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Kim WSH, Dimick MK, Omrin D, Mitchell RHB, Riegert D, Levitt A, Schaffer A, Belo S, Iazzetta J, Detzler G, Choi M, Choi S, Herrmann N, McIntyre RS, MacIntosh BJ, Orser BA, Goldstein BI. Proof-of-concept randomized controlled trial of single-session nitrous oxide treatment for refractory bipolar depression: Focus on cerebrovascular target engagement. Bipolar Disord 2022; 25:221-232. [PMID: 36579458 DOI: 10.1111/bdi.13288] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND There remain few efficacious treatments for bipolar depression, which dominates the course of bipolar disorder (BD). Despite multiple studies reporting associations between depression and cerebral blood flow (CBF), little is known regarding CBF as a treatment target, or predictor and/or indicator of treatment response, in BD. Nitrous oxide, an anesthetic gas with vasoactive and putative antidepressant properties, has a long history as a neuroimaging probe. We undertook an experimental medicine paradigm, coupling in-scanner single-session nitrous oxide treatment of bipolar depression with repeated measures of CBF. METHODS In this double-blind randomized controlled trial, 25 adults with BD I/II and current treatment-refractory depression received either: (1) nitrous oxide (20 min at 25% concentration) plus intravenous saline (n = 12), or (2) medical air plus intravenous midazolam (2 mg total; n = 13). Study outcomes included changes in depression severity (Montgomery-Asberg Depression Rating Scale scores, primary) and changes in CBF (via arterial spin labeling magnetic resonance imaging). RESULTS There were no significant between-group differences in 24-h post-treatment MADRS change or treatment response. However, the nitrous oxide group had significantly greater same-day reductions in depression severity. Lower baseline regional CBF predicted greater 24-h post-treatment MADRS reductions with nitrous oxide but not midazolam. In region-of-interest and voxel-wise analyses, there was a pattern of regional CBF reductions following treatment with midazolam versus nitrous oxide. CONCLUSIONS Present findings, while tentative and based on secondary endpoints, suggest differential associations of nitrous oxide versus midazolam with bipolar depression severity and cerebral hemodynamics. Larger studies integrating neuroimaging targets and repeated nitrous oxide treatment sessions are warranted.
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Affiliation(s)
- William S H Kim
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Mikaela K Dimick
- Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Omrin
- Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rachel H B Mitchell
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Riegert
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Levitt
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Ayal Schaffer
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Susan Belo
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Iazzetta
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Mabel Choi
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen Choi
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nathan Herrmann
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Roger S McIntyre
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
| | - Bradley J MacIntosh
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Beverley A Orser
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin I Goldstein
- Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Kim WSH, Ji X, Roudaia E, Chen JJ, Gilboa A, Sekuler A, Gao F, Lin Z, Jegatheesan A, Masellis M, Goubran M, Rabin JS, Lam B, Cheng I, Fowler R, Heyn C, Black SE, Graham SJ, MacIntosh BJ. MRI Assessment of Cerebral Blood Flow in Nonhospitalized Adults Who Self-Isolated Due to COVID-19. J Magn Reson Imaging 2022. [PMID: 36472248 PMCID: PMC9877942 DOI: 10.1002/jmri.28555] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Neurological symptoms associated with coronavirus disease 2019 (COVID-19), such as fatigue and smell/taste changes, persist beyond infection. However, little is known of brain physiology in the post-COVID-19 timeframe. PURPOSE To determine whether adults who experienced flu-like symptoms due to COVID-19 would exhibit cerebral blood flow (CBF) alterations in the weeks/months beyond infection, relative to controls who experienced flu-like symptoms but tested negative for COVID-19. STUDY TYPE Prospective observational. POPULATION A total of 39 adults who previously self-isolated at home due to COVID-19 (41.9 ± 12.6 years of age, 59% female, 116.5 ± 62.2 days since positive diagnosis) and 11 controls who experienced flu-like symptoms but had a negative COVID-19 diagnosis (41.5 ± 13.4 years of age, 55% female, 112.1 ± 59.5 since negative diagnosis). FIELD STRENGTH AND SEQUENCES A 3.0 T; T1-weighted magnetization-prepared rapid gradient and echo-planar turbo gradient-spin echo arterial spin labeling sequences. ASSESSMENT Arterial spin labeling was used to estimate CBF. A self-reported questionnaire assessed symptoms, including ongoing fatigue. CBF was compared between COVID-19 and control groups and between those with (n = 11) and without self-reported ongoing fatigue (n = 28) within the COVID-19 group. STATISTICAL TESTS Between-group and within-group comparisons of CBF were performed in a voxel-wise manner, controlling for age and sex, at a family-wise error rate of 0.05. RESULTS Relative to controls, the COVID-19 group exhibited significantly decreased CBF in subcortical regions including the thalamus, orbitofrontal cortex, and basal ganglia (maximum cluster size = 6012 voxels and maximum t-statistic = 5.21). Within the COVID-19 group, significant CBF differences in occipital and parietal regions were observed between those with and without self-reported on-going fatigue. DATA CONCLUSION These cross-sectional data revealed regional CBF decreases in the COVID-19 group, suggesting the relevance of brain physiology in the post-COVID-19 timeframe. This research may help elucidate the heterogeneous symptoms of the post-COVID-19 condition. EVIDENCE LEVEL 2. TECHNICAL EFFICACY Stage 3.
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Affiliation(s)
- William S H Kim
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Xiang Ji
- LC Campbell Cognitive Neurology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Eugenie Roudaia
- Rotman Research Institute, Baycrest Academy for Research and Education, Toronto, Ontario, Canada
| | - J Jean Chen
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Rotman Research Institute, Baycrest Academy for Research and Education, Toronto, Ontario, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Asaf Gilboa
- Rotman Research Institute, Baycrest Academy for Research and Education, Toronto, Ontario, Canada.,Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Allison Sekuler
- Rotman Research Institute, Baycrest Academy for Research and Education, Toronto, Ontario, Canada.,Department of Psychology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Ontario, Canada
| | - Fuqiang Gao
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,LC Campbell Cognitive Neurology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Zhongmin Lin
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Aravinthan Jegatheesan
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Mario Masellis
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,LC Campbell Cognitive Neurology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Maged Goubran
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jennifer S Rabin
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Lam
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,LC Campbell Cognitive Neurology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ivy Cheng
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Integrated Community Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert Fowler
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Emergency & Critical Care Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Chris Heyn
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Sandra E Black
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,LC Campbell Cognitive Neurology Research Group, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Simon J Graham
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Bradley J MacIntosh
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Computational Radiology & Artificial Intelligence Unit, Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
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