 19 62:9 65:14 68:23 69:7 70:1, 11, 21 72:1,25 73:24 74:16 75:3, 7, 10, 13, 15 77:11, 20 83:8, 24 85:6 89:19case-by-case 36:4cases 6:11, 22 7:1 8:3, 11 9:3, 6 10:16 14:7, 9, 12,16, 21, 22 15:5 16:5 22:22 32:12 47:6 60:9CAT 37:7 71:13cause 70:8 71:5 76:22caused 12:21 22:21 66:12, 19causing 25:19 31:10 40:19, 23 41:3, 9 50:18 71:19, 24centimeters 11:25 76:14CENTRAL 1:8certain 48:11, 12certainly 21:13, 25 39:20 40:22 42:17certainty 29:15 80:14CERTIFICATE 88:1 89:1Certified 1:19 89:4certify 89:6, 14, 17change 31:7 37:10 43:15changes 24:12, 13 25:5 71:24characteristics 10:24 36:5characterize 12:3charge 15:7, 14,17 16:2, 3charged 86:10charted 81:6Chicago 2:7 15:16chiropractic 14:23chopping 68:16CIRCUIT 1:2, 2circulation 32:17circumstances 16:3citations 18:17, 17claim 83:5, 6clarify 82:23classically 73:22classroom 58:22

clear 28:23 36:17 66:1 79:21, 23 82:7clearing 79:3clearly 75:1, 19 76:11client 4:18 26:13CLIFFORD 2:5close 15:4 32:5 82:19closed 73:15closing 73:18co-authored 18:8 58:6cognitive 62:14colleagues 12:16,20 78:11combination 83:19come 5:14 15:8 16:17 45:3comes 25:16 44:6 46:4 80:3coming 13:18, 19 46:10 61:5commencing 1:17common 20:18, 21 21:17, 22 38:2, 4,12, 15commonly 20:14Community 35:15company 7:21compared 72:4 76:10Complaint 3:18 16:13, 25 85:8complete 5:10 68:24completed 61:15completely 32:1 71:20complication 12:17, 18 49:4 67:11 76:25complications 12:13 34:5 47:4,5, 8, 17, 18, 21, 25 62:16 66:23 76:3comprehend 56:15concept 68:8concern 37:15 42:17concluded 87:6condition 62:8confusion 24:8 25:2consent 52:23 54:14, 16, 25 55:1conservative 30:22 55:2, 25 64:1 83:18

conservatively 44:2 55:9consideration 22:17 55:4considered 36:4consultation 73:6consuming 61:11contained 6:1, 5 62:11content 70:14contents 88:6context 54:25 55:1Conti-Medical 3:18continue 37:14 45:12 53:12 56:21 75:12continued 45:5 66:7 82:24continuing 36:21 64:20contraindicated 34:22contrary 42:5controlled 66:14convey 52:12coordination 47:2,23copies 86:9copy 84:17 85:8,13, 21 86:11, 18,19, 21, 22cord 71:7Corona 35:15corporation 1:9 8:18Correct 19:7 24:23 25:12 28:12 40:3 44:16,17, 22 61:22 63:8 65:17 66:20, 23 67:12 68:4 69:12,17 70:18, 22, 24 71:2 72:5, 18 74:9, 14, 20 75:25 76:2, 24 77:2, 6,15 78:8, 9, 13 79:11, 20 80:4 83:15 86:12 88:11 89:15correctly 81:22correlate 73:17COUNSEL 2:1 3:9 85:20 89:17COUNTY 1:3 89:3couple 14:21, 22 17:19 37:19 43:12, 16 49:2



65:7 72:7course 41:6Court 4:17 6:18 13:23 85:11cover 49:2 56:11 57:7covered 46:6 51:1cracking 58:5cranial 20:9 35:25Craniotomy 9:25 26:20 38:13, 23 39:22 45:15 46:23 47:5, 9, 13created 67:8CSR 89:4, 24CT 26:5 51:1, 6 52:10 65:15, 25CTA 26:5 51:6,13, 23 52:10curious 57:24current 19:3, 3currently 7:2 58:23 78:19curriculum 3:16 85:7cutoff 51:18CV 9:10 17:15,21, 25 19:8, 15 56:20 58:3, 4 59:10 85:4CyberKnifing 80:6

< D >daily 15:18damage 65:20, 24dangerous 69:2data 16:9 75:10date 17:22dated 3:13, 17 17:16 85:5DAVIS 1:5 19:6 24:16 27:13, 25 28:16, 16 29:7 30:8, 9, 13 31:14 37:1 43:4 46:3 54:20 56:14 62:7 65:24 66:16, 22 67:1 68:13 70:11,16, 24 72:2, 10 73:5, 5, 10 74:23 76:1, 25 77:17 83:14day 5:7 15:17 37:5 59:22 88:15 89:22days 28:24 30:22 42:23day-to-day 62:20deal 60:12deals 18:9

dealt 60:13debulk 68:17debulking 68:8, 15 69:7, 10, 25 70:4December 66:7decisions 11:19declare 88:4, 6, 10decline 62:14declined 46:11, 14declines 46:17decrease 55:23decreases 73:18, 22decreasing 32:13 71:17, 22 76:16 77:7defect 67:6DEFENDANT 2:10 15:2Defendants 1:10,16 3:9 85:19defer 64:24, 24deferring 62:10deficit 41:19deficits 27:2 62:15defined 12:6definite 51:18definition 11:22,24degree 29:15 80:14delivery 85:24demonstrate 51:14, 24demonstrated 51:10 75:3demonstrating 67:8demonstrative 52:3, 5department 24:17 26:14 44:6 83:15depending 36:4 38:18depends 13:2 28:15deponent 4:6 88:4 89:7deposed 4:7DEPOSITION 1:15 3:11 4:13,20, 22 69:9 74:20 77:24 85:2 87:5 89:8, 11, 14depositions 6:20 14:3, 8describe 65:22described 25:4, 14 49:22 52:9DESCRIPTION

3:9desires 45:22detaching 81:18details 83:7determining 10:23devascularization 27:7develop 45:19 46:23 47:9devitalization 12:21, 25devitalized 80:25diagnosis 25:10diem 15:14, 15 16:6difference 34:7differences 27:12 34:5different 15:8, 10 28:19 29:6 30:9 31:1, 12 42:25 54:21 57:23 58:1 66:11 70:16 71:10 74:19 75:14differentiating 82:6differently 29:7difficult 21:8 70:3 81:4dimensions 81:10direction 89:13disability 15:5disagree 27:10 35:3, 4 40:25 41:25 42:3, 4, 8 51:21 52:1discharged 75:5Disclosure 3:13 5:12 52:20 53:5 54:15 85:4Discovery 3:9 4:12discuss 18:10 22:5 32:18 52:18 55:2, 19, 24 56:12discussed 20:2 22:11, 14 30:7 47:11 52:7 55:10,16 74:16discussing 31:3discussion 6:9 48:16 56:15Disorientation 23:20 24:20dissection 32:22distinguishes 31:14disturbances 23:9,12Doctor 4:19doctors 57:1

document 4:25 16:13 17:11 53:17, 20 54:3documented 21:11documenting 31:3documents 5:13doing 8:25 14:4 63:4, 6 86:13DONNA 1:18 87:1, 1 89:4, 24doses 45:1Dr 4:13, 18 22:20 26:13 29:12 32:9 46:22 49:22 50:2 63:10 65:16 77:22 80:24 81:13 82:18 85:4drafts 53:20drainage 69:5 82:14drawer 7:1Drawings 52:6duly 4:7 89:9

< E >earlier 14:7 47:11early 74:20easier 73:16easily 49:23ED 25:17 44:11edema 26:11, 12,17 30:7 41:20, 21 51:10 70:15, 18,22 71:11, 12, 15,19, 20 72:5 83:23editorial 19:9education 29:5effect 49:24 70:25efficacy 31:21either 45:15 70:6 81:9 89:18, 20ELEVENTH 1:2eliminate 63:22, 23e-mail 3:15 85:6 86:24embolic 20:24 21:2Embolization 20:8,14 21:7 22:4, 9 26:23 27:5, 8 28:5, 21 31:21 32:1, 5, 18, 19 33:10, 13, 16 34:6,18, 22 35:1, 5, 22,24 36:3 38:9, 14 48:17 55:5, 19, 20 56:5 73:7, 9, 13 74:2embolize 32:10, 11embolized 33:24

emergency 24:17 26:14 28:23 44:6 70:21 71:1 83:15EMILIO 1:8 2:17 3:18employed 35:17,21ensuing 27:1entail 56:25enter 49:20entered 49:21 73:15entire 15:17ER 43:17errata 86:7especially 40:18 41:2 66:4 69:25 75:20ESQ 2:5, 11essentially 49:19 51:17 68:16 71:19, 22established 51:9estimate 7:4, 6 8:7, 14, 16 9:17 13:7 14:2 78:20estimated 33:23estimating 10:19e-tran 85:23Evaluators 7:20events 89:19everybody 81:16evidence 49:16, 17 50:17 65:20exact 7:6 11:23 15:12 16:8exactly 6:13 15:4 20:18Exam 58:11, 14EXAMINATION 3:5 4:10 65:11 80:22examined 89:9example 55:16, 25Executed 88:15executive 66:13, 13exhausting 30:22Exhibit 5:4, 9, 13 6:2, 5 16:22 17:15 36:10 52:21, 22 53:24 62:11 85:2EXHIBITS 3:7 4:19 16:12 84:24 85:19experience 19:1 21:14 29:5 65:4 70:17 78:16 80:2expert 7:15, 18 8:19 13:24 14:4 16:17 83:2



explain 68:11 74:23extension 23:10extensive 27:7external 32:17extremely 34:1 42:22 68:4

< F >Facial 33:18fact 21:24 74:2factors 36:6 72:12, 20failure 20:23 21:1fair 9:13 26:3 42:7 81:15fancy 68:15far 10:12 27:12 57:10feeders 73:13, 14,14, 24feeding 73:1feel 68:19fees 8:18field 23:3Fifty 8:11figured 69:16file 7:1filed 85:8films 67:2finalized 54:5find 6:14, 15fine 8:17 13:13 35:20 45:8 56:18 64:24firm 6:18, 20first 4:7, 20 5:21 43:25 44:22 71:4 74:22 89:9five 9:20 10:16 14:2Floor 2:6flow 32:16focus 9:12 23:20focused 16:21follow 37:14 44:1 69:17followed 11:12 38:8, 14 45:5 55:8following 31:5 75:5follows 4:8follow-ups 80:18foregoing 88:5, 11 89:8, 14foreign 71:6, 10,18, 23, 25forever 44:13forget 13:4Form 29:23

30:10 67:18, 23found 25:25 72:5foundation 29:23four 16:12 17:13 28:24 87:2, 2frame 36:18, 20Friday 1:18 4:1frontal 65:24 66:4, 9, 14 67:14 68:2full 70:25 89:14full-day 16:5functioning 66:13funneled 8:19FURTHER 80:22 89:17

< G >games 49:8Gamma 80:7gather 72:17, 21gears 22:24 56:18general 18:25 29:2 40:6 41:25 54:17 69:13generally 34:19 36:24 40:7 69:20 78:2getting 68:18 78:17give 8:6 38:9, 21 45:1 58:25 59:5,9 61:9 84:16, 23 85:11Given 6:20 14:3,8 34:18 43:10 52:16 70:1 73:10,24 75:22 76:4 80:12 83:13giving 8:16 29:14 52:16glued 50:9, 13go 5:18 8:22, 22,23 10:5, 8 11:5, 6,9 12:6, 8 16:16,18 22:17 37:24 38:6 48:22, 24 64:3 65:13 74:15 82:15 85:18goes 8:24 38:17 86:16, 17going 4:19 10:5,7, 7 11:5, 6, 9, 11,14 13:10 14:24 16:21 17:17 18:10 22:17 26:1 28:6 29:6 35:23 36:11 42:18, 25 43:3, 4, 18 44:20 45:20 46:12, 13 50:4 51:3 53:3

54:10 56:20 58:4 60:7 62:8, 9, 19,21 63:9 64:10 65:13 67:22 69:7 73:4 74:2 77:15 78:3 79:2 81:5 82:18, 23 83:2, 17,19 84:13, 14, 18,23 85:10, 11, 25good 52:15 64:19 69:8 76:15 85:16,17Gordhan 50:2, 2G-o-r-d-h-a-n 50:3grade 37:23, 24 39:3, 6, 20 40:9graduated 61:7great 57:1greater 41:22gross 69:10, 11 70:10 74:24 76:4,8 77:1, 13, 17, 22group 35:8groups 35:17growing 37:20 40:18grown 37:17growth 56:10 63:17 76:16, 16guess 5:21 10:19 13:4 21:5 39:9 52:14 53:16 61:4 64:14 76:22guys 48:20

< H >half 8:6, 7 9:1hand 4:19 17:17 36:11 89:22handed 5:1hang 61:13happen 22:23 24:9, 11, 15 33:3 34:2 47:6, 10 71:5, 21happened 12:14,16 14:22happening 42:22 73:21happy 13:22 67:9hard 8:6 38:7, 9,21 81:8haul 75:7head 39:12Headache 23:14 24:18headaches 46:5healing 20:10HEALTH 1:8 19:18 39:2, 7

41:13 85:9healthy 30:20he'd 86:25held 6:9help 57:13 62:5 63:16 64:11 65:1,5helped 22:22 32:5 45:4helpful 28:21 32:2, 13helping 64:15, 21hemorrhage 20:23 21:2, 18, 23 22:1hemorrhagic 33:5hereto 89:18, 20herniated 66:22herniating 67:7herniation 66:25 67:3, 10High 20:22, 25 21:1 76:3higher 75:21 82:3hole 67:7home 37:4 75:5honest 39:8Honestly 7:10 13:6 15:12 16:8 65:1hopefully 36:3Hopkins 57:19hospital 35:14, 15,17, 21 57:19 75:13hospitals 35:18 57:2, 6, 10hot 48:19, 20hour 13:7, 16 16:3hourly 15:8, 18how-to 58:8Huh 16:15hundred 38:16hypothetical 12:11 46:4, 9hypothetically 21:5 22:3 26:25 32:21 43:7 45:10

< I >identification 85:20identified 81:17identify 73:13ILLINOIS 1:1, 8 2:7, 13 4:17 13:18 85:25 86:6image 43:18, 20, 23imaged 43:8images 25:22 50:25 52:9, 17, 18

imaging 10:25 26:4 28:2, 3 31:6,16 32:2 36:5 43:4 44:1 55:3, 9 65:14 69:17 70:7 71:12 72:17, 21,24 73:25impairment 23:7important 10:23 61:13 75:23impression 77:24improved 37:3 44:10improvement 75:4,16include 23:2 26:19 28:5 38:14 39:21 42:14 55:17, 19 56:4, 9 65:15 67:25including 55:2 79:18income 7:8, 8, 12incomplete 55:17increased 55:21increasing 41:19indicate 26:9indicated 37:21individual 8:3individualize 11:2,18infarct 33:6infection 55:18inflammation 44:25 71:22inflammatory 71:11, 18INFORMATION 3:24 4:21 15:13 16:11 19:19 63:3,5 72:16, 21 88:8informed 52:22 54:14, 16, 25 55:1inherent 76:12initial 43:9, 17 45:1 70:21 75:11initiation 24:5, 6injured 14:23 49:10 66:17 68:3injury 14:16, 19,23 20:9 22:21 42:14 66:12 67:1,13inside 32:3 66:3 76:19Institute 7:18 19:18 41:13integral 31:7intense 56:6interested 89:19interesting 75:16



interpretation 81:23interrupt 78:24interventional 32:7 35:9interventions 56:3intracranial 60:18intraoperative 22:1 77:7intraoperatively 21:9investigated 21:14invoices 3:16 85:7involve 9:6 50:23involved 14:8, 9 49:17 50:3, 18 60:9 78:1 80:24involves 27:7 67:12involving 9:3 66:11ischemic 33:5issue 31:2 45:2 52:20 53:4 54:17 63:16 69:1its 76:12

< J >Jefferson 2:12JO 1:5job 72:2 74:9John 40:13 57:19join 61:6Journal 19:21, 25 20:2 42:2 78:7journals 19:25 20:1JSN 19:12JUDICIAL 1:2

< K >KALOOSTIAN 1:15 3:3, 13 4:5,13 22:20 32:9 46:22 85:4 88:20 89:7KAPLAN 13:9keep 19:2 44:23 83:11Keppra 45:12 46:6 64:7, 22key 48:9kill 76:22kind 5:5 31:1 36:13 45:17 58:8 60:22KING 2:5 3:7, 15 5:16, 18 13:10, 15 16:16, 20 17:7 21:20 29:23 30:10 40:6 45:7

48:22 52:2 53:7,12 54:4 59:11 64:17 65:7, 12 67:21 68:7 79:2,6, 8, 21 80:1, 16 84:7, 9, 16, 20, 25 85:6, 15, 17, 21, 23knew 60:22Knifing 80:7know 5:2 6:17 7:6, 10, 10 8:14 10:18 11:23 13:9 15:20, 21, 22 16:10 17:21 18:5 20:17, 20, 20 21:11 24:16 32:9,11 34:18 35:18,20, 20 38:22 40:13 42:20 44:3 46:6 48:12, 13 50:2 52:3, 12 57:21 59:6 61:25 64:13, 25 66:1 69:1, 2, 3, 9 70:8 71:9, 24 72:1 75:20 81:9 82:4 88:6knowledge 18:25 58:16 88:7known 12:17 47:4, 17, 21, 24Known, 48:1

< L >lack 54:16 72:2 76:11Lake 1:16Large 32:22 40:18larger 33:23LaSalle 2:6laterally 81:17LAW 2:5 3:18 6:16 85:8lawsuit 16:13 17:4, 12lead 26:23 27:1 67:1leaving 68:19lecture 59:5 61:4,9, 25left 63:10 68:21 78:24legal 8:5Letter 3:16 59:10levels 57:23License 1:19Licensing 58:11lied 16:12ligated 49:10

limit 43:1line 11:22 37:23list 3:16 85:6listed 5:22 19:15 72:7 85:6listing 5:12lists 3:15literature 18:14 19:3 34:9, 15 41:4, 6liters 50:20litigation 7:3little 10:10 22:24 42:13 56:19 63:25 67:23 70:14 74:5, 15LIVINGSTON 2:11LLP 2:11lobe 23:2 65:24 66:4, 4, 8, 9, 9, 9,14 67:14, 14, 14,15, 16, 17, 24 68:2,2, 3, 3, 14localized 70:22 71:2, 5, 15located 38:19location 30:8 36:5 70:3 72:11 75:23 76:4 82:2,10, 12locums 56:21, 24 57:1, 12long 41:24 61:14 75:7long-term 8:7 64:7look 7:24 18:4 24:24, 25 53:1, 2,9 58:3, 16, 16, 20 59:10 60:13, 22 61:23Looked 6:22 9:10 10:10 19:8 25:22 33:22 51:6, 16 64:13looking 13:5 17:12 49:9 53:17 65:25 66:6looks 16:17 17:20,21 19:8 48:15 60:16LOS 89:3Losing 50:23loss 20:10 23:2,20 24:3, 5, 6 32:13 33:23 50:20lost 79:5lot 16:10 38:17 53:3 60:8, 9

63:10 71:10 74:18low 42:22 75:25lower 33:19 76:25 77:17, 21

< M >M.D 1:8, 15 2:17 3:3, 13, 18 4:5 88:20 89:7ma'am 65:9, 18,21 66:15, 18, 21,24 68:10 69:14,18, 23 70:13, 19 72:6, 13, 15, 19, 23 73:2 74:4, 8, 17,21 76:6 77:10 79:12, 16 80:11, 15Maine 57:5major 73:13, 14 75:2 77:7 82:14majority 10:12, 18 14:13 29:15 30:2 32:12 41:15 48:14making 74:12 77:8malignant 37:15,17malpractice 83:5management 27:12 39:21 55:3 56:1 64:1, 18 74:22, 24 75:1, 7,19 76:1 83:18, 18manner 68:18marathon 60:24mark 16:22marked 5:4, 13 85:19markers 71:11, 18MARY 1:5Maryland 57:6, 20mass 70:25material 59:4materials 5:22, 24 20:24 21:3 58:25 59:1 60:5, 20 62:2matter 39:4, 5, 9,11 88:5matters 88:7, 9MCLEAN 1:3mean 11:23 17:18, 20, 20 40:6 48:1 57:17 64:13 75:9 78:23 86:15means 68:11meant 82:4, 10, 16measure 81:9Med 7:20Medical 7:20 8:5 29:15 47:20 58:8,11 59:21 60:5

64:18 74:22, 24 75:1, 7, 19 76:1 80:14 83:5, 18medically 46:15medication 46:15 64:18medications 55:3 56:2 64:2, 3, 9, 14,15, 21 65:3 75:8medicine 37:4 61:6 65:3medicines 75:12meet 82:18 84:11meeting 84:12Memory 23:7 47:2, 12, 23meningeal 35:23 50:9, 11, 12, 13 72:25meningioma 9:4, 7,8, 19, 23, 25 10:2,4 12:5, 12 14:9 18:6, 11, 15 21:19,23 22:2 23:1 25:8, 19 26:10, 20 27:13 30:8 37:24 38:3, 4, 13, 18, 18,24 39:3, 21 40:11,22 41:9 46:8 48:7, 15 49:5 58:16, 19 59:24 60:14, 19 67:11,24 68:13 69:24 70:3 71:16 72:14 75:22 79:19 82:2,4Meningiomas 9:20 20:15 21:7 40:18 41:2 59:18, 25 60:3 69:12, 19 78:16 80:3mental 24:10mentioned 33:8 65:13 66:16 68:8 69:9, 15 72:10meticulous 61:11Microcatheterization 32:24microfracture 32:24middle 35:22 50:9, 12mind 12:2 36:21 78:25minds 12:2 42:8mine 84:4Mini 87:4minority 29:18, 25minute 9:11 11:21 82:18



missed 67:15mistaken 30:18mitigate 30:24moment 42:10monitor 28:2month 62:19months 17:19 36:19, 20 37:8, 9,20 43:12, 14, 16Motion 3:9Motor 23:9, 10move 57:25MRA 26:7 51:6,13, 24 52:9MRI 26:5 37:7, 8 43:10, 24 51:1, 6,6 52:10 65:15 66:1, 6MRIs 71:14Muscle 23:22

< N >named 89:8NARDONE 1:8 2:17 3:18 4:18 26:13 29:12 49:22 63:10 65:16 82:18Nardone's 77:22 80:24 81:13National 19:18 41:13near 82:12necessary 75:14neck 14:23 82:16need 10:20 22:5 52:12 53:1 55:17,22 64:22 65:22 85:12 86:24needing 76:11needs 37:11Negligence 3:18 83:5neighbor 71:8nerve 20:9 33:18nerves 35:25nervous 32:4NEURO 1:8neurocranial 21:17, 22Neurologic 47:1,12neurological 27:2 41:19, 21 47:22neurologically 37:21neurologist 35:10 45:6 62:9, 19neurology 46:20,21

neurosurgeon 35:11 40:16 61:13 72:8, 17 74:10 79:9neurosurgeons 27:21 29:6 56:16 59:1Neurosurgery 19:12, 21, 23 20:1,2, 2 42:3 56:21 60:24 61:10neurosurgical 57:7 59:14nice 57:12 81:17,23 84:11NIH 78:8nonoperative 10:13, 15 31:4normal 71:24North 2:6Northern 57:6Nos 61:24, 24note 49:22 78:13 81:13, 16noted 41:5 54:15 62:15notes 6:1, 4 24:24 89:15Notice 3:11 4:16,20 85:2November 85:8number 7:7 15:12 16:8, 21 19:9 38:22 42:18 60:12 74:19 77:25numbers 16:17, 19 36:10 48:13numeral 57:16, 17

< O >object 67:18Objection 29:23 30:10 64:19 68:5objective 75:10oblige 13:22obviously 28:15 31:2 32:1 52:11 55:24 56:9occipital 23:2 66:8 67:14, 24 68:3, 14occluded 51:17occlusion 33:2 51:14, 24occur 20:23 21:2 22:1 47:14 71:25occurred 66:23occurring 28:22offer 81:5office 6:12, 16

18:14 54:4OFFICES 2:5Oftentimes 38:7Oh 17:2Okay 4:16, 23 5:4, 12, 15, 21 6:4,8, 14, 17, 22 7:5,14, 17, 19, 23 8:1,9, 13, 21 9:19, 22,25 10:11, 14, 21 11:1, 6 12:4, 15,24 13:4, 9, 12, 17,23 14:3, 6, 17, 20 15:1, 7, 14, 20, 24 16:2, 7, 12, 14 17:2, 15 18:2, 7 19:12 20:19, 22 21:13, 17, 25 22:4,16, 24 23:9, 12, 22 24:5, 10 25:13 26:12, 23 27:1, 4,20 29:11, 18, 21 33:18 34:2, 4, 17 35:12, 17, 22 36:2,9, 10, 11, 15, 16 37:2 38:11, 20 39:2, 9, 13 40:22 41:3, 12, 17 42:2,11 43:13, 22 45:11, 13, 19, 24 46:2, 9, 16 47:11 48:5, 11, 21, 21 49:13 50:14, 22,25 51:9, 20 52:2,8, 14, 24 53:1, 6,11, 16, 20 54:1, 10 55:12 56:11, 18,18, 20, 24 57:4, 15,22, 24 58:3, 5, 12,20, 25 59:23 60:7,17, 22, 23 62:4, 13,24 63:2, 11, 19, 22,24 64:12 66:19 67:22 68:6, 20 69:22 70:14, 20 71:4 77:5 80:19 81:25 82:11, 17 83:8, 12 84:8, 10,15, 16, 22 85:14,15 86:8, 10old 7:20 17:19 42:23 70:2olfactory 24:3once 12:24 45:19 48:2 83:22ones 22:13 47:22oOo 4:3 87:7opening 49:18, 19operate 28:23 79:9

operated 74:3operation 56:7operative 10:17 34:5 49:22 73:22 81:13, 16opinion 29:14 39:6 49:13 56:14 57:12 64:16 70:10 73:3, 25 77:11 81:1opinions 3:16 5:14 34:19 39:14,16 53:3, 4 62:7,10, 12 64:4 80:12 85:7opportunity 57:1,12opposed 15:18 20:15option 26:22 37:18 41:8 69:8 77:3, 17options 45:17, 23 46:18 55:2, 4, 16 74:6, 16, 19 77:21order 5:14 43:23 85:23Organization 39:2,7original 86:7, 10,12, 14, 14, 15, 16, 17outcome 34:14 42:21 73:17outcomes 34:8 57:11 62:14outside 32:3outweigh 76:8outweighed 74:24 77:12overall 78:17

< P >packet 53:22PAGE 3:5, 9 17:4 58:3, 20 59:10, 17 60:13, 22, 23 61:23 81:16 87:2,2paid 8:21 86:10palsy 33:18panoply 38:24papers 16:14 17:4, 12paragraph 53:7, 12parietal 66:9 67:16, 17 68:3Park 40:13part 57:17 59:11,14 74:9 81:2partial 77:16partially 67:24

particles 20:9, 13 21:7particular 17:25 21:15 28:20, 25 30:16 36:23 37:2 42:25 54:17 55:7 58:19 59:9 60:2 68:23 69:6 70:1 75:3, 15, 21particularly 36:17particulate 20:24 21:2parties 89:18, 20Pasadena 1:17 4:1pass 54:3 58:13pathologies 79:18pathology 37:22 39:5 66:8 79:10,10patient 10:25 11:2, 19 22:6, 17 24:6 26:21 27:6,13, 15, 21 28:23,24 29:7, 19 30:1,6, 24 31:3, 5 32:15 36:13 38:21 43:3 45:15,24 46:11 50:19 54:21 55:8, 13 64:10 65:5 68:20,23 69:17 71:13 73:17 74:11 83:14patients 10:4 11:5 12:4, 8 28:10 29:2 30:11 33:24 36:22 41:18, 19, 22 46:8,19, 23 47:8 48:7,14 54:19, 22 57:8 65:4 74:7patient's 31:16 36:6 40:22PAUL 1:15 3:3,13 4:5, 13 88:20 89:7pay 86:[email protected] 2:14PDF 87:1peer 18:9penalties 88:10PENALTY 88:1people 32:14 37:6 57:13 68:25 75:11people's 12:2percent 7:13 9:18,21 10:15, 18, 19 38:16 78:21, 21,21 79:14, 14



percentage 7:12 9:15, 19 10:2, 5, 6,7 48:11, 12, 17 78:18 79:17percents 10:16perform 9:22 10:3 35:5 57:13performed 12:12 43:4 51:7 65:16 80:3period 43:16, 16 44:10PERJURY 88:1,11permanent 41:21 65:20 66:12 67:1person 62:10 66:14 71:9personality 24:12,14 25:5personally 32:4 49:6pertain 58:19pertinent 17:23PETER 2:11 3:15phone 65:23phrase 48:9pieces 72:20pipeline 82:14place 12:25 26:5 89:12Plaintiff 1:6 2:4 15:1 85:23Plaintiff's 3:11 85:3plan 69:7 70:10 77:22play 49:8plays 68:12Please 51:22 87:1pleasure 84:4, 12point 43:19 44:1 45:14, 17, 21 46:11 61:10 66:22 73:4, 12 75:4points 51:19polyvinyl 20:8, 13 21:6poor 20:10 57:11position 41:1possibility 74:19Possible 6:23 12:7, 8, 11 21:16 22:3 23:8, 10, 21,23, 25 24:2, 7 25:9 27:19 32:6 33:4, 14, 20 34:16 35:19 36:1 38:5 42:16 47:3, 19 48:4 49:12 55:4

Possibly 7:25 34:3, 10 55:21posterior 50:11, 13post-operative 21:18, 23, 25 65:15, 19post-operatively 46:24 70:16post-surgical 66:8potential 56:10Potentially 31:7 56:7 68:21 70:9 77:9practice 9:12, 15 10:9 21:12 29:5 35:13 78:19 79:13, 17pre-embolization 20:16 22:18, 21 29:9 45:16 67:12 68:1 77:4, 5, 6, 12,16preferred 40:17 41:2pre-op 20:14 21:7 22:4, 8 26:23 27:5 28:5 48:8preoperative 28:21 32:2 38:8pre-operative 48:17 71:13 72:17, 21, 24 73:6,9, 12, 25 74:1preoperatively 34:7pre-operatively 26:5 51:7 83:13prepare 16:24 53:17, 18prepared 17:13,25 53:19PRESENT 2:16 10:4 27:6 30:23 31:8 46:8 54:20,22 68:21 74:10presentation 10:25 26:21 30:13, 25 38:21 43:17 60:15 74:5presentations 59:14, 20 60:11presented 24:17 53:23 54:19 70:20, 25presents 26:12, 14 30:6 37:2 83:14presumed 41:10pretreatment 41:20

pretty 30:20 37:11 56:11 66:2 75:16 82:19prevented 28:22primary 41:23 61:25print 89:13prior 30:20 56:5 70:20 89:8probably 6:21 10:20 14:2 15:3 37:8 41:15 43:21,24 51:3 52:15 60:7 63:23, 25 82:19problem 25:11 51:5 56:4 65:4problems 14:21 23:24 24:22 47:1,2, 9, 11, 12, 12, 13,13, 23, 23, 24 70:9procedure 49:11 50:3, 4 61:14procedures 55:11proceedings 87:5Produce 3:11 5:6produced 5:5product 17:6, 9,14 21:15Production 3:13 85:5products 20:15professionals 85:9professor 57:15pronouncing 4:14proper 13:1, 2proposition 33:9 36:12 81:14provide 44:7 57:2provided 17:18 18:13, 16, 18 50:14 53:21 54:8,16 75:8proximity 75:23publication 41:13publications 19:10,16 78:1publish 19:19published 18:9 42:2 60:5 78:7pull 81:21pulled 49:23purpose 43:2purposes 85:12pursuant 4:16pursued 73:4put 26:2 46:2 84:25 86:4

< Q >quantify 81:4, 8

question 5:9, 21 9:7 16:23 17:5,24 26:3 29:17 30:5, 16 33:11 34:23 38:10 39:19 41:3 45:6,9 52:15 53:16 64:14, 20 67:22 78:24, 25 79:5QUESTIONS 3:21 53:10 63:12 65:7 74:18 77:25 78:15 80:16 82:2,9 84:3quick 75:3 78:25quicker 32:14quickly 40:19quite 32:17 37:17 75:6, 15, 18quote 12:3

< R >radiated 43:2radiation 38:8 39:25, 25 42:18,22 55:5 70:7 76:17, 19radio 10:8radiologic 52:17radiologist 35:10,13radiologists 35:9radiosurgery 10:17, 20 12:1 42:24 43:2 55:22 56:8 76:7, 8, 10,13, 24 80:4radiosurgical 80:9rare 10:16 34:1 47:6 67:13 68:1, 4rate 13:15 15:7, 9,18, 18rates 13:5 20:23,25 21:1reacting 71:10read 20:5 21:6,10, 13 22:20 41:17 52:21 54:11, 12 59:7 78:13 81:15, 20 88:5reading 81:21 82:1real 78:25really 7:10 8:6,15 10:10 30:22 34:12 37:19 38:7,9, 21 45:4, 5 48:19 57:1, 12, 13 61:17 64:22 65:1 69:8 71:17, 19

75:3, 10, 15 76:15 78:24 81:11realm 38:11 47:14reason 51:18reasonable 29:15 42:8 78:3, 12 80:13reasonably 19:16,19 41:14 72:8 74:10 78:8recall 9:5 12:14 50:8 60:18 83:7receive 20:3 34:6 62:22recognized 22:13 47:5, 7recollection 14:25recommendation 43:19 55:7recommendations 74:13recommended 41:18record 4:12, 17 6:9 48:22, 24 53:24 64:13 84:13, 20, 21, 23 86:2, 4records 62:23 64:13reduce 63:19refer 16:14, 17reference 59:1, 4,7 84:24references 59:9referred 33:8 73:6reflect 4:12regarding 58:15 73:6 74:6 77:25Regardless 83:17region 71:18 75:21Regional 35:16regular 85:24related 18:14 62:15 89:20relates 18:5relative 19:5 22:4 59:8relatively 43:10 70:2reliable 19:16, 19 41:14 78:4, 8, 12remain 71:23remember 6:23,24, 25 7:22 13:6,8 15:12 16:9, 10 39:8, 11 49:25 50:6 51:15 61:3



removal 56:4 80:24remove 9:22, 25 26:20 68:20removed 13:1 37:11 81:2, 10removes 71:20repeat 21:20 33:11 37:7, 18, 19 51:2, 22repeating 63:25report 16:24 17:4,12 18:5 36:9, 19 62:15 68:8 85:9reported 48:2Reporter 1:19 23:18 85:11, 21 86:2, 12, 17, 20, 22 87:3 89:5REPORTER'S 89:1reports 26:4, 9request 5:6REQUESTED 3:24required 73:5 74:1research 18:20 19:5resect 22:1 70:5resected 67:6, 25resection 37:24 41:18, 23 49:4 55:17 67:12 68:25 69:11 70:11 73:21 74:25 76:4, 9, 11 77:1, 13, 16, 18, 23reserve 84:9residents 58:9residual 66:7respect 54:13 68:12respectively 69:6respond 75:11response 5:5, 10 75:8, 9rest 68:19 70:6result 20:9 26:10 27:8 33:5 35:24 76:15resume 18:4Retained 3:9 85:20return 45:3, 11 83:23returned 44:19, 19review 5:22 51:16 78:4 86:7

reviewed 5:14 6:11 9:3, 6 18:9 50:25 65:14rid 68:18Rider 3:11 4:21 5:10 85:3right 4:14, 25 5:4 6:17 7:22 8:13,25 9:10 11:16, 19,19 14:6 17:23 18:13, 24 19:3, 8,13 22:8, 11, 14, 18,24 24:18, 20 25:2,5, 17, 20, 22 26:7,17 27:22, 25 28:3,6, 8, 18 30:14, 19 32:20 33:3 39:23 40:1 41:7 43:5 44:4, 8, 15, 24 47:16 48:19 50:10 51:7, 12, 17 52:14 54:10 59:18 60:1, 4, 25 61:8 63:20, 24 64:7 65:6 66:5 76:2 78:5 79:6 82:8 83:20 85:18 86:3risk 22:4, 8 27:6 32:19, 25 33:16 41:21 73:19 74:24 75:25 76:3,25 77:7, 17, 21 82:3 84:1risks 22:13 42:13 55:10, 15, 16, 19,19, 20 72:9 74:6,11, 12, 19 75:20,21 76:8, 12Riverside 35:15road 60:24Roman 57:16, 17room 70:21 71:1roughly 14:5 17:20, 21 78:20routine 28:3 43:4Rule 3:11 85:3rules 4:17rushed 61:21

< S >safe 68:18safely 70:5safer 32:15 73:11,22 77:8Santa 40:14, 16SARAH 2:5 3:15 8:21 13:9 15:22 18:13 54:3, 4 85:6Sarah's 6:11

save 60:7saw 5:2 31:16saying 11:1 19:2 39:13 47:7 64:17scan 37:7 72:4scans 65:15, 19, 25 66:1 70:21 71:13scares 69:2school 59:21 60:5 61:6SCHROEDER 2:11SCIENCE 1:9sclerosing 76:17script 87:4second 62:4section 58:18see 4:25 5:11 10:3 17:1, 2 27:24 28:23 31:7,18 37:9 39:18 42:23 51:18 65:19 71:11 72:25 73:10, 25 75:17seeing 28:24 75:9seen 32:12 33:21,25 34:3, 9, 14 41:4 56:16 64:12 71:20seize 75:12seizure 37:4 45:3 46:15 65:2 75:12Seizures 23:5 25:14 42:14 45:12 46:6, 10, 23 47:12, 22send 46:19 86:6sending 86:14, 15,15sense 66:11 69:24senses 70:16sensory 23:12sent 37:4sentences 42:4September 30:18 37:3 38:12 43:11 81:3 89:22sequelae 41:22 47:14serial 55:3, 9 69:17 70:7series 58:5 61:25services 7:14 8:4 57:2, 8, 13set 62:[email protected] 2:8sheet 86:7shipped 57:10

shorten 62:5shorter 56:7 77:9Shorthand 1:19 89:5, 15short-term 64:5show 4:18 33:22 67:2showed 32:2 34:4 75:15shown 76:15shrinking 76:20,21shrinks 76:19side 24:4 51:17 66:5signature 84:6, 9significant 34:5, 7 66:2 69:5 75:16significantly 37:18 45:4 73:19signing 86:7similar 5:3similarly 54:20, 22simple 16:23sinus 49:10, 18, 19,21, 23 50:15, 18 51:14, 16, 25 69:1 81:19, 21 82:13, 15sir 4:15, 24 5:23,25 7:16 9:9, 14,24 10:1 11:4, 8,13, 17, 20 12:7, 11,19, 23 13:25 14:11, 14 15:19,23 16:1 18:19 19:4, 11, 14, 17, 20,22, 24 20:4, 6 22:3, 7, 12, 19 23:4, 6, 15 24:19,21, 24 25:1, 3, 6,15, 18, 21, 24 26:6,8, 16, 18, 22 27:16,23 28:1, 4, 7, 9 29:20 31:20 32:21, 23 33:1, 7,17 34:20 35:6 36:8 39:5, 24 40:2, 4, 10, 12, 24 42:9, 12 43:6 44:5, 9, 12, 14 45:18, 22 46:1 47:6, 15 48:6 50:1, 5, 7, 16 51:8,11 52:25 53:14,25 54:9, 23 56:13,17, 23 58:7 59:16,19 60:6, 21 61:16,19 62:3 63:18 64:6, 8 80:20 82:20 83:1, 4, 16,

21 84:2sister 25:4sit 79:13site 55:21 66:2sites 66:10 81:24situation 13:3 68:2situations 12:20six 14:2, 2 37:9size 10:22, 24 12:5 37:10, 17 55:23 63:19 72:14 76:14slow-growing 69:12, 16, 24small 10:22 11:21 12:3, 5 30:7 31:19 41:9 68:13 70:2 73:14smaller 11:25 50:24somebody 31:14 53:18 54:4 85:10somebody's 32:11sooner 43:10sorry 9:7 13:17 14:9 17:11 18:3,23 21:20 23:16 26:2 33:11, 21 34:21, 24 36:9 37:1 46:3 48:23 49:7 50:12 52:5,14 59:2 78:23 79:4, 23 81:25sort 56:3sound 85:16sounds 11:1 14:6 27:11 36:2 85:17South 1:16speak 59:5speaking 34:19 40:7 78:2specialist 32:8specific 19:5 36:6 48:15specifically 65:23 69:19, 22specifics 78:18Speech 23:24 24:22 47:1, 12spend 53:3spinal 59:18, 24 60:2 71:7spine 9:12 14:12,13 19:12 59:25 78:17, 21 79:10, 14spines 79:9sprint 60:25SRS 11:6, 9, 12 28:11 38:14 39:25 41:22



42:10, 13, 17, 20,21 44:20 45:15 47:16, 17, 18, 21,25 63:16 83:19ss 89:2stable 37:12, 12,13 43:25stages 58:1stagnating 76:15stagnation 56:10standard 11:24 12:9, 24 21:12 22:2 26:19 27:17 28:14, 17 29:1, 13,21 30:2, 22 31:1 34:11, 13 37:25 38:11 67:25 68:12 70:11 73:5 74:1 75:22 82:3started 8:5starting 30:18 45:13starts 45:19 46:4STATE 1:1 55:14 78:3, 10 89:2, 5stated 80:13 88:8 89:12statement 9:13 20:11, 12, 17, 22 21:4 36:7 40:20 41:1, 5, 24 42:1, 7 51:20, 21statements 20:8states 15:24 58:11status 24:10stay 44:13stereotactic 10:8 42:24 76:12steroid 44:7 64:5 65:2steroids 31:5 37:4 44:13, 23 45:1, 11 46:12, 15 71:15, 17, 21 72:1 75:11 83:13, 20, 22stick 30:12stop 21:8 44:1 63:17stopped 83:22straight 37:24Street 2:6, 12stroke 20:10 33:16 55:18, 20strong 65:3structures 70:4 75:24student 47:20students 58:9 61:5 78:11

studies 33:22, 25 34:4 51:19 65:14 70:7 71:12study 31:6 37:7,18, 19 38:7 43:9substance 20:14suction 81:11suctioned 81:11sued 83:10suggesting 36:18suitable 33:9, 12Suite 1:16 2:12superiorly 81:17supervision 89:13supply 35:25 69:5 73:10 76:21Supreme 4:17sure 6:13 12:17 20:18 21:21 33:15 38:16, 16,20 51:23 64:3 86:13surgeon 27:14, 14surgeons 28:11 29:11, 16, 18, 25 73:15surgeries 32:14 65:16surgery 9:22 10:3,5 11:5, 11 12:6, 9,9, 12, 18 14:12, 13 18:3 22:1 26:19 27:7, 21 28:6 29:8, 19 30:1, 21 33:23 36:13 38:2,3, 8, 13, 15 39:22,25 40:17 41:1, 20 44:20 45:16 46:12, 14 55:16,18, 22 56:1, 3, 5, 6,9 59:2 62:16 65:25 67:8 68:24 69:8 70:17, 20 72:9 73:4, 11, 11,16, 20 75:2, 20 76:12 77:4, 8, 12,15 80:24 81:3 83:19surgical 27:12 38:23 41:18, 23 55:6surveillance 41:7,8sustained 65:24swelling 25:25 26:1, 9, 18, 24 42:14 45:1 55:21 70:25 71:5switch 22:24 56:18

swollen 67:5sworn 4:7 89:9symptomatic 25:16symptomatically 31:6 37:13symptoms 23:1 25:19 26:14 30:6,17, 21, 24 37:3 40:19, 23 41:3, 9 44:4, 10, 19, 19 45:11, 13, 19, 24 46:5, 7, 10 56:2 72:3, 10 75:4

< T >take 19:25 20:1,3 24:24, 25 29:8,19 30:1 44:20 45:15 48:23 53:1,9 62:6 63:9 64:20 72:8, 12 82:17taken 1:15 4:13,16 22:17 39:14 48:25 63:14 82:21 89:11, 16takes 12:25 61:14talk 32:7, 8 35:23 36:19, 23 42:10 54:24 60:2 62:19 63:10 65:24 70:15 74:22talked 11:21 27:11 32:20 36:2 39:20, 22 42:13 46:8 47:22 52:2 63:24 64:1, 2, 5 74:5 77:5 81:25talking 5:16 16:18 28:16 29:2 34:12, 14 36:24,25 37:1 41:17 52:3 61:17 62:17 73:14talks 36:19 52:22 59:5, 17 60:4 81:13teaching 21:12 58:22, 22technically 31:9 73:20techniques 80:10tell 15:22 27:5 41:7 47:24 55:12,13 62:13 84:6 86:1temporal 66:4, 9 67:14 68:2ten 7:4, 7tentorial 81:18

term 68:11, 15 72:2terms 10:17 28:19 32:13 34:13, 14 39:13 43:20 54:25 76:15testified 4:8 6:18 13:23 14:15 15:5,24testify 13:19 15:1,8 52:9 62:9, 21,22 82:24 83:2 89:9testifying 7:9testimony 14:8 52:16, 18 83:13textbooks 58:13Thank 65:6 79:22 80:16, 17 82:20 84:5 85:1Thanks 79:7 84:10therapy 39:25thereof 88:6things 16:10 25:7 33:19 39:22 49:2 51:3 62:20, 21 72:7think 5:6, 9 7:23 8:11 10:9 12:2 13:21 14:4, 24 16:7 18:7 24:22 25:13 27:10 28:20 30:16, 24 31:11, 13 33:8 37:4, 6, 18, 22, 25,25 38:5, 5 41:12,25 44:7, 22 45:3,4, 6 48:22 49:3 50:11, 12 51:1, 9 53:7 54:7, 17 57:19, 23, 25 60:12 61:5, 9, 25 64:2, 11, 23 65:1,4 66:6 68:25 69:8, 10 70:7 75:6, 9, 14, 18, 18 78:2 79:2, 14 81:13thought 28:19thoughts 52:13three 11:24 17:13 28:24 37:9 43:14 76:14 83:19time 16:16 24:23 25:14, 16 26:1 28:3 31:6, 15 36:18, 20 43:16,16 44:10 45:2, 5,14, 15 46:11 53:4,9 55:23 56:15

60:8 61:11 62:6 73:16, 22 75:19 76:16 84:10 89:12times 14:1, 2 71:21tissue 12:22, 25 42:15, 19 43:1 80:25 81:2, 10title 57:21today 8:22 18:10 35:24 56:22 62:8,18 63:4 64:17, 21 70:15 78:10 79:13 80:13 82:24 83:13 85:3told 39:10 49:3top 39:11topic 18:22 42:8topics 18:9total 51:14, 24 69:10, 11 70:10 74:24 76:4, 8 77:1, 13, 18, 22touched 70:14trained 80:9training 19:1 29:6 60:11 80:2transcribed 89:13transcript 85:22 88:5 89:15transpired 43:8 54:13transverse 49:10,18, 19 50:15, 18 51:14, 24 81:19,21 82:13, 15traumatic 14:16,18travel 16:3 57:2,13traveled 15:16traveling 16:6treat 9:8 44:18 46:2, 12, 14, 19 64:10 70:6 71:15 79:10, 10, 18treated 37:12 57:9 68:21treating 29:2 56:2treatment 10:8 11:2, 18 17:24 18:10, 14 38:2, 4 40:17 41:2 45:4,20, 25 46:20 50:14 55:2, 5, 6 59:2, 2 74:7, 12 75:14 76:17 83:17treatments 30:23 31:4 38:6 46:17 68:22trend 75:5



trial 15:8 16:5 32:18 48:16 52:3,10, 17tricking 71:22tried 32:10 69:9tripled 37:10trouble 31:10 82:1true 11:3, 9, 12 12:4, 10, 17 20:11,12, 17 21:4, 5 22:6, 9 25:11, 14 26:1, 5, 10, 15, 21 27:15, 18 28:10,11, 14 29:9, 10, 22 31:22 32:25 33:6,10, 13 34:15 35:22 36:7 38:3,4, 13, 15, 17, 23, 25 39:18 40:20, 23 41:11 42:15, 20 44:11, 13 45:21 46:22 47:5, 8, 14,16, 17 59:15 61:1,11, 15 63:17, 22 64:5 69:20, 21, 22 70:23 81:7 83:23 88:7, 9, 11 89:15truth 89:10, 10, 10try 15:3 19:2trying 17:16 45:6 49:8tumor 14:10, 18 18:3 21:18, 22 30:7 31:8, 17, 25 32:3 33:9, 12 37:10, 15, 17 39:7 45:20 48:15 49:17, 20, 23 55:5,6, 6, 17, 21, 23 56:4, 10 60:12 63:17, 19, 22, 23 66:3, 10, 17 67:6 68:16, 18, 19, 25 70:22 71:3, 5 72:11, 22 73:1, 21 74:2 75:21 76:5,10, 18, 19, 22, 25 77:4 78:21, 22 81:18, 21, 24 82:12 83:8tumors 9:16 11:21 17:25 29:3 32:16 33:14 34:6,17, 25 40:18 41:3 59:3, 8 61:25 69:2, 4, 12 76:13,14, 21 78:16tunnel 14:21turn 76:7 77:3

turning 17:3, 3twice 48:2two 7:9 18:5 19:25 20:1 35:18 36:19 37:5 43:25 45:16 50:20 63:12 64:9, 11 70:15 72:3type 38:18 41:5 59:20typically 34:17, 25 44:25 45:2 54:24 76:14

< U >UCLA 61:6unclear 78:24undergo 41:20, 22underserved 57:3,9, 14understand 40:25 53:4 54:12, 13, 21 62:17understanding 29:4 64:4 77:20 81:1Unintended 33:2unique 30:13, 14United 58:11university 8:23unnecessary 27:6unsafe 68:20unwanted 71:24 73:19upset 67:4, 5, 9 71:7up-to-date 17:18use 11:6 28:11 35:8 52:12, 13, 17 85:12USMLE 58:10, 11Usually 35:9utilize 75:10

< V >varies 8:5various 79:18 81:24vary 27:14vascular 48:15 69:4 70:4 72:22 75:23vasogenic 71:12,20vast 10:18, 18 32:12 41:15veins 69:6 82:14,16venous 33:2 73:20ventricles 66:3

versions 54:7versus 62:18 77:4vessel 32:22, 25vessels 14:24 32:3, 6, 10, 11 73:18, 20 76:18, 20viewpoint 63:1vision 20:10visual 23:2vitae 3:16 85:7

< W >wait 27:24waiting 36:14 40:3 70:6want 13:20 36:12 42:10 44:15 45:25 49:2 53:2 56:18 64:3, 25 70:15 71:8 74:15 76:7 77:3 82:23 84:6, 16 85:21 86:22wanted 61:9wants 85:10 86:21watch 10:7 11:14 36:21 43:3watchful 70:6watching 36:14 40:3way 6:15 30:14,25 32:15 44:2 59:22 69:16 76:23 83:11 89:19ways 30:12 31:11weakness 23:22 47:1, 23week 62:18weigh 74:11 81:9weighing 72:9Well 27:20 28:19 30:14 34:12 38:6,8 39:10, 20 43:9 44:22 53:5 54:15 55:3 57:9 60:7 65:3 66:3 67:2 73:12, 23 75:6, 19 81:19went 57:5, 5 72:3 84:7We're 16:21 18:10 32:9 35:23 37:1 41:17 59:17 65:6 69:7 73:13 82:8 84:21 86:2West 2:12we've 5:13 30:7 32:19 36:2 39:22 51:1, 6, 9wing 60:13

WITNESS 3:2 5:19 13:14 17:8 29:25 40:7 48:21 53:14 59:12 63:11 65:9 67:20 79:23 80:17, 20 82:20 83:3 84:4,12 89:22woman 69:25 70:2women 69:19, 22word 5:2, 2words 10:3 24:6,13 26:20 27:13,20 28:2 29:8 34:7 35:7 44:3 47:8 49:23 55:13 57:5 61:20 76:18work 8:5, 19, 22 14:4 17:6, 9 65:3 71:21working 7:2 47:20works 76:17World 39:2, 6worries 42:20worse 63:6 75:12worsening 37:21 41:21worsens 44:2wound 20:10write 5:24 17:5writing 82:1written 6:5 17:24 18:2, 8 27:4 53:5 54:11wrong 24:23 32:22 51:20wrote 27:4 40:16 81:14

< Y >Yeah 8:2, 10, 12 9:2 13:15 14:13 16:20 17:2, 8 41:25 57:20 64:11 67:2 71:17 73:12 79:2 81:5,8 84:7, 21year 7:9 8:4, 6, 7 9:1 43:25 45:11 46:4, 9yearly 43:21years 7:9 17:13 31:9 37:13 44:23 70:2yesterday 5:7 63:4

1 STATE OF ILLINOIS 2 IN THE CIRCUIT OF THE ELEVENTH...

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Transcript of 1 STATE OF ILLINOIS 2 IN THE CIRCUIT OF THE ELEVENTH...