ECT in the Presence of Cerebral Aneurysms: Literature Review
Out on PubMed, from investigators at Columbia University Medical Center, is this review:
Electroconvulsive Therapy in Elderly Patients With Cerebral Aneurysms: A Systematic Review With Clinical Recommendations.
J Geriatr Psychiatry Neurol. 2021 Aug 17:8919887211039016. doi: 10.1177/08919887211039016. Online ahead of print.PMID: 34402339
The abstract is copied below:
Introduction: Electroconvulsive therapy (ECT) is commonly used in the elderly due to its proven efficacy and safety profile. However, presence of cardiovascular comorbidities such as cerebral aneurysms may complicate the course of treatment. Our knowledge about the possible risk factors and precautionary measures remains limited.Methods: We performed a systematic review of published case reports of elderly patients with cerebral aneurysms treated with ECT.
Results: A total of 11 cases were included for the review. One patient died because of subarachnoid hemorrhage (SAH) secondary to ictal hypertensive surge during treatment with ECT.
Discussion: Risk factors such as history of hypertension, age of the patient, extent of the ictal surge in blood pressure, efficacy of prophylactic treatment to control surge in blood pressure and characteristics of cerebral aneurysm each elevated the risk of complication in these cases. We reviewed safety measures based on the evidence from the current literature available.
Conclusion: ECT is safe in elderly patients with cerebral aneurysms provided appropriate safety measures are employed. Screening for cerebral aneurysms in high risk patients, effective prevention and management of blood pressure elevation acutely during ECT is the best practice to avoid adverse outcomes.
Keywords: blood pressure; cerebral aneurysm; electroconvulsive therapy.
This review details the small literature on the subject of ECT in the presence of known cerebral aneurysms. The authors also discuss options for management and present some background neurology/anatomy about types/locations of cerebral aneurysms.
Given the rarity of adverse outcomes and the likelihood that vast numbers of patients have been safely treated with occult cerebral aneurysms, their screening algorithm (above) seems extremely conservative and somewhat impractical. Still, one cannot argue against prudent and cautious management.
Practitioners should read this review in full (~10 minutes), to be reminded of this potential complicating clinical issue and for the comprehensive review of medications to control hypertension.
The paper discusses an important topic, however I think the conclusions are premature:
ReplyDeleteEven though the paper mentions that the epidemiological data might argue against it, it does not address it in a quantified way. In the literature, one repeatedly finds numbers from autopsy studies suggesting a prevalence of undetected cerebral aneusymata between 3-6%, with the higher number tending to be in older patients (e.g. Wardlaw JM, White PM. The detection and management of unruptured intracranial aneurysms. Brain. 2000 Feb;123 ( Pt 2):205-21.). Let's conservatively assume only 1%. With 1 million ECT patients per year, that makes 10,000 ECTs in aneurysm patients worldwide. If only one in 100 would die (and not, as the paper suggests, possibly one in ten), that would be 100 deaths per year. Or additional 10 per 100,000, where from your Charlie Kellner's paper in Acta Psychiatr Scand (2017 May;135(5):388-397) rather 1 per 100,000 would be expected. So, even with a very conservative estimate, this does not add up.
A second point, which is not discussed in the paper, is the ethical context. On the one hand, a real aneurysm search means a non-insignificant risk for the patients (contrast agents, angiography, etc.) and on the other hand also a considerable stressor and not only if no aneurysm is found. What about very small asymptomatic aneurysms in elderly patients that would otherwise never have been detected ? Additionally, the mere announcement of the need for such investigations could lead to a significantly higher rejection rate of ECT.
Sascha Sartorius