Elevated body mass in National Football League players linked to cognitive impairment and decreased prefrontal cortex and temporal pole activity.

Obesity is a risk factor for neurodegenerative disease and has been shown to adversely affect cognitive function. Professional athletes who participate in sports, which expose them to repetitive concussions, may be at heightened risk for cognitive impairment. Here, we investigated the effects of body mass as measured by waist-to-height ratio (WHtR) on regional cerebral blood flow using single-photon emission computed tomography imaging in 38 healthy weight (WHtR mean 49.34 ± 2.8; age 58 ± 9.6) and 38 overweight (WHtR mean 58.7 ± 4.7; age 58 ± 13.3) retired National Football League football players. After matching for age and position, we used a two sample t-test to determine the differences in blood flow in healthy versus overweight subjects. Statistical parametric mapping revealed a higher WHtR ratio is associated with decreased blood flow in Brodmann areas 8, 9 and 10, brain regions involved in attention, reasoning and executive function (P<0.05, family-wise error) along with deficits in the temporal pole. Moreover, overweight athletes had significant decrease in attention (P = 0.01326), general cognitive proficiency (P = 0.012; Microcog: Assessment of Cognitive Functioning) and memory (P=0.005; Mild Cognitive Impairment Screen). The association between elevated WHtR percentage and decreased blood flow in the prefrontal cortex and temporal pole may be correlated with the decreased performance on tests of attention and memory. These findings suggest that a weight management program may be critical to the health of athletes who have been exposed to mild brain trauma during their careers.

Decreased cerebral blood flow in the limbic and prefrontal cortex using SPECT imaging in a cohort of completed suicides.

Suicide has a high comorbidity with impulsivity and depression, and finding imaging biomarkers indicative of patients at high risk for suicidal behavior is invaluable to the clinician. Using single-photon emission computed tomography (SPECT) imaging, we have previously reported regional cerebral blood flow (rCBF) decreases in the medial prefrontal cortex, ventral tegmental area and subgenual cingulate cortex (Brodmann area 25 (BA 25)), a region found to be hypoperfused with treatment-resistant depression. From 2007 to 2010, we have extended our analysis to include nine additional completed suicides. In all, 27 healthy, age- and gender-matched subjects from a previously acquired healthy brain study served as controls to our 21 completed suicides. All 21 suicides had been previously diagnosed with depression according to Diagnostic and Statistical Manual of Mental Disorder-IV criterion. Voxel-by-voxel analyses were performed using statistical parametric mapping to compare the differences in technetium-99m hexamethylpropylene amine oxime brain uptake between the groups. Factor analysis of the data identified the top 10 regions of hypoperfusion in the suicidal group, including the bilateral superior frontal lobes, the right precuneus, the rolandic operculum, postcentral gyrus, left caudate and insular cortex. We also demonstrate more focal decreases in rCBF in the subgenual cingulate cortex (BA 25) in 18 subjects, supporting our previous hypothesis that hypoperfusion of BA 25 may be a risk factor for suicide in depressed patients. This work suggests that SPECT might be useful in predicting risk for suicide completion in subjects with depression or treatment-resistant depression. Further investigation of this work is necessary to better understand the predictive value of this finding.

Regional cerebral blood flow in alcohol-induced violence: a case study.

A case is presented of a 20-year-old man who became violent on many occasions after ingesting alcohol. On one occasion he committed an armed robbery. Two brain SPECT studies were performed: one when he was alcohol free, and one after he ingested alcohol in the same pattern as the night of the crime. The "alcohol free" study revealed marked hyperactivity in the cingulate gyrus, right and left lateral frontal lobes, right and left lateral parietal lobes and the right lateral temporal lobe. The "alcohol intoxication" study showed an overall dampening effect on the hyperactive areas of the brain, with only the anterior cingulate gyrus showing excessive activity. In addition, the right and left prefrontal cortex became hypoperfused, decreasing impulse control and judgment, as did the left and right temporal lobes, increasing the likelihood for aggression. This study suggests that this man may have been "self-medicating" an overactive brain, but in the process induced a state that increased the likelihood for aggressive behavior. This case study suggests the need for further research in the area of alcohol-induced violence and the potential usefulness of SPECT imaging, although no conclusions can be drawn from one case.

High resolution brain SPECT imaging of marijuana smokers with AD/HD.

Marijuana abuse is common among young Americans and even more common among teenagers and adults with attention deficit/hyperactivity disorder (AD/HD). Many teenagers and young adults believe that marijuana is a safe substance to use despite a number of studies demonstrating cognitive impairment with chronic or heavy usage. Brain single photon emission computer tomography (SPECT) imaging is being used increasingly in psychiatry to study underlying functional brain problems, including AD/HD. SPECT provides information on cerebral blood flow and metabolic function. Brain SPECT studies were performed on 30 heavy marijuana users (who had used on at least a weekly basis for a minimum of one year) with AD/HD from an outpatient psychiatric clinic and 10 AD/HD control group subjects matched for age and sex who had never used drugs. The three-dimensional surface images were used in the analysis of the scans, and were blindly interpreted without knowledge of the clinical data. Decreased perfusion in the prefrontal cortex was the only abnormality seen in the AD/HD control group (80%). In the marijuana group, there was a similar decrease in the perfusion of the prefrontal cortex while performing the same concentration task (83%). However, the marijuana group also demonstrated marked decreased activity in the right and left temporal lobes. The severe and moderate ratings were found in the heaviest users, but not necessarily the longest users. This study demonstrates decreased cerebral perfusion in the temporal lobe regions of the brain on SPECT imaging from chronic marijuana usage.

High-resolution brain SPECT imaging in ADHD.

Children and adolescents with ADHD were evaluated with high-resolution brain SPECT imaging to determine if there were similarities between reported PET and QEEG findings. Fifty-four children and adolescents with ADHD by DSM-III-R and Conners Rating Scale criteria were evaluated. A non-ADHD control group was also studied with SPECT. Two brain SPECT studies were done on each group, a resting study and an intellectual stress study done while participants were doing a concentration task. Sixty-fiver percent of the ADHD group revealed decreased perfusion in the prefrontal cortex with intellectual stress, compared to only 5% of the control group. These are findings consistent with PET and QEEG findings. Of the ADHD group who did not show decreased perfusion, two-thirds had markedly decreased activity in the prefrontal cortices at rest.

Three years on clomipramine: before and after brain SPECT study.

A case is presented of a patient diagnosed with attention deficit disorder, obsessive thinking, anger outbursts, and depression who had a SPECT study prior to treatment and after 3 years of treatment on clomipramine. The follow-up SPECT study showed marked improvement overall in the cerebral perfusion of the brain. At rest marked overactivity was noted in the anterior medial aspects of the frontal lobes, along with "patchy" (increased and decreased) uptake throughout the cortical and subcortical areas of the brain. After treatment for 3 years on clomipramine at 225 mg a day, the follow-up SPECT study revealed a normalization of activity in the anterior medial aspects of the frontal lobes as well as no patchy uptake cortically and subcortically as noted in the study prior to treatment. The clinical usefulness of the SPECT study as it relates to this case is discussed.

Visualizing the firestorms in the brain: an inside look at the clinical and physiological connections between drugs and violence using brain SPECT imaging.

The connection between drugs and violence has been well documented. Understanding the intricacies of this connection is essential to finding effective interventions. Much has been written about the psychosocial causes of these problems, but there have been few studies exploring the biophysiological interface between drug effects, violent behavior and brain metabolism. Over the past eight years, The Amen Clinic has been extensively involved in the clinical use of brain SPECT imaging to evaluate complicated neuropsychiatric problems, especially related to the issues of both violence and substance abuse. From this work several clinical patterns, as well as brain SPECT imaging patterns, have been recognized that may help further our understanding of these problems. In this article, following a brief review of the literature on drugs, violence and the brain, five clinical examples are explored; the authors show how these support the clinical utility of incorporating SPECT imaging into psychiatric assessment of drug abuse and violence. Finally, a model is proposed to help explain the complex interaction between the brain, violence and drug abuse.

Brain SPECT findings and aggressiveness.

Forty adolescents and adults who exhibited aggressive behavior within the six months prior to evaluation by physically attacking another person or destroying property were evaluated with brain SPECT imaging. A control group of 40 psychiatric patients who had never been reported to exhibit aggressive behavior were also studied. The brain SPECT studies were read blind to aggressiveness by nuclear physician on two separate occasions. The interreading reliability was very high. The brain SPECT patterns of the group with aggressive behavior showed significant differences from the control group in several areas of brain. These findings were most often seen in the following combination: decreased activity in the prefrontal cortex, increased activity in the anteromedial portions of the frontal lobes, leftsided increased activity in the basal ganglia and/or limbic system in comparison to the whole brain and focal abnormalities in the left temporal lobe. These findings indicate a possible cerebral perfusion profile for those who exhibit violent or aggressive behavior. Several case studies and the implications for treatment are discussed.

Emergency room use of hypnosis.

Myths about hypnosis have interfered with its use in emergency settings. Specifically, included are myths about who induces the hypnotic state, the length of induction time, and the traumatized patient's inability to concentrate on a focal point. It is suggested, however, that altered states of awareness occur rapidly and spontaneously in the patient who has experienced acute trauma and/or pain. Two cases are presented that illustrate spontaneous trancelike states occurring in traumatic situations. The cases also show how the recognition of these altered states can facilitate the patient's care and treatment in an emergency setting.

Post-Vietnam stress disorder: a metaphor for current and past life events.

Delayed posttraumatic stress reactions are often triggered by events that echo the original trauma. It is not uncommon, however, for these delayed reactions to represent a metaphor for other current or past life events. A case is presented that illustrates the diagnostic and therapeutic significance of understanding these reactions as a metaphor.