Role of Nuclear Medicine in Psychiatry-SVIMS Experience. Dr.Ranadheer Manthri Faculty Sri Venkateshwara Institute of Medical Sciences Tirupati

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1 Role of Nuclear Medicine in Psychiatry-SVIMS Experience Dr.Ranadheer Manthri Faculty Sri Venkateshwara Institute of Medical Sciences Tirupati

2 Areas and their definite function Prefrontal cortex- Executive function such as planning,decision making,set shifting Medial frontal cortex-arousal and motivation Orbitofrontal cortex-social behaviour and inhibition centre Anterior Cingulate-Emotional Regulation

3 Right Parietal lobe-consciousness of self and surrounding environment Temporal lobes-memory,language and orientation Insula- emotions related to pain- Plays crucial role in somatoform disorders

4 Case 1 36 year Female Mixed anxiety and depression Active suicidal ideation Precipitating factor:marital conflict

5 Clinical Diagnosis- DSM-5 Major Depressive disorder ICD (F32.2) with anxious distress

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7 Case 2 55 year female Hopelessness Severe disinterest towards life Passively awaits Death No Precipitating factor

8 Clinical Diagnosis DSM-5 Major Depressive disorder ICD (F33.2) with melancholic features

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10 Comparison of Case 1 and Case 2

11 Coco

12 Case 3 21 year female Mutism Decreased Psychomotor Activity Enuresis (passing urine in clothes) and Encoparesis(passing stools in clothes) Precipitating factor:suicidal death of mother

13 Clinical Diagnosis DSM-5 Catatonia ICD (F06.1)

14 Global Hypometabolism

15 Case 4 21 F Involuntary movements of both hands and legs and thrusting movements of trunk lasting for more than half an hour for more than 10 times a day Predisposing factor:psychosocial distress due to alcohol dependency in father Precipitating event:marriage against will

16 Clinical Diagnosis Psychogenic Non Epileptic Seizures/ Conversion Disorder with Seizures ICD (F44.5)

17 Global Hypermetabolism and Hippocampal hypometabolism

18 Case 5 30 years M History of Mild Traumatic Brain Injury,\ [defined as an injury which produced a period of unconsciousness for 30 minutes or less and/or retrograde amnesia less than 24 hrs, a Glassgow score of 13 to 15],

19 Clinical Diagnosis Mild Neuro cognitive disorder due to Traumatic Brain Injury (G31.84)

20 MRI vs N-PET

21 SCAN FDG -PET scan forms an important diagnostic tool in early identification of lesion not found on CT/MRI in patients suffering from neuropsychological disturbances. FDG PET results correlated better with PGI Battery of Brain Dysfunction than MRI.

22 Case 6 24 y Male Repeated Hand wash Repeated checking Repeatedly fears that he has done something wrong

23 Clinical Diagnosis Obsessive Compulsive Disorder-300.3(F42)

24 Image Pre and Post Therapy

25 Case 7 16 years Male Scholastic Backwardness

26 Clinical Diagnosis Attention Deficit Hyperactivity Disorder - predominantly inattentive presentation (F90.0)

27 Image

28 Case 8 Loss of motivation to everything

29 Clinical Diagnosis Frontal lobe syndromes Diagnosis-Hypometabolism in frontal lobes

30 Medical conditions we encountered where Patient Presented with Psychiatric Manifestations

31 Patient Presented with Conversion Disorder PNESTurned out to be Glioma

32 Patient Presented with Conversion disorder with depression-temporal lobe Infarct

33 Diagnosed outside as Depression and referred to Our Psychiatrist. 15 days back MRI Negative D Diagnosed Evolving Tuberculosis Confirmed by Followup MRI and CSF Analysis

34 We also have 3 cases of Herpes simplex Encephalitis presented to Neurology with Psychiatric Manifestations with negative MRI.

35 What is the best Imaging Technique Low tumor to background High tumor to background Low Tumor:background contrast:poor imaging technique Eg-FDG PET Scan

36 Steep Learning curve as the contrast between normal and abnormal is low

37 Reasons for Steep Learning curve RP with low target to background ratio. Patterned Recognition not specific as presence of insight into disease,drugs can change the pattern Overlap of patterns Eg-Hypofrontality

38 What benefits our patients had Increasing the compliance of the drugs by showing them Metabolic cause of their illness Regrouping the patients of depression who need counselling and who do not.

39 Effect of Cranioplasty on cerebral glucose metabolism : a case series of 15 patient Dr. vivek sharma 1,Dr.BCM Prasad 1,Dr. VV Rameshchandra 1, Dr.TC kalawat 2 DEPTT OF NEUROSRGERY,SVIMS,TIRUPATHY INTRODUCTION Severe traumatic brain injury with refractory intracranial hypertension and space-occupying ischemic stroke are the major indications of Decompressive Craniectomy (DC).(1). The indication of doing cranioplasty in these patients after DC is mainly cosmetic repair and cerebral protection. Doing crainoplasty(cp) is noted to improve the neurological status as well as cerebral blood flow as demonstrated by colour doppler studies and also improves cerebral glucose metabolism(2,3). The present study was undertaken to analyze the influence of cranioplasty on cerebral glucose metabolism 30 and its correlation with neurological 22.5 improvement. 15 MATERIALS AND METHODS This is a case series of 15 Patients with status DC planned for cranioplasty.detailed history and thorough clinical examination was done for all patients.ct scan brain (plain) and PET scan was done preoperative and 7 day postoperatively. Neuropsychological assessment was done by using MMSE and Glasgow Outcome Score (GOS) before and 7 days after cranioplasty. Preop (left)and post op (right)pet images total % improvement in PET values after cranioplasty in each patient Case no Age(yrs) Reason of craniectomy Time lapse %improvement in PET Clinical improv Ipsilateral Contra 1 45 SDH 11 wks Yes RESULTS The diagnosis at the time of DC and time lapse till cranioplasty are listed in table. Mean time interval between DC and cranioplasty in 13 pateints was 23 weeks. In case no 11 and 13 cranioplasty was done after 2 yrs and 22 months respectively. Overall functional and cognitive improvement was observed after cranioplasty. Case no 7 and 15 had not much clinical improvement and case no 2 had partial improvement but PET scanning could not be done in this patient.cerebral metabolism was found to be depressed in operated side compared to contralateral side.p value for ipsilateral verses contralateral SUV values is It is significant (p<0.05). Cranioplasty resulted in significant improvement in 18 FDG uptake in both hemispheres (table and fig ) (p<0.05). Improvement was noted more on the operated side. However in case no 7 glucose metabolism was found to be depressed after cranioplasty for unknown reasons. DISCUSSION Exact cause for nurological improvement after cranioplasty is not well known. Altered CSF hydrodynamics, effects of atmospheric pressure and impact on dynamic CBF could be possible explanations. Study done by P.A. winkler et all (jan2000) overall functional improvement was noted in 12 out of 13 patients.cerebral metabolism was significantly depressed on operated side(p<0.01) and post cranioplasty showed improvement (p<0.0001).their mean improvement I/C was 12% and 5% which is close to our 10.6% and 9.3%. We have noted 2 patients had no much improvement in cerebral metabolism and clinical condition also remained same after cranioplasty. CONCLUSION The result of above study showed there is significant improvement in cerebral glucose metabolism after cranioplsty, which may be the cause of neurological improvement but we propose cohort study in large population to confirm or refute our findings 2 44 EDH,SDH, 22 wks - - Yes(partial) 3 53 contusion 17wks Yes 4 34 EDH,SDH, 28wks Yes BIBLIOGRAPHY 1. Grant FC, Norcross NC. Repair of cranial defects by cranioplasty. Ann Surg. 1939;110(4): Honeybul S, Janzen C, Kruger K, et al. The impact of cranioplasty on neurological function. Br J Neurosurg. 2013;27(5): Isago T, Nozaki M, Kikuchi Y, Honda T, Nakazawa H. Sinking skin flap syndrome: a case of improved cerebral blood flow after cranioplasty. Ann Plast Surg. Sept; (3): [PubMed: ] 4. Winkler PA, Stummer W, Linke R, Krishnan KG, Tatsch K. The influence of cranioplasty on postural blood flow regulation, cerebrovascular reserve capacity, and cerebral glucose metabolism. Neurosurg Focus. 2000; 8(1):e9. [PubMed: ] 5 36 EDH,SDH 15wks Yes

40 Where we failed PNES-(though we found some areas of hypo metabolism,few organic causes we couldn't identify specific pattern Schizophrenia- We couldn't comment on Patterns because of wide spectrum and less no of subcategory of patients

41 Type a quote here. Johnny Appleseed

42 THANK YOU

43 Acknowledgements Dr.T.C.Kalawat Dr.Shivanand Asst Professor Psychiatry Dr.Amruthalakshmi Final year Resident Nuclear Medicine

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46 CORRELATION OF NEUROPSYCHOLOGICAL DEFICITS WITH LESIONS ON MRI AND NEUROPET IN PATIENTS WITH MTBI

47 INTRODUCTION Mild traumatic brain injury (MTBI) is a common neurological disorder with highest incidence in young population and is the most common cause of cognitive impairment in this group. The head injury task force of National institute of neurological disorders has estimated that there are 2,000,000 cases of head injury in USA annually of which 80% sustain MTBI. Kurtzke JF. The epidemiology of neurologic disease. In: RJ J, editor.clinical neurology, rev. Philadelphia: JB Lippincott; 1993.

48 DEFINITION MTBI is defined as an injury which produces a period of unconsciousness for <30 minutes and /or brief retrograde amnesia, A GCS of 13-15, no focal neurological deficit, No intracranial complications. WHO Task Force JF. The epidemiology of neurologic disease. In: RJ J, editor.clinical neurology, rev. Philadelphia: 1996.

49 Although majority of MTBI experience transient symptoms, a significant minority will have persistent and disabling conditions termed as post concussion syndrome (PCS) preventing them from returning to premorbid lifestyle.

50 Neuropsychological testing in patients with PCS assesses the deficits more precisely and also helps to some extent in treatment planning and prognostication.

51 Many studies have shown MRI to be more sensitive than CT especially in detection of non hemorrhagic contusion, DAI and show some correlation between these MRI lesions and the deficits on neuropsychological tests. Cyrus Eierud R. Cameron Craddock, Sean Fletchere, Manek Aulakhe, Brooks King-Casas Damon Kuehl g, Stephen M. LaConteNeuroImage: Clinical 4 (2014)

52 Modalities like SPECT and PET may detect areas of hypoperfusion and decreased metabolic activity (glucose uptake) in patients with MTBI, Might prove to be more sensitive than other imaging modalities in the initial diagnostic evaluation of patients with MTBI. M. Wintermark, P.C. Sanelli, Y. Anzai, A.J. Tsiouris, and C.T. Whitlow, on behalf of the American College of Radiology Head Injury Institute. J Neurol Neurosurg Psychiatry 2007;78:

53 Why this study? Most of the studies done previously were retrospective and were done more than one week post injury thus negating its usefulness as initial diagnostic tool.

54 AIMS and OBJECTIVES To assess neuropsychological deficits in patients following MTBI. To find correlation between MR image findings and PCS. To explore the value of FDG -PET scan in MTBI.

55 MATERIALS AND METHODS This is a prospective, cohort study which includes 15 consecutive patients with MTBI. Informed consent is obtained from all the patients recruited in the study.

56 Duration of the study: 1 year with follow up of individual patients at 1month by neuropsychological assessment (PGIBBD).

57 PGIBBD

58 PGIBBD DYSFUNCTION RATING SCORE

59 INCLUSION CRITERIA History of MTBI, defined as an injury which produced a period of unconsciousness for 30 minutes or less and/or retrograde amnesia less than 24 hrs, a Glassgow score of 13 to 15, Age group between years, Chen JK, Johnston Km, Collie A, McCrory P, Ptito A. A validation of the post concussion symptom scale in assessment of complex concussion using cognitive testing and functional MRI. J Neurol Neurosurg Psychiatry 2007;78:1231-8

60 No focal neurological deficit, No intracranial complications.

61 EXCLUSION CRITERIA Head injuries with GCS <13 Head injuries with other extracranial injuries Age < 15 and > 60 years (pediatric and old age population)

62 Patients who have undergone any neurosurgical procedure, or required hospital admission or prior to head injury. Patients with neurological, neurosurgical, psychiatric illnesses were also excluded. Pregnant and lactating women, patients with cardiac pacemakers and ferromagnetic materials in their bodies were also excluded.

63 All the patients included in the study underwent clinical examination, CT, MRI, and F18 FDG-PET scan within 7 days of injury and follow up at 1 month by neuropsychological assessment.

64 RESULTS All the 15 patients had neuropsychological deficits. Mean age 36 Yrs GCS at presentation

65 Mechanism of head injury was road traffic accident (RTA) in 11 patients, falls in 3, assault in 1.

66 PRESENTING COMPLAINTS OF THE PATIENTS SYMPTOM NUMBER(%) Head ache 12(80) Behavioural disturbances 11(73.3) Sleep disturbances 9(60) Attention deficit 7(46.6) Giddiness 4(26.6) Visual 3(20)

67 8 NUMBER OF PATIENTS WITH IMPAIRED NEUROPSYCHOLOGICAL TEST RESULTS PATIENT NUMBER Mental balance Attention Verbal memory Comprehension

68 MRI LESION CHARACTERISTICS SEEN IN MTBI LOCATION FRONTAL (13) TEMPORAL (13) PARIETAL (8) RIGHT LEFT BILATERAL 5 1 2

69 8 MRI LESION LOCATION FRONTAL TEMPORAL PARIETAL RIGHT LEFT BILATERAL

70 7 NEUROPSYCHOLOGICAL PROFILE OF PATIENTS WITH (GROUP A) AND WITHOUT (GROUP B) LESIONS ON MRI PATIENT NUMBER GROUP A GROUP B 0 Mental balance Attention Verbal memory

71 RIGHT LEFT BILATERAL

72 5 COMPARISION OF SYMPTOMS WITH LOCALISATION OF NEUROPSYCHOLOGICAL DEFICITS 4 PATIENT NUMBER 3 PARIETAL TEMPORAL FRONTAL 1 0 HEADACHE SLEEP MEMORY DEFICITES GIDDINESS

73 NEUROPSYCHOLOGICAL DEFICIT LOCALIZATION IN PATIENTS WITH FRONTAL LESIONS ON MRI FRONTAL NEUROPSYCHOLOGICAL DEFICIT LOCALIZATION Frontal MRI lesions PRESENT ABSENT TOTAL PRESENT ABSENT TOTAL

74 NEUROPSYCHOLOGICAL DEFICIT LOCALIZATION IN PATIENTS WITH TEMPORAL LESIONS ON MRI TEMPORAL NEUROPSYCHOLOGICAL DEFICIT LOCALIZATION TEMPORAL MRI lesions PRESENT ABSENT TOTAL PRESENT ABSENT TOTAL

75 MRI vs N-PET

76 HYPERMETABOLISM IN B/L F, T,BG,POST CENTRAL GYRUS

77 DISCUSSION In this prospective study all the fifteen patients with PCS following MTBI had deficits on neuropsychological tests. All symptoms were associated with frontal dysfunction on neuropsychological testing.

78 The mean age of 36 years reflects the relatively young and productive age profile of the patients. Neuropsychological deficits (NPD) were seen as soon as 1 month post injury. These observations suggest that PCS can manifest early and may persist thereafter.

79 The commonest symptoms reported by patients in this study were headache, memory and sleep disturbances, and behavioural changes similar to the observations in studies conducted by Hugh and voller et al. Voller B, Benke T, Benedetto K, Schnider P, Auff E, Aichner F. Neuropsychological, MRI and EEG findings after very mild traumatic brain injury.

80 The most frequently seen deficits were verbal learning, verbal memory, sustained attention. The most frequent neuropsychological localization was frontal and temporal which is similar to study conducted by Hughes et al. Hughes DG, Jackson A, Mason DL, Berry E, Hollis S, Yates DW. Abnormalities on magnetic resonance imaging seen acutely following mild traumatic brain injury: Correlation with neuropsychological tests and delayed recovery Neuroradiology 2004;46:550-8.

81 Of the 59 children studied by Koelfen et al. one year after head injury, MRI lesions were seen in 66%. In the present study MRI lesions were seen in 90 % of patients.

82 Van der Nalt et al studied MRI in 67 patients within one to three months and again within 6 to 12 months after injury. The lesion location was predominantly in the frontal and temporal regions in comparision to the present study. Vander JT, Wiedmann KD, Hadley DM, Condon B, Teasdale G, Brooks DN. Early and late magnetic resonance imaging and neuropsychological outcome after head injury. J Neurol Neurosurg Psychiatry 1988;51:391-6.

83 In study by Levin et al the MRI lesion location was mostly seen in the frontal and temporal lobes and they have concluded that newer imaging sequences like f MRI may help to maximize the sensitivity of MRI. M. Wintermark, P.C. Sanelli, Y. Anzai, A.J. Tsiouris and C.T. Whitlow on behalf of the American College of Radiology Head Injury Institute American Journal of Neuroradiology February 2015, 36 (2) E1-E11.

84 Hughes and Hoffmann et al found imaging abnormalities in 32.5% and 57% respectively and found a correlation between the MRI lesions and neuropsychological deficits to frontal lobe. Most of the patients (>90%) in the present study has correlation between neuroimaging findings and neuropsychological deficits. Hughes DG, Jackson A, Mason DL, Berry E, Hollis S, Yates DW. Abnormalities on magnetic resonance imaging seen acutely following mild traumatic brain injury: Correlation with neuropsychological tests and delayed recovery. Neuroradiology 2004;46:5508.

85 Frontal lesions seen in MRI done in the early period after head injury were found to be predictive of cognitive outcome in the study by van der Naalt et al. The results of present study also provide similar information that MRI lesions found in MTBI patients were predictive of neuropsychological deficits (NPD) if scan was done as early as within 1 week post injury.

86 Wallesch et al noted that even in patients with clinically mild head injury, if CT showed evidence of either diffuse axonal injury or focal contusions, patients were likely to have frontal dysfunction on neuropsychological tests and suggested that MRI may further improve the predictions. Wallesch Wilson JT, Wiedmann KD, Hadley DM, Condon B, Teasdale G, Brooks DN. Early and late magnetic resonance imaging and neuropsychological outcome after head injury. J Neurol Neurosurg Psychiatry 1988;51:391-6.

87 Previous studies using functional MRI (f MRI) and positron emission tomography (PET) have demonstrated functional abnormalities in patients with PCS. In the present study FDG F18 Neuropet has demonstrated hypometabolic lesions not seen on MRI and these lesions are in correlation to NPD of respective patients. Paul A.M. Hofman, Sven Z. Stapert, Marinus J.P.G. van Kroonenburgh, Jelle Jolles, Jelle de Kruijk, and Jan T. Wilmink. MR Imaging, Single-photon Emission CT, and Neurocognitive Performance after Mild Traumatic Brain Injury AJNR Am J Neuroradiol 22: , March 2001

88 CONCLUSIONS FDG -PET scan forms an important diagnostic tool in early identification of lesion not found on CT/MRI in patients suffering from neuropsychological disturbances.

89 Structural lesions on MRI may not always be present but when present may influence the degree or severity of the symptoms in patients with MTBI.

90 Introduction of FDG PET as an early diagnostic modality in patients with neuropsychological disturbances after MTBI might be beneficial as the patients will be opted for relevant pharmocological and cognitive behavioural interventions.