Brain SPECT as Imaging Biomarker for Evaluating Effects of Novel Treatments in Psychiatry.

Objectives: Complex Neuropsychiatric conditions with multiple comorbidities can benefit from novel treatments, in addition to medication. Among these are 1) concurrent application of Transcranial Magnetic Stimulation and ketamine infusion (combination TMS/ketamine). 2) Hyperbaric Oxygen Therapy (HBOT). 3) Perispinal administration of etanercept (PSE). In our clinic, complex patients undergo a baseline Brain SPECT and occasionally follow-up studies after periods of treatment. We are presenting the findings for patients who underwent such repeat studies.

Methods: 6 patients presented with disabling Neuropsychiatric conditions of various causes after having been treated unsuccessfully for long periods of time elsewhere. Brain SPECT : on triple head camera, HMPAO, and special software combining a set of multiparametric displays. A discrete color scale was used for orthogonal + temporal lobe sections as well as for a set of normalized surface displays, and a monochrome display of thresholded volumes. The clarity and complementarity of the displays enabled reliable visual evaluation. The comorbidities differed in each case. (I) 62 y.o.f.: on verge of suicide with Treatment Resistant Depression, grief and effects of prolonged polypharmacy. (II) 34 y.o.f.: regulatory disorder of childhood, 2 concussions, post-traumatic epilepsy, and RSD, resulting in major incapacitation. (III) 54y.o.m: childhood Tourette’s, long hx of alcohol abuse, severe depression, fatigue , sleep apnea. (IV) 55y.o.f: major depression, panic/agoraphobia, long term back pain, frequent headaches. (V) 43y.o.m: bipolar II, anxiety, impulsive behavior, family stressors, inability to hold job. (VI) 77y.o.m: 3 years post dementia induced by General Anesthesia with major cognitive, physical and emotional impairments.

Results: Baseline SPECT showed multiple extensive perfusion abnormalities in all 6 cases. Post treatment results are as follows: Patient (I). Following 5 months of combination TMS / ketamine, SPECT showed a marked improvement, across the board, in cortical and subcortical structures. Patient (II). After HBOT : multiple areas of improved perfusion. Subsequent follow-up done after 4 PSE injections showed major improvements in all lobes and subcortical areas. Patient (III). Following combination TMS /ketamine treatment, SPECT done 5 months later showed several improvements including in the area of severe frontal underperfusion. After] ongoing medication and the addition of CPAP, life style changed and 14 mo later SPECT showed additional significant improvements. Patient (IV). Following combination TMS /ketamine, SPECT 14mo later shows major bilateral improvement in all affected areas. Patient(V). Post combination TMS /ketamine, at 5 ½ mo SPECT showed improvement in practically all previously under-perfused areas. Patient(VI) : Following a combination HBOT and PSE injections, SPECT at 5 mo showed localized areas of improvement in key locations including right mesial temporal, cingulate gyrus and parts of the lateral frontal lobes. Improvements in all patients were documented via periodic clinical evaluations, Neuropsycholgic testing (in some cases) and family members observations. Baseline brain SPECT contributed to decision and tailoring of treatment. Followup SPECT not only validated the beneficial treatment effect but also had a significant role in guiding long term treatment strategy by showing the topographic functional status.

Conclusion: The use of brain SPECT, in this context, provides a useful biomarker for confirmation / explanation of the therapeutic benefit of the novel types of treatments used, as well as for deciding upon future therapeutic needs or, lack of thereof. Research Support: None