ORIGINAL ARTICLE

Resolution of SPECT-Determined Anterior Cerebral
Hypoperfusion Correlated With Maintenance ECT-Derived
Improvement in Residual Symptoms in a Case of Late-Life
Psychotic Depression
Kazumasa Suzuki, MD,* Shuichi Awata, MD,† Takehisa Takano, MD,‡ Yukio Ebina, MD,*
Shinichi Numata, MD,§ Atsushi Saito, MD,‡ Kae Ito, MD,* and Hiroo Matsuoka, MD‡

Abstract: A 70-year-old widow with recurrent psychotic depression
was successfully treated with maintenance electroconvulsive therapy (ECT) for 4 years up to the present. Anterior cerebral hypoperfusion visualized by single photon emission computerized tomography (SPECT) before ECT persisted (second SPECT study 14 days
after the last ECT session) despite a response to the first course of
acute ECT. Only mild symptoms remained. Relapse occurred 2
weeks after the post-ECT SPECT study. The hypoperfusion improved after response to a second course of acute ECT (per SPECT
5 days after the last ECT session), and perfusion was normalized
after 2-year maintenance ECT (per SPECT 14 days after the last
ECT session). The normalization coincided with improvement in
depressive symptoms remaining after the second course of acute
ECT. We speculate that the effectiveness of maintenance ECT might
have been in part the result of the improvement in residual symptoms and that resolution of the persistent anterior hypoperfusion,
which might underlie medical refractoriness, illness chronicity, and
relapse tendency in late-life depression, might have been associated
with the improvement in residual symptoms achieved by maintenance ECT.

itate elderly patients and often threaten their lives. Early
consideration of acute electroconvulsive therapy (ECT) is
warranted for the elderly with psychotic depression.1 However, such patients tend to experience recurrence after response
to acute ECT despite the use of combined medications.2
The efficacy of maintenance ECT in preventing recurrence of psychotic depression has been shown in one retrospective study and 2 case reports.3–5 Only one report pertains
to the elderly.5 The mechanism of action for maintenance
ECT is not known. Functional imaging techniques such as
single photon emission computed tomography (SPECT) have
been used recently to investigate brain function in patients
with depression. In this report, the resolution of SPECTdetermined anterior cerebral hypoperfusion in accordance
with improvement in residual symptoms achieved with maintenance ECT in a patient with recurrent late-life psychotic
depression is described.

CASE REPORT

Received for publication June 16, 2005; revision accepted November 15,
2005.
From the *Department of Psychiatry, Tohoku University Hospital, Sendai,
Japan; the †Department of Psychiatry, Sendai City Hospital, Sendai, Japan;
the ‡Department of Psychiatry, Tohoku University Graduate School of
Medicine, Sendai, Japan; and §Inokashira Hospital, Tokyo, Japan.
Reprint: Kazumasa Suzuki, MD, Department of Psychiatry, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574 Japan. Email: kazumasa-tohoku@umin.ac.jp.
Copyright © 2006 by Lippincott Williams & Wilkins
ISSN: 0363-9762/06/3105-0253

The patient was a 70-year-old widow. At age 55 years,
viral hepatitis type C was detected during a medical checkup.
Her premorbid character was assiduous and syntonic. There
was no family history of mental disorders.
At age 68 years, the patient reported gradual memory
loss, difficulty in preparing a boxed lunch, and insomnia. She
exhibited a depressive mood and a delusional idea that she
had transmitted hepatitis C virus to someone and that her son
consequently had to pay a fine. She was admitted to a psychiatric hospital. She was treated with amoxapine (at least 60
mg/d for 6 weeks), sulpiride (at least 300 mg/d for 4 weeks),
and perphenazine (at least 9 mg/d for 8 weeks). However,
after 6 months, she was discharged from the hospital without
improvement. She was admitted to another hospital after 8
months and treated with amoxapine (at least 150 mg/d for 30
weeks) and risperidone (at least 1 mg/d for 12 weeks).
However, her condition deteriorated progressively. She described delusions of persecution that people assembling in
front of the hospital shouted to her that she was a criminal and
intended to burn her to death. She was sometimes agitated
because of the delusions.

Clinical Nuclear Medicine • Volume 31, Number 5, May 2006

253

Key Words: electroconvulsive therapy, psychotic depression,
maintenance ECT, elderly, SPECT, cerebral perfusion
(Clin Nucl Med 2006;31: 253–255)

M

anagement of patients with late-life psychotic depression is an important issue in clinical geriatric psychiatry
because some psychotic symptoms (agitation, delusion, hallucination, suicidal tendency, and refusal to eat) easily debil-

Suzuki et al

Clinical Nuclear Medicine • Volume 31, Number 5, May 2006

She was transferred to our hospital 2 years after the
onset of symptoms. Her motor function, thought, and speech
were inhibited, and she exhibited depressive mood, various
body pains, anorexia, anxiety, suicidal ideation, auditory
hallucination, and delusions of guilt, poverty, and persecution. She said that the cost of building a facility to purify her
waste was demanded of her and that she was threatened with
violence. She was bedridden almost all day long without
rigidity. She had a 17-item Hamilton Rating Scale for Depression (17-HRSD) score of 30.
On detailed examination, including full blood tests,
liver, kidney, and thyroid function tests, magnetic resonance
imaging study of the brain, electroencephalography (EEG)
study, and neurologic tests, no abnormalities were found
except hypoalbuminemia and thrombocytopenia. A SPECT
study with Tc-99m hexamethylpropylene amine oxime (Tc99m HMPAO) revealed bilateral frontal, parietal, and temporal hypoperfusion. ECT was considered because of the
patient’s severity of the psychotic and medical conditions.
Her legal guardian provided consent for the acute ECT.
Modified ECT was performed. Atropine sulfate (0.5 mg),
thiopental (150 mg), succinylcholine (60 mg), and nicardipine (1
mg) were used. A bag–valve mask was used for artificial
ventilation. The Thymatron System IV brief pulse square wave
apparatus (Somatics, LLC, USA) was used. Electrodes were
placed in the traditional bilateral frontotemporal manner.
Acute ECT was administered 2 to 3 times per week. At a
seizure threshold of 76 mC, determined by stimulus dose
titration, motor and EEG seizure durations of 0 seconds and
34 seconds, respectively, were recorded during the first session. The stimulus dose was increased over this first course of
acute ECT to a final stimulus dose of 151 mC, which elicited
motor and EEG seizure durations of 18 seconds and 27
seconds, respectively. After 12 ECT sessions, the patient’s
psychiatric symptoms were almost completely resolved. Only
mild motor inhibition remained (17-HRSD score: 13).
One month after the partial remission, the patient relapsed into a substupor despite the use of fluvoxamine (150
mg/d) (17-HRSD score: 33). She underwent a second course
of acute ECT (10 sessions). ECT was conducted in the same
manner as in the first course. At a seizure threshold of 76 mC,
determined by stimulus dose titration, motor and EEG seizure
durations of 57 seconds and 77 seconds, respectively, were
recorded during the first session. The stimulus dose was
increased over this second course of acute ECT to a final dose
of 227 mC, which elicited motor and EEG seizure durations
of 21 seconds and 27 seconds, respectively. The patient
showed marked improvement, with the exception of mild
motor inhibition (17-HRDS score: 11). Because of the patient’s responsiveness to ECT and the failure to prevent
relapse with pharmacotherapy alone, we decided to use maintenance ECT with milnacipran (75 mg/d), a serotonin norepinephrine reuptake inhibitor. She provided consent for the
maintenance ECT. Thus far, there have been a total of 50
maintenance ECT sessions; the first 4 sessions were at weekly
intervals, the next 10 sessions occurred every 2 weeks, the
next 6 occurred every 3 weeks, and the next 34 occurred
every 4 weeks to the present. Maintenance ECT was con-

ducted in the same manner as acute ECT. At a stimulus dose
of 227 mC, motor and EEG seizure durations of 15 seconds
and 57 seconds, respectively, were recorded during the first
session. The stimulus dose was increased over the course of
maintenance ECT, with the most recent stimulus dose being
504 mC, which elicited motor and EEG seizure durations of
18 seconds and 27 seconds, respectively. The residual symptoms gradually improved with maintenance ECT (17-HRDS
score just after 2-year maintenance ECT: 3). The patient
began to use daycare services for the elderly twice a week
after discharge from our hospital. We have succeeded in
preventing recurrence for 4 years (17-HRDS score at present:
3). There have been no adverse effects resulting from the
ECT. We continued EEG examination and Mini-Mental Status Examination (MMSE) before and after both acute ECT
courses and each maintenance ECT session. There was no
difference between EEG findings obtained before the first
course of acute ECT and those obtained after the most recent
maintenance ECT session. The MMSE score after 2.5 years
of maintenance ECT was higher than the score obtained
before the first course of acute ECT (scores: 25 and 18,
respectively).
Cerebral blood flow (CBF) determined by SPECT did
not change after the response to the first course of acute ECT
(14 days after the last ECT session). Clinical relapse occurred
2 weeks after the SPECT study. Just after the second course
of acute ECT (5 days after the last ECT session), CBF was
improved, and 2 years later, further improvement was noted
(14 days after the last ECT session) in concert with the
improvement in residual symptoms achieved by 2-year maintenance ECT. SPECT findings are shown in Figure 1.

254

DISCUSSION
In our case, anterior cerebral hypoperfusion observed
before ECT persisted despite response to the first course of
acute ECT. Only mild symptoms remained. Relapse occurred
2 weeks after the post-ECT SPECT study. The hypoperfusion
improved just days after response to the second course of
acute ECT, and perfusion was normalized after 2-year maintenance ECT. The normalization of cerebral perfusion appeared to coincide with improvement in the depressive symptoms remaining just after the second course of acute ECT.
In an earlier study of patients with late-life depression
referred for ECT, we observed that mean SPECT-determined
regional CBF reduction was resolved, in association with a
clinical response, 2 weeks after acute ECT. We also observed
a significant regional CBF reduction in right and left anterior
cingulate and caudal orbitofrontal cortices and the right
insular and posterior middle frontal cortices in these patients
versus control subjects; this reduction persisted for at least 12
weeks after acute ECT despite a clinical response.6 We also
reported that prefrontal and anterior cingulate hypoperfusion
might relate to refractoriness and illness chronicity in late-life
depression.7 Sackeim et al showed that pre-ECT medication
resistance was associated with an increased relapse rate after
acute ECT; thus, a common neurobiologic substrate may
underlie both the pre-ECT medication resistance and postECT relapse vulnerability to depressive episodes.8 Therefore,
© 2006 Lippincott Williams & Wilkins

Clinical Nuclear Medicine • Volume 31, Number 5, May 2006

FIGURE 1. Imaging findings. (A) Magnetic resonance images
of the brain in our case before the first course of acute ECT.
(B) Images obtained by single photon emission computed
tomography (SPECT) with Tc-99m hexamethylpropylene
amine oxime (Tc-99m HMPAO) before the first course of
acute ECT. Bilateral frontal, parietal, and temporal hypoperfusion is seen. One hundred percent in color scale is compatible with 1911 megabecquerel (MBq) (51 mCi). (C) Images obtained by SPECT with Tc-99m HMPAO after the first
course of acute ECT (14 days after the last ECT session). Bilateral frontal, parietal, and temporal hypoperfusion. Relapse
occurred 2 weeks after these images were obtained. One
hundred percent in color scale is compatible with 2504
MBq (68 mCi). (D) Images obtained by SPECT with Tc-99m
HMPAO after response to the second course of acute ECT (5
days after the last ECT session). Improvement in cerebral
perfusion is seen. One hundred percent in color scale is
compatible with 5503 MBq (149 mCi). (E) Images obtained
by SPECT with Tc-99m HMPAO after 2-year maintenance
ECT (14 days after the last ECT session). Normalization of
cerebral perfusion is seen. One hundred percent in color
scale is compatible with 2312 MBq (62 mCi).

we speculated that persistent anterior paralimbic hypoperfusion might relate to relapse vulnerability as well as a tendency
toward medication failure and illness chronicity in late-life
depression.7 This notion is consistent with our observation in
the present case that anterior hypoperfusion did resolve despite clinical improvement after response to the first course of
acute ECT and that relapse occurred soon thereafter.
Changes in regional CBF after continuation or maintenance ECT in depressed patients has not been reported with
the exception of one case report. Conca et al. reported that
reduced bilateral uptake of Tc-99m HMPAO and 关18F兴fluorodeoxyglucose after continuation ECT (7 days after the

© 2006 Lippincott Williams & Wilkins

Resolution of SPECT-Determined Anterior Cerebral Hypoperfusion

last ECT session) in the prefrontal regions correlated with
relapse prevention in 2 patients that showed normal cerebral
perfusion and glucose metabolism before acute ECT.9 In our
case, anterior hypoperfusion resolved after 2-year maintenance ECT, and this normalization was associated with
improvement in residual symptoms. These findings are discrepant and remain difficult to interpret. However, a major
reason for the effectiveness of maintenance ECT may be the
improvement in residual symptoms; partial remission leaves
a patient at risk for relapse.10 In addition, resolution of
persistent anterior hypoperfusion, which may relate to medication refractoriness, illness chronicity and relapse tendency
in cases of late-life depression, may correlate with improvement in residual symptoms resulting from maintenance ECT.
Further studies in large numbers of patients are needed to
validate these notions.

ACKNOWLEDGMENTS
The authors thank Dr. Shigeo Kinomura, Institute of
Development, Aging and Cancer, Tohoku University, Sendai,
Japan, for his useful suggestions. The authors appreciate the
assistance of the doctors and nurses of psychiatric service at
Tohoku University Hospital.
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