Low pressure hyperbaric oxygen therapy and SPECT brain imaging

Case report
Open Access
Low pressure hyperbaric oxygen therapy and SPECT brain imaging
in the treatment of blast-induced chronic traumatic brain injury
(post-concussion syndrome) and post traumatic stress disorder:
a case report
Paul G Harch1*, Edward F Fogarty2, Paul K Staab1 and Keith Van Meter1
Addresses: 1Section of Emergency Medicine, Department of Medicine, Louisiana State University Health Sciences Center, 2021 Perdido St, Room
W535, New Orleans, Louisiana, 70112, USA and 2Department of Radiology, University of North Dakota School of Medicine and Health Sciences,
Post Office Box 1975, 515 ½ East Broadway Avenue, Suite 106, Bismarck, North Dakota, 58502, USA
Email: PGH* - paulharchmd@aol.com; EFF - efogarty@medicine.nodak.edu; PKS - pstaab@wjmc.org; KVM - kvanmeter@aol.com
* Corresponding author
Published: 5 June 2009 Received: 12 March 2009
Accepted: 4 April 2009
Cases Journal 2009, 2:6538 doi: 10.4076/1757-1626-2-6538
This article is available from: http://casesjournal.com/casesjournal/article/view/6538
© 2009 Harch et al; licensee Cases Network Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
A 25-year-old male military veteran presented with diagnoses of post concussion syndrome and post
traumatic stress disorder three years after loss of consciousness from an explosion in combat. The
patient underwent single photon emission computed tomography brain blood flow imaging before
and after a block of thirty-nine 1.5 atmospheres absolute hyperbaric oxygen treatments. The patient
experienced a permanent marked improvement in his post-concussive symptoms, physical exam
findings, and brain blood flow. In addition, he experienced a complete resolution of post-traumatic
stress disorder symptoms. After treatment he became and has remained employed for eight
consecutive months. This case suggests a novel treatment for the combined diagnoses of blastinduced
post-concussion syndrome and post-traumatic stress disorder.
Introduction
By January, 2008 it was estimated that as many as 300,000
servicemen and women from the current Iraq and Afghanistan
Wars have PTSD or major depression, 320,000 have
experienced a TBI, and 82,000 have all three diagnoses [1].
Treatment is available for PTSD and depression, but there is
no proven therapy for the dual diagnoses of PTSD and the
residual effects of TBI, the PCS [2].
HBOT is the use of greater than atmospheric pressure
oxygen in an enclosed chamber to treat basic disease
processes [3]. HBOT has been traditionally applied to
certain emergent conditions and chronic wound conditions,
but not to blast-induced TBI/PCS or PTSD. This case
report is the first application of the authors’ low pressure
HBOT protocol for chronic brain injury to blast-induced
TBI/PCS and PTSD. An early version of this protocol was
recently reported in an animal model of chronic TBI that
duplicated the human experience [4].
Case presentation
A 25-year-old retired Caucasian male U.S. Marine presented
with headaches, tinnitus, and sleep disturbance.
Three years before evaluation the patient sustained LOC
Page 1 of 4
(page number not for citation purposes)
(a few minutes) from an IED explosion with anterograde
memory loss and confusion (one hour), and persistent
right ear tinnitus, headaches, imbalance, and sleep
disturbance. He developed PTSD symptoms within
3 months and experienced six more explosions with near
LOC within 15 months. After medical evaluation diagnoses
were TBI/PCS, PTSD, depression, hearing loss, and
tinnitus.
Prioritized Symptom List: 1) Constant headaches with
intermittent confusion, irritability, tunnel vision, and
dizziness, 2) Bilateral tinnitus, 3) Sleep disruption, 4) Left
eye blurred vision, 5) Irritability, 6) Depression, social
withdrawal; Additional Symptoms: 7) Fatigue, 8)
Decreased hearing, 9) Imbalance, 10) Cognitive problemsmemory,
attention, decreased speed of thinking, 11) Back
pain, 12) Bilateral knee pain, 13) PTSDsymptoms: intrusive
thoughts, combat thoughts, nightmares, tachycardia.
Med-Surg, Medications: None. FH, ROS, and PHIS: noncontributory
or negative. PSH: Engaged, no children, lives
with parents, 3 years college education, no tobacco or
drugs, one to two beers/week. Neuro PEx Abnormalities:
Slight deviation of right eye laterally, bilateral: decreased
hearing to softly rubbing fingers at one foot, noxious
response to 512 Hz tuning fork, decreased finger tapping
speed, unstable: rotation exam, tandem gait, and Romberg.
Treatment and testing: MRI brain-normal. SPECT
brain imaging pre-HBOT and 72 h after the 39th HBOT.
The patient underwent 39 HBOT’s in 26 calendar days at
1.5 ATA/60 minutes total dive time, twice/day, five days/
week in a monoplace chamber with 100% oxygen.
Outcome: Headache permanently gone after the 1st
HBOT. After 12 HBOT’s symptoms 3, 6, and 7 improved.
At 25th HBOT absence of PTSD symptoms. Re-evaluation
after 37 HBOT’s: 1) 4/6 primary problems improved
(#’s 1, 3, 5, 6), 2/6 no change, 2) 4/7 additional symptoms
improved (7, 9, 10, 13), 3/7 no change, 3) 6/6 abnormal
exam findings retested improved, 1 finding not retested
(right eye deviation). SPECT: heterogeneous with bilateral
frontal and temporal defects-all improved post HBOT. See:
Movie 1, Figures 1 and 2. (Movie 1): Side by side Pre and
Post HBOT processed transverse SPECT brain blood flow
images-movie. File Format: Quicktime Video. Description
of Data: Pre-HBOT scan is on the left and post-HBOT on
the right. Click on either image to initialize movie. Images
were obtained on a Picker Prism 3000 triple-head gamma
camera. Both scans were processed by technologist PJT:
25 mCi of ECD was prepared with the standard manufacturer’s
kit and injected in a peripheral vein in a low
noise low light area while the patient was quiet and
motionless. One hour after injection acquisition proceeded
with a 360 degree rotation and 40 stops,
20 seconds/stop on a 128 x 128 matrix, using low energy
high resolution fan beam collimators. Motion correction
was used for minor movement. Raw data was processed by
transverse reconstruction using 360 degree filtered back
projection and a ramp filter, followed by a LoPass filter,
order 2.2. Cutoff was taken at the intersection of the
best fit LoPass filter and noise on the power spectrum
graph. Per file attenuation correction and best fit ellipse
were applied. Images were oblique reformatted with slice
thickness at 4 mm (2 pixels), aligned, and off-center zoom
Figure 2. Post-HBOT SPECT brain scan three dimensional
surface reconstruction and processed transverse images.
Note relative improvement in brain blood flow to bilateral
focal frontal and temporal defects and overall normalization of
blood flow to a more homogeneous pattern.
Figure 1. Pre-HBOT SPECT brain scan three dimensional
surface reconstruction and processed transverse images.
Note bilateral orbital frontal and temporal lobe defects and
diffuse heterogeneous pattern of blood flow.
Page 2 of 4
(page number not for citation purposes)
Cases Journal 2009, 2:6538 http://casesjournal.com/casesjournal/article/view/6538
applied (20 cm2 area). Images were presented in all
3 orthogonal planes. Transverse processed images were
analyzed with Osirix Open-source software (version 3.3.2)
and windowed at a level of 1000 with a window width of
2000. They were subsequently rendered in QuickTime
movie format starting from vertex and proceeding through
the base of the brain. Images are in standard SPECT format
and orientation. Color map is red, yellow, green, blue, and
violet from highest brain blood flow to lowest. Note the
marked generalized increase in perfusion on the post-
HBOT scan. (Figure 1): Pre-HBOT SPECT brain scan three
dimensional surface reconstruction and processed transverse
images. Pre-HBOT scan was rendered in three
dimensional surface reconstruction format by PJT based
on the method developed and taught by Picker International
using Picker software. In this method brain blood
flow is computer indexed to frontal lobe blood flow. A
frontal lobe surface defect was identified on a selected
transverse slice. Processed/filtered transverse slices were
then featured with a 100% window such that all pixels
render a white image. Counts were slowly subtracted by
decreasing the window threshold until the defect was
visible as a full thickness black defect in the contour of the
cortex. As the defect emerged and was registered in proper
anatomic proportion to the rest of frontal cortical blood
flow the numerical window level was taken as the
determination threshold. Three separate determinations
were made for each scan and the final threshold taken as
an average of the three determinations. The technologist
was blind to the final image reconstruction due to software
restrictions that only allow threshold determination. The
surface reconstruction image at this threshold is featured
in the image above. Color is aesthetic. Note bilateral
orbital frontal and temporal lobe defects, areas typically
injured in traumatic brain injury, consistent with processed
transverse images in the right hand columns.
Processed images also show an abnormal diffuse heterogeneous
pattern of blood flow. Description of processing
is in (Movie 1). (Figure 2): Post-HBOT SPECT brain scan
three dimensional surface reconstruction and processed
transverse images. Three dimensional surface image was
prepared in identical fashion to the image in Figure 1.
Note relative improvement in brain blood flow to bilateral
focal frontal and temporal defects, consistent with
processed transverse images in the right hand columns.
Transverse slices also show normalization of the blood
flow to a more homogeneous pattern.
Discussion
The present case is the first application of the author’s
HBOT protocol to blast-induced TBI/PCS and PTSD. The
patient’s symptomatic, physical exam, and SPECT
improvements are similar to ours [3,5,6,9] and others’
[7,8] previous cases/case series of non-blast TBI suggesting
common pathophysiology. The unexpected result was the
complete resolution of PTSD. With the overlap of
symptoms, pathophysiology, and anatomy in TBI/PCS
and PTSD [10] HBOT is likely impacting common shared
targets in this case.
Conclusion
Thirty-nine low pressure HBOT’s caused a reduction in
symptoms and signs of chronic mild-moderate blastinduced
TBI/PCS and PTSD. The resolution of symptoms
and signs of TBI/PCS and PTSD were reflected in global
and focal improvements in brain blood flow imaging,
suggesting a novel treatment for these combined
diagnoses.
Patient’s perspective
Patient has declined to submit his perspective due to
privacy concerns.
List of abbreviations
ATA, Atmospheres absolute; ECD, Ethyl cysteinate dimer;
FH, Family history; HBOT, Hyperbaric oxygen therapy;
HPI, History of present illness; IED, Improvised explosive
device; LOC, Loss of consciousness; MRI, Magnetic resonance
imaging; PCS, Post-concussion syndrome; PEx,
Physical exam; PHIS, Prior head injury history; PMH, Past
medical history; PSH, Personal and Social history; PTSD,
post-traumatic stress disorder; ROS, Review of systems;
SPECT, Single photon emission computed tomography;
TBI, Traumatic brain injury.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal. In addition,
this case was approved by the LSU School of Medicine’s
Institutional Review Board as a case report.
Competing interests
The authors declare competing interests. The primary
author has a small corporation, Harch Hyperbarics, Inc.
that does hyperbaric consulting. Author KVM has a
corporation that leases hyperbaric oxygen chambers and
a corporation that contracts to provide hyperbaric oxygen
and woundcare services. None of the authors have
personal or financial relationships with people or organizations
that would influence the interpretation of data in
this report.
Authors’ contributions
PGH evaluated the patient, ordered the treatment and
imaging, and wrote the draft of the manuscript. EFF
analyzed and presented the SPECT imaging and assisted in
writing the manuscript. PKS assisted in the treatment of
the patient and assisted in writing the manuscript. KVM
Page 3 of 4
(page number not for citation purposes)
Cases Journal 2009, 2:6538 http://casesjournal.com/casesjournal/article/view/6538
assisted in development of the hyperbaric protocol and
writing the manuscript. All authors read and approved the
final manuscript.
Acknowledgements
The authors are indebted to nuclear technologist Philip J.
Tranchina for expert processing and three dimensional
thresholding of the SPECT brain imaging.
References
1. Tanielian T, Jaycox LH, Eds: Invisible Wounds of War: Psychological
and Cognitive Injuries, Their Consequences, and
Services to Assist Recovery. Center for Military Health Policy
Research, the Rand Corporation, Arlington, VA, 2008.
2. King NS: PTSD and traumatic brain injury: Folklore and fact?
Brain Injury 2008, 22:1-5.
3. Harch PG, Neubauer RA: Hyperbaric oxygen therapy in global
cerebral ischemia, anoxia, and coma. In The Textbook of
Hyperbaric Medicine, Chapter 18, 3rd Edition. Edited by Jain KK. Seattle,
Washington, Hogrefe and Huber; 1999:318-349.
4. Harch PG, Kriedt C, Van Meter KW, Sutherland RJ: Hyperbaric
oxygen therapy improves spatial learning and memory in a
rat model of chronic traumatic brain injury. Brain Res 2007,
1174:120-129.
5. Harch PG, Van Meter KW, Neubauer RA, Gottlieb SF: Use of
HMPAO SPECT for assessment of response to HBO in
ischemic/hypoxic encephalopathies. In The Textbook of Hyperbaric
Medicine. Chapter 35, Appendix 2. 2nd Edition. Edited by Jain KK.
Seattle, Washington, Hogrefe and Huber; 1996:480-491.
6. Harch PG, Neubauer RA: Hyperbaric oxygen therapy in global
cerebral ischemia/anoxia and coma. In The Textbook of Hyperbaric
Medicine. Chapter 18, 4th Revised Edition. Edited by Jain KK. Seattle,
Washington, Hogrefe & Huber; 2004:223-262.
7. Neubauer RA, Gottlieb SF, Pevsner NH: Hyperbaric oxygen
treatment of closed head injury. South Med J 1994, 87:933-936.
8. Golden ZL, Neubauer RA, Golden CJ et al.: Improvement in
cerebral metabol-ism in chronic brain injury after hyperbaric
oxygen therapy. Int J Neurosci 2002, 112:119-131.
9. Harch PG, Gottlieb SF, Van Meter KW, Staab P: HMPAO SPECT
brain imaging and low pressure HBOT in the diagnosis and
treatment of chronic traumatic, ischemic, hypoxic and
anoxic encephalopathies. Undersea & Hyperbaric Medicine 1994,
21:30.
10. Kennedy JE, Jaffee MS, Leskin GA et al.: Posttraumatic stress
disorder and posttraumatic stress disorder-like symptoms
and mild traumatic brain injury. J Rehab Res Devel 2007,
44:895-920.
Movie 1. Side by side Pre and Post HBOT processed
transverse SPECT brain blood flow images-movie. Click on
this link to activate the video: http://casesjournal.com/
casesjournal/article/downloadFile/6538/303311
Page 4 of 4
(page number not for citation purposes)
Cases Journal 2009, 2:6538 http://casesjournal.com/casesjournal/article/view/6538
Do you have a case to share?
Submit your case report today
• Rapid peer review
• Fast publication
• PubMed indexing
• Inclusion in Cases Database
Any patient, any case, can teach us
something
www.casesnetwork.com