ECT and Radiology- a New Finding

Out on PubMed, from researchers at Vanderbilt University School of Medicine, in Nashville, Tennessee, is this case report:

Chronic Electroconvulsive Therapy May Induce Calvarial Hyperemia and Marrow Replacement.

Khattab MH, Sherry AD, Aulino JM, Becker JE, Petrie WM, Cmelak AJ.J ECT. 2020 Oct 27. doi: 10.1097/YCT.0000000000000728. Online ahead of print.PMID: 33122499

The abstract is copied below:

Electroconvulsive therapy (ECT) is a treatment option for a number of psychiatric disorders, including refractory major depression and obsessive compulsive disorder. There are no known structural sequelae of ECT. Here we present a patient with severe refractory obsessive compulsive disorder and major depression treated over 2 years with ECT every 2 weeks. Planning magnetic resonance imaging intended for a potential procedural intervention for her psychiatric disease incidentally demonstrated a new area of increased enhancement and loss of marrow signal within the right frontal bone. Imaging findings were suggestive of underlying bone marrow or bone changes, although there was no evidence of bone destruction on bone-windowed computed tomography (CT) and there was no uptake on nuclear bone scan. The CT chest/abdomen/pelvis were also reassuring that this did not represent metastatic disease, and findings were unchanged on repeat magnetic resonance imaging 4 months later. Thus, this area corresponded to the site directly underlying the unilateral ECT electrode placement, suggestive of never-before described ECT-induced hyperemia. We report for the first time that frequent, chronic ECT may induce asymptomatic skull bone marrow hyperemia with radiologic findings. This appears to be a direct consequence of electrical current leading to chronic inflammatory and edematous marrow replacement. Electroconvulsive therapy should be added to the neuroradiological differential diagnosis of calvarial enhancement and loss of marrow signal. Psychiatrists should counsel patients on the possibility of this rare radiological finding, which may be confused for other processes.

And from the text:

These findings, although notable radiologically, do not appear to be associated with any adverse clinical effect and were asymptomatic. Moreover, although ECT-induced hyperemia has never been previously described, such incidental findings may be more prevalent than currently appreciated, since patients treated with ECT are not typically followed serially with MRI. Patients being treated with frequent ECT who possess a neurologic indication for MRI, such as the patient discussed here, may have increased association with this incidental finding. Importantly, from this report, ECT-induced calvarial changes, most likely representing hyperemia, should be added to the neuroradiological differential diagnosis of MRI-evident calvarial enhancement and loss of marrow signal in a patient with a history of chronic ECT. An appropriate workup for metastatic malignancy and trauma is indicated in such patients before confirmation of this diagnosis of exclusion. Psychiatrists who perform ECT may counsel patients on the potential for this benign radiologic finding with frequent and long-standing ECT

It is surprising, if this finding is truly associated with the ECT that the patient received, that it has never been noticed before. A radiologist friend of mine was kind enough to review the images in the case report, and found them convincing.

The patient in this case was a 71 year-old woman with severe OCD and depression who got the MRI as part of the workup for a radiosurgical capsulotomy to treat her OCD. Further follow up about her clinical status would be very instructive...