ECHOENCEPHALOGRAPHS OF 100 CONSECUTIVE ACUTE PSYCHIATRIC ADMISSIONS by Conrad H. Daum, MD; William M. McKinney, MD; Richard C. Proctor, MD; Ralph W. Barnes, PhD, and Patty Potter
ABSTRACT Echoencephalography (ECHO) on 100 consecutive acute short-term psychiatric admissions showed a high (12 per cent ) incidence of abnormalities. Incidence of midline ECHO abnormalities was 2 per cent, comparable to similar studies. Ventricular enlargement accounted for the majority of ECHO abnormalities. This study also confirmed a previous report of a relationship between third ventricular size and response to treatment. Use of the ECHO as a screening test for these patients was safe and rapid. Correlative studies tended to confirm ECHO findings.
Indexing Words Echoencephalography Psychiatric
Treatment Response Patients
INTRODUCTION
The problem of brain structure parameters as they relate to psychiatric illness has fascinated many observers (1-3). With the advent of echoencephalography (ECHO), a new tool has evolved to assist scientists in further exploring these parameters. The ECHO yields a reliable, satisfactory measure of brain midline position, ventricular size, and neurosurgical pathology (4-7). A number of investigators have used ECHO to evaluate psychiatric patients. McKinney et al (8) evaluated 500 psychiatric Veterans Administration Hospital patients by ECHO. They found a 1 per cent incidence (six patients) of abnormal midline shifts. All had diagnosable cerebral pathology, including two tumors. White and Clark (9) replicated this study on over 1,000 mental hospital patients and found a .5 per cent incidence of midline ECHO shift, with pneumoencephalographic evidence of ventricular dilatation OT actual shift in all four cases so examined. Holden et al (10) reported a relationship between third ventricular size and therapy From the Departments of Psychiatry and Neurology. Bowman Gray School of Medicine of Wake Forest University. Winston-Salem, North Carolina 27103. Received February 1 7 . 1 9 7 6 ; revision accepted May 1 7 . 1 9 7 6 . For reprints cqntact: William M . McKinney. MD. Department of Neurology. Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina 27103. VOLUME 4. NUMBER 5
Lateral Ventricle Third Ventricle
resistance in chronic schizophrenics, with the resistant patients on the average having larger ventricles. They found no shifts in their sample of 79. Clarke (11) reported a high (14per cent) incidence of midline ECHO abnormalities in her sample of 100 mentally handicapped subjects, but unfortunately, she had little correlative study data. The population had a high incidence of clinically diagnosed congenital or organic brain structural illnesses. This paper presents data on the use of the ECHO measurements in screening acute psychiatric patients. It extends the ECHO measurements to include estimates of third and lateral ventricular size in the patient sample. METHOD
The subjects were 100 patients consecutively admitted to a psychiatric receiving unit at a university hospital. Other than an encephalographic sonogram, they received treatment customary for patients admitted to the unit. Routinely, each patient had a history and physical examination from a psychiatric resident, an intake interview from a medical student, and a diagnostic interview from the attending physician. The staff gave psychotherapy, chemotherapy, and electroconvulsive therapy as indicated. Routine laboratory data included complete blood count, urinalysis, syphilis serology, 329
TABLE I
TABLE II
MEAN, STANDARD DEVIATION, AND RANGE OF ECHOENCEPHALOGRAPHIC MEASUREMENTS IN MILLIMETERS
SUMMARY OF MAJOR PSYCHIATRIC DISCHARGE DIAGNOSES* Diagnosis
Measure
Standard Sample Mean* Deviation Range Number
Midline position A
0.87
.70
0-3
102
Midline position B
0.92
.81
0-3.5
103
Midline position C
1.32
.60
0-6
101
Frequency
Neurosis-Depressive(300.4)" *
46
Neurosis-Anxiety (300.0)
13
Neurosis-Other (300)
Ventricle position A (third) Ventricle position B (lateral) Ventricle position C (lateral)
5.69
1.7
3-12
100
15.97
4.9
2-34
86
14.04
4.4
6-24
82
"Midline mean deviations all are to the right of midline. ""Midline ranges all are absolute deviations.
and SMA 12/60 blood chemistry profile. Additional consultative, laboratory, and psychological examinations were ordered as indicated. Conferences between attending and resident physicians provided the discharge diagnoses. We used McKinney's method for taking ECHO measurements (12). Briefly, this involves placing the ultrasound probe at the side of the skull just above the auditory meatus (A position), orle inch vertical t o position A (B position), and one inch horizontal t o position B (C position). Reflected sound in the A mode registers on a cathode ray screen. An expenenced interpreter read a photograph of the cathode ray image. The interpreter read six values for each subject, midline shift in A, B, and C positions and ventricular size in A, B, and C positions. In this laboratory, a midline shift of more than 3 mm from midline in any position is abnormal. Third ventricular size greater than 10 mm (A position) or lateral ventricular size greater than 20 mm (B or C position) are likewise abnormal (13 ) . It was technically difficult t o obtain accurate ECHOs on lateral ventricles. For this reason, this study reports lateral ventricular size for positions B and C as the largest single reading. The analysis calls lateral ventricular size undetermined only if unavailable in both B and C positions. RESULTS
Sixty-nine patients were female and 31 were male. The average age was 42.7 with a range of 330
Personality Disorders (301-304)
5 11
Manic-Depressive Psychosis (296.1-296.3)
9
Organic Brain Syndrome (290-294, 309)
9
Schizophrenia (295)
7
Alcoholism (303)
7
Drug Dependence (304)
4
Transient Situational Disturbance (307)
3
Psychophysiological Disorder (305)
3
Other Psychosis (298)
2
I nvolutional Depression (296)
2
Suicide Attempt (317)
2
"Adds t o more than 100 because of multiple major psychiatric diagnoses. ""Numbers in parentheses refer t o DSM-II codes (77).
1 7 t o 73. Of the 100 patients, 11 had enlarged (over 20 mm) lateral ventricles, two had enlarged (over 10 mm) third ventricles, and two had significant midline shifts (over 3 mm). A summary of values for ECHO measurements appears in Table I. During the study, three patients had multiple admissions; none had multiple ECHOs. Three other patients had multiple ECHOs; in these cases the larger ECHO measurements appear in subsequent data analyses. Several patients did not have clear ECHO measurements for all six values. Midline ECHOs were undetermined for two patients in A position, one patient in B position, and three patients in C position. Ventricular size ECHOs were undetermined for two patients in A position (third ventricle), 16 patients in B position, 20 patients in C position, and six patients in both B and C positions (lateral ventricle). Table I1 gives a breakdown of major discharge diagnoses. Nine patients had diagnoses of organic brain syndromes; of these three had enlarged lateral ventricles, none had enlarged third ventricles, and one had a midline shift. Eight patients had abnormal ECHOs with no organic brain syndrome diagnoses. Four diagnoses were of depressive neurosis, two were of manic deJ O U R N A L O F CLINICAL U L T R A S O U N D
TABLE Ill CORRELATIVE STUDIES WITH ECHOENCEPHALOGRAPHY
Test
Patients
Abnormal Tests*
Abnormal ECHOs**
Both Test and ECHO Abnormal***
Electroencephalogram
24
9(3)
6(2)
3
Skull Roentgenograms
22
3
7
1
Nuclear Brain Scan
19
1
5(2)
0
Lumbar Puncture
2
0
2
0
Pneumoencephalogram
2
2
2
2
Cerebral Arteriogram
1
1
1
1
*Number in parentheses refers to borderline tests. Number in parentheses refers to incomplete normal ECHOs * * * N O ECHOs incomplete.
**
pressive psychosis, one was of chronic alcohol abuse, and one patient had attempted suicide. One manic depressive patient had a mild midline shift; the others had ventricular enlargement. The average age of the patients with organic brain syndromes was 53.2 years (range 29-73) and of those with nonorganic syndromes 48.6 years (range 36-66). When indicated, the attending physician ordered additional correlative studies. Twentynine patients had psychological testing; one patient was unable to cooperate. Twenty-eight patients completed psychological testing; five of these showed signs of organic impairment. Of the five, one had a significant midline shift, none had dilated ventricles, and two patients had borderline lateral ventricular enlargement (1620 mm). A total of 31 patients had additional neurological tests. A summary of the test results appears in Table 111. One patient had pneumoencephalography which demonstrated midline septum, ventricular dilatation, and cortical atrophy. These findings are in agreement with ECHO findings of no significant midline shift and dilated ventricles (24 mm) in B position. A second patient had clinical symptoms of an intracranial mass. Despite examination by skull roentgenography, 1131 nuclear brain scans, and electroencephalograms, no tumor was localized. An ECHO showed gross right-to-left midline shift and no ventricular dilatation. Pneumoencephalography and cerebral angiography confirmed the shift and showed a suprasylvian mass effect of undetermined type. One patient, with a referring diagnosis of anxiety, demonstrated thrombotic thrombocyVOLUME 4, NUMBER 5
topenic purpura on workup. She died after a stormy hospital course. Serial ECHOs demonstrated a progressive midline shift t o the right. Autopsy confirmed the clinical diagnosis. The fixed brain showed multiple old infarcts in the left hemisphere and multiple recent infarcts in theright. Holden et a1 ( 1 0) observed a relation between treatment response in schizophrenics and the sizes of their third ventricles. The data from this study permit an analysis t o corroborate their observation. The analysis is indirect and involves an assumption that the number of days’ stay in the hospital reflects the rate of response t o the psychiatric treatment. Days’ stay thus is the index of treatment response. Regression statistical analysis (14 ) detailed the relation of this treatment index t o variables of this study. It used the response of 91 subjects who had complete measures on age, sex, third ventricular size, lateral ventricular size, severity of diagnosis index, and number of days’ stay in the hospital. The severity of diagnosis index was the average days’ stay for the discharge diagnostic category. The nationwide data of the Commission on Professional and Hospital Activities ( 1 5 ) , as well as the International Classification of Diseases Adapted ( 1 6 ) , provided the statistics on average days’ stay by discharge diagnostic category for this analysis.
A regression equation for third ventricular size as the independent variable and days’ stay as the dependent variable was signficant. (Y = .81 x + 7.1, F (1, 89) = 4.9, p
ABSTRACT Echoencephalography (ECHO) on 100 consecutive acute short-term psychiatric admissions showed a high (12 per cent ) incidence of abnormalities. Incidence of midline ECHO abnormalities was 2 per cent, comparable to similar studies. Ventricular enlargement accounted for the majority of ECHO abnormalities. This study also confirmed a previous report of a relationship between third ventricular size and response to treatment. Use of the ECHO as a screening test for these patients was safe and rapid. Correlative studies tended to confirm ECHO findings.
Indexing Words Echoencephalography Psychiatric
Treatment Response Patients
INTRODUCTION
The problem of brain structure parameters as they relate to psychiatric illness has fascinated many observers (1-3). With the advent of echoencephalography (ECHO), a new tool has evolved to assist scientists in further exploring these parameters. The ECHO yields a reliable, satisfactory measure of brain midline position, ventricular size, and neurosurgical pathology (4-7). A number of investigators have used ECHO to evaluate psychiatric patients. McKinney et al (8) evaluated 500 psychiatric Veterans Administration Hospital patients by ECHO. They found a 1 per cent incidence (six patients) of abnormal midline shifts. All had diagnosable cerebral pathology, including two tumors. White and Clark (9) replicated this study on over 1,000 mental hospital patients and found a .5 per cent incidence of midline ECHO shift, with pneumoencephalographic evidence of ventricular dilatation OT actual shift in all four cases so examined. Holden et al (10) reported a relationship between third ventricular size and therapy From the Departments of Psychiatry and Neurology. Bowman Gray School of Medicine of Wake Forest University. Winston-Salem, North Carolina 27103. Received February 1 7 . 1 9 7 6 ; revision accepted May 1 7 . 1 9 7 6 . For reprints cqntact: William M . McKinney. MD. Department of Neurology. Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina 27103. VOLUME 4. NUMBER 5
Lateral Ventricle Third Ventricle
resistance in chronic schizophrenics, with the resistant patients on the average having larger ventricles. They found no shifts in their sample of 79. Clarke (11) reported a high (14per cent) incidence of midline ECHO abnormalities in her sample of 100 mentally handicapped subjects, but unfortunately, she had little correlative study data. The population had a high incidence of clinically diagnosed congenital or organic brain structural illnesses. This paper presents data on the use of the ECHO measurements in screening acute psychiatric patients. It extends the ECHO measurements to include estimates of third and lateral ventricular size in the patient sample. METHOD
The subjects were 100 patients consecutively admitted to a psychiatric receiving unit at a university hospital. Other than an encephalographic sonogram, they received treatment customary for patients admitted to the unit. Routinely, each patient had a history and physical examination from a psychiatric resident, an intake interview from a medical student, and a diagnostic interview from the attending physician. The staff gave psychotherapy, chemotherapy, and electroconvulsive therapy as indicated. Routine laboratory data included complete blood count, urinalysis, syphilis serology, 329
TABLE I
TABLE II
MEAN, STANDARD DEVIATION, AND RANGE OF ECHOENCEPHALOGRAPHIC MEASUREMENTS IN MILLIMETERS
SUMMARY OF MAJOR PSYCHIATRIC DISCHARGE DIAGNOSES* Diagnosis
Measure
Standard Sample Mean* Deviation Range Number
Midline position A
0.87
.70
0-3
102
Midline position B
0.92
.81
0-3.5
103
Midline position C
1.32
.60
0-6
101
Frequency
Neurosis-Depressive(300.4)" *
46
Neurosis-Anxiety (300.0)
13
Neurosis-Other (300)
Ventricle position A (third) Ventricle position B (lateral) Ventricle position C (lateral)
5.69
1.7
3-12
100
15.97
4.9
2-34
86
14.04
4.4
6-24
82
"Midline mean deviations all are to the right of midline. ""Midline ranges all are absolute deviations.
and SMA 12/60 blood chemistry profile. Additional consultative, laboratory, and psychological examinations were ordered as indicated. Conferences between attending and resident physicians provided the discharge diagnoses. We used McKinney's method for taking ECHO measurements (12). Briefly, this involves placing the ultrasound probe at the side of the skull just above the auditory meatus (A position), orle inch vertical t o position A (B position), and one inch horizontal t o position B (C position). Reflected sound in the A mode registers on a cathode ray screen. An expenenced interpreter read a photograph of the cathode ray image. The interpreter read six values for each subject, midline shift in A, B, and C positions and ventricular size in A, B, and C positions. In this laboratory, a midline shift of more than 3 mm from midline in any position is abnormal. Third ventricular size greater than 10 mm (A position) or lateral ventricular size greater than 20 mm (B or C position) are likewise abnormal (13 ) . It was technically difficult t o obtain accurate ECHOs on lateral ventricles. For this reason, this study reports lateral ventricular size for positions B and C as the largest single reading. The analysis calls lateral ventricular size undetermined only if unavailable in both B and C positions. RESULTS
Sixty-nine patients were female and 31 were male. The average age was 42.7 with a range of 330
Personality Disorders (301-304)
5 11
Manic-Depressive Psychosis (296.1-296.3)
9
Organic Brain Syndrome (290-294, 309)
9
Schizophrenia (295)
7
Alcoholism (303)
7
Drug Dependence (304)
4
Transient Situational Disturbance (307)
3
Psychophysiological Disorder (305)
3
Other Psychosis (298)
2
I nvolutional Depression (296)
2
Suicide Attempt (317)
2
"Adds t o more than 100 because of multiple major psychiatric diagnoses. ""Numbers in parentheses refer t o DSM-II codes (77).
1 7 t o 73. Of the 100 patients, 11 had enlarged (over 20 mm) lateral ventricles, two had enlarged (over 10 mm) third ventricles, and two had significant midline shifts (over 3 mm). A summary of values for ECHO measurements appears in Table I. During the study, three patients had multiple admissions; none had multiple ECHOs. Three other patients had multiple ECHOs; in these cases the larger ECHO measurements appear in subsequent data analyses. Several patients did not have clear ECHO measurements for all six values. Midline ECHOs were undetermined for two patients in A position, one patient in B position, and three patients in C position. Ventricular size ECHOs were undetermined for two patients in A position (third ventricle), 16 patients in B position, 20 patients in C position, and six patients in both B and C positions (lateral ventricle). Table I1 gives a breakdown of major discharge diagnoses. Nine patients had diagnoses of organic brain syndromes; of these three had enlarged lateral ventricles, none had enlarged third ventricles, and one had a midline shift. Eight patients had abnormal ECHOs with no organic brain syndrome diagnoses. Four diagnoses were of depressive neurosis, two were of manic deJ O U R N A L O F CLINICAL U L T R A S O U N D
TABLE Ill CORRELATIVE STUDIES WITH ECHOENCEPHALOGRAPHY
Test
Patients
Abnormal Tests*
Abnormal ECHOs**
Both Test and ECHO Abnormal***
Electroencephalogram
24
9(3)
6(2)
3
Skull Roentgenograms
22
3
7
1
Nuclear Brain Scan
19
1
5(2)
0
Lumbar Puncture
2
0
2
0
Pneumoencephalogram
2
2
2
2
Cerebral Arteriogram
1
1
1
1
*Number in parentheses refers to borderline tests. Number in parentheses refers to incomplete normal ECHOs * * * N O ECHOs incomplete.
**
pressive psychosis, one was of chronic alcohol abuse, and one patient had attempted suicide. One manic depressive patient had a mild midline shift; the others had ventricular enlargement. The average age of the patients with organic brain syndromes was 53.2 years (range 29-73) and of those with nonorganic syndromes 48.6 years (range 36-66). When indicated, the attending physician ordered additional correlative studies. Twentynine patients had psychological testing; one patient was unable to cooperate. Twenty-eight patients completed psychological testing; five of these showed signs of organic impairment. Of the five, one had a significant midline shift, none had dilated ventricles, and two patients had borderline lateral ventricular enlargement (1620 mm). A total of 31 patients had additional neurological tests. A summary of the test results appears in Table 111. One patient had pneumoencephalography which demonstrated midline septum, ventricular dilatation, and cortical atrophy. These findings are in agreement with ECHO findings of no significant midline shift and dilated ventricles (24 mm) in B position. A second patient had clinical symptoms of an intracranial mass. Despite examination by skull roentgenography, 1131 nuclear brain scans, and electroencephalograms, no tumor was localized. An ECHO showed gross right-to-left midline shift and no ventricular dilatation. Pneumoencephalography and cerebral angiography confirmed the shift and showed a suprasylvian mass effect of undetermined type. One patient, with a referring diagnosis of anxiety, demonstrated thrombotic thrombocyVOLUME 4, NUMBER 5
topenic purpura on workup. She died after a stormy hospital course. Serial ECHOs demonstrated a progressive midline shift t o the right. Autopsy confirmed the clinical diagnosis. The fixed brain showed multiple old infarcts in the left hemisphere and multiple recent infarcts in theright. Holden et a1 ( 1 0) observed a relation between treatment response in schizophrenics and the sizes of their third ventricles. The data from this study permit an analysis t o corroborate their observation. The analysis is indirect and involves an assumption that the number of days’ stay in the hospital reflects the rate of response t o the psychiatric treatment. Days’ stay thus is the index of treatment response. Regression statistical analysis (14 ) detailed the relation of this treatment index t o variables of this study. It used the response of 91 subjects who had complete measures on age, sex, third ventricular size, lateral ventricular size, severity of diagnosis index, and number of days’ stay in the hospital. The severity of diagnosis index was the average days’ stay for the discharge diagnostic category. The nationwide data of the Commission on Professional and Hospital Activities ( 1 5 ) , as well as the International Classification of Diseases Adapted ( 1 6 ) , provided the statistics on average days’ stay by discharge diagnostic category for this analysis.
A regression equation for third ventricular size as the independent variable and days’ stay as the dependent variable was signficant. (Y = .81 x + 7.1, F (1, 89) = 4.9, p
