ECT with Cavernous Malformation in the Brainstem

Out on PubMed, from clinicians in Rotweil, Germany, is this case report:Electroconvulsive therapy in a female patient with a cavernous malformation in the medulla oblongata.

Kozian R, Grözinger M, Graf B.Fortschr Neurol Psychiatr. 2020 Oct 13. doi: 10.1055/a-1167-2952. Online ahead of print.PMID: 33051863

The abstract is copied below:

The implementation of ECT treatment should not be ruled out in principle even if there is a cavernoma of the medulla oblongata with previous bleeding, but it requires appropriate conditions such as neurosurgical consultation, strict blood pressure monitoring and special information from the patient.

And from a text translation from the German:

[74-year old female patient]

The neurological findings did not reveal any particularities in the patient. According to her own statements the patient had suffered a cerebral hemorrhage years ago. In fact, 10 years ago, a left-sided hypaesthesia of hand and leg was documented with bleeding from a cavernoma of the medulla oblongata. The symptomatology was under stationary conditions within one week. The MRI of the skull, the current MRI, performed during the treatment period, revealed a 7 × 8 x 9 mm lesion in the central and right medulla oblongata, and the findings seemed to be most compatible with a cavernoma, since there was also a clear contrast agent enhancement and a venous malformation...

...the possibility of ECT was discussed. We therefore initially consulted a neurosurgical clinic to clarify the risk of ECT treatment. The aspects discussed were then discussed with the authorized son and patient. In particular, it was expressly pointed out that the risk of bleeding can be increased as a result of an increase in blood pressure during electroconvulsive therapy and that neurological complications such as paralysis or sensory disturbances can occur as a result, which may be irreversible. After weighing up the benefits and risks, the patient's relatives and the patient finally decided to undergo electroconvulsive therapy. A series of 8 electroconvulsive therapy sessions was performed at a frequency of 2 per week. The ECT was performed under propofol anesthesia. Stimulation was performed unilaterally (RuL) on the right side using the titration method, initially at 10%, increasing to 80% at the end of the series. Immediately after convulsions, multiple systolic blood pressure increases of up to 200 mg of mercury occurred systolically, so that Ebrantil was administered intravenously. Under this combined drug and electroconvulsive therapy the depressive and psychotic symptoms remitted, so that the patient could be discharged after a total of 3 month.

...In our case, the risk was even more difficult to assess for two reasons: First, cavernomas of the brain stem may have a higher tendency to bleed than in other localizations [12]. Secondly, the risk of bleeding after 10 years ago could hypothetically be increased [3]. However, Rasmussen et al. recommend a waiting period of 2-4 weeks after bleeding before a new ECT [3]. In view of the risk of persistent psychiatric disease, we decided to perform ECT after informing the patient and her authorized relatives and taking precautions. Short-term increases in blood pressure during the generalized seizures occurred during the ECT series of 8 sessions with no evidence of rebleeding. This shows that even if there is a previous bleeding from a cavernoma and if it is localized in the brain stem, ECT need not be dispensed with in principle. However, the possible benefits and risks should be carefully weighed.

This is a very instructive case report, demonstrating safe ECT in a patient with a brainstem cavernoma. Ebrantil is urapidil, an antihypertensive agent (alpha 1 blocker). While the risk of re-bleeding with brief BP elevations is probably unknown, and cavernomas are on the venous side of the circulation, prudence suggests tight BP control during ECT in this situation.

Thanks to Dr. Michael Grozinger for providing the translated text.