Is ect safe in patients with cerebrovascular disease?

Abstract

SUMMARYA 70-year-old man with a history of peripheral vascular disease was treated initially with antidepressants, then bilateral electroconvulsive therapy (ECT) for a depressive illness. Apart from an episode of delirium following ECT he recovered fully. Four years later he relapsed. Low-dose antidepressants caused disorientation and oversedation, as did ECT. Shortly afterwards he developed a multi-infarct state with Parkinsonian symptoms, transient ischaemic attacks (TIAs) and cerebrovascular attacks (CVAs). His cognitive deficits implicated pathology in the frontal and subcortical areas of the brain. Postmortem examination confirmed widespread atherosclerotic disease, also cerebrovascular disease. The haemodynamic and cerebral effects of ECT are considered in the context of vascular disease. It is postulated that ECT given to such patients might cause permanent impairment of cognitive function through ischaemia of an already compromised cerebral circulation. Suggestions are outlined regarding a policy for a more comprehensive assessment of patients with atherosclerotic disease. Deficiencies of ECT procedures are highlighted.KEY woms-Electroconvulsive therapy, ECT, elderly, multi-infarct dementia, delirium.Mr G initially presented with depressive illness at the age of 70. His medical history included intermittent claudication. His mother had suffered from long-standing cardiac disease and died at the age of 66. He was a non-drinker and non-smoker. As his depression failed to improve on standard doses of mianserin and prothiaden, he was admitted for electroconvulsive therapy (ECT). Cardiovascular evaluation was normal. Following the fourth ECT he became disorientated with perseveration, disinhibition and aggression. This resolved over the next 2 days with phenothiazines. He was given one further bilateral ECT before being discharged on parstelin (compound tranylcypromine/trifuoperazine). Two months later he was readmitted with a relapse of depressive illness. Cognitive function tests were performed in detail but no impairment was demonstrated. Physical examination, routine blood tests, electrocardiograph (ECG) and chest X-ray (CXR) were all normal. ECT again resulted in delirium, this time after the ninth application. Mental state gradually improved as before. A computerized tomography (CT) scan was reported as normal. Six further ECTs were given without incident, and the patient was discharged improved in mood on lithium 1 g daily.Four years later (aged 74) Mr G again became depressed. Physically he complained of painful legs. An arteriogram showed calcification of the abdominal aorta and iliac arteries. Over the next 2 years his mood worsened, despite his receiving a range of antidepressants which included lithium, tricyclics and 5HT antagonists. Very low doses of all drugs resulted in oversedation and disorientation. Right unilateral ECT was given. Each one of the 12 treatments was followed by prolonged anaesthetic recovery, daytime drowsiness and confusion. Two months later a number of investigations were pe...

The Use of Electroconvulsive Therapy in Special Patient Populations

“…Base line pre-ECT cog ni tive scores and pos tic tal dis ori en ta tion have been shown to pre dict the de gree of long-term ret ro grade am ne sia in pa tients who are not neuro logi cally im paired (46). Cog ni tive im pair ment as so ci ated with de pres sion may ac tu ally im prove with ECT, even when as so ci ated with un der ly ing cere bral vas cu lar dis ease (47,48). ECT is known to cause hy po pro fu sion in fron tal ar eas (48); this may con trib ute to the de men tia pro cess in pa tients with com pro mised cere bral vas cu lar sys tems, but there are no controlled stud ies to help with this clini cal ques tion.…”

“…Cog ni tive im pair ment as so ci ated with de pres sion may ac tu ally im prove with ECT, even when as so ci ated with un der ly ing cere bral vas cu lar dis ease (47,48). ECT is known to cause hy po pro fu sion in fron tal ar eas (48); this may con trib ute to the de men tia pro cess in pa tients with com pro mised cere bral vas cu lar sys tems, but there are no controlled stud ies to help with this clini cal ques tion. There fore, the risk of not treat ing an older per son with se vere de pres sion must be weighed against the po ten tial risk of ex ac er bat ing cog ni tive im pair ment (54).…”