Reversal of cerebral glucose hypometabolism on positron emission tomography with electroconvulsive therapy in an elderly patient with a psychotic episode

Abstract

AB, a 74-year-old Caucasian woman, was admitted for acute onset of psychosis, anxiety, and cognitive impairment. Pharmacotherapy was unsuccessful and the patient was referred for electroconvulsive therapy (ECT). Pre-ECT, F-fluorodeoxyglucose-positron emission tomography (PET)/computed tomography showed extensive frontal, parietal, and temporal cortical hypometabolism suggestive of a neurodegenerative disease. After eight ECT sessions, the psychotic and anxiety symptoms as well as the cognitive impairment resolved. The rapid improvement in symptoms was more suggestive of a psychotic episode rather than dementia. Two days after the ECT course, F-fluorodeoxyglucose-PET/computed tomography showed improvements in cerebral cortical hypometabolism, especially in the left parietal cortex, left temporal/occipital cortex. and bifrontal regions. At a follow-up visit 2 months after the ECT course, the psychotic episode was still in remission, and F-fluorodeoxyglucose-PET/computed tomography continued to show improved cerebral cortical hypometabolism in these areas. This case illustrated the effect of ECT in reversing cerebral glucose hypometabolism on PET. The improvement in cerebral glucose hypometabolism may represent the neurophysiological mechanism of ECT in the treatment of a psychotic episode. Improved cerebral glucose hypometabolism was present 2 months post-ECT, which suggests that ECT caused sustained functional neural changes.

Acute electroconvulsive therapy in the elderly with schizophrenia and schizoaffective disorder: A case series

“…At the time of writing, there was a notable paucity of literature addressing the specific use of acute ECT in the elderly with primary psychotic conditions, this being limited to one case series and five individual case reports, reporting a total of 10 patients (Kumagaya & Halliday, ). Similar to this case series, ECT was found to be highly effective in this group of patients, resulting in full or partial remission in eight and two patients, respectively (Hassamal et al, ; Kramer, ; Meyen et al, ; Selvadurai et al, ; Suzuki, Shindo, et al, ; Tang & Park, ). Studies of mixed age and diagnoses that have included elderly patients with treatment‐ and clozapine‐resistant primary psychotic conditions have also demonstrated improvements in the Brief Psychiatric Rating Scale (BPRS) (Suzuki, Awata, & Matsuoka, ; Tang & Ungvari, ; Tor et al, ), Clinical Global Impression (CGI) (Chiu, Lee, & Lee, ; Kales, Dequardo, & Tandon, ; Kaster et al, ; Tang & Ungvari, ), Positive and Negative Syndrome Scale (PANSS) (Kho et al, ), Global Assessment Scale (GAS) (Tang & Ungvari, ), Scale for the Assessment of Negative Symptoms (SANS) (Tang & Ungvari, ), and Global Assessment of Functioning (GAF) scores (Kales et al, ; Suzuki et al, ).…”

“…This is particularly significant given that most patients in this study received a substantial number of treatments. No severe adverse effects were likewise noted in studies specific to the elderly with psychotic conditions (Hassamal et al, ; Kramer, ; Meyen et al, ; Selvadurai et al, ; Suzuki, Takano, et al, ; Tang & Park, ). A comparative study of ECT safety in patients above and below the age of 60 did, however, show that adverse effects were more commonly experienced in late‐life patients; these were predominantly cardiovascular and cognitive in nature (Antosik‐Wojcinska & Swiecicki, ).…”

“…Factors contributing to the lower ECT utilization rates in the elderly with primary psychotic conditions are manifold (Kumagaya & Halliday, ). Foremost, there is a notable absence of literature specific to this population—at the time of writing, this was limited to one case series of five patients and five single case reports (Hassamal, Jolles, & Pandurangi, ; Kramer, ; Meyen, Acevedo‐Diaz, & Reddy, ; Selvadurai, Farahmand, Jain, & Alvarado, ; Suzuki, Shindo, et al, ; Tang & Park, ). Furthermore, international treatment guidelines have reflected a general lack of agreement regarding the role of ECT in schizophrenia, much less its focused application in elderly patients (Chanpattana, ; Galletly et al, ; Kaster, Daskalakis, & Blumberger, ; Kristensen et al, ; Lehman et al, ; National Institute for Health and Care Excellence, ).…”

Acute electroconvulsive therapy in the elderly with schizophrenia and schizoaffective disorder: a literature review

“…The literature search yielded six studies focusing specifically on ECT efficacy in the elderly with primary psychotic conditions (Table 1). 5,[14][15][16][17][18] A further 17 studies included at least one patient older than 60 years of age within a mixed-age cohort, or a mixed-diagnoses cohort where outcomes specific to patients with primary psychotic conditions were reported (Table 2). 4,10,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]…”

Current progress in neuroimaging research for the treatment of major depression with electroconvulsive therapy

“…After improving the patient’s symptoms through ECT, PET imaging showed that her brain metabolism was normal. Hassamal et al [ 43 ] adopted 18 F-FDG-PET/CT before ECT to show extensive hypometabolism in the frontal, parietal and temporal cortices. After eight sessions of ECT, symptoms of psychosis and anxiety symptoms as well as cognitive impairment were resolved.…”