Successful ECT For SRSE in a Pregnant Patient: Case Report
Out on PubMed, from clinicians in Georgia, is this case report:
Electroconvulsive therapy for super refractory status epilepticus in pregnancy: case report and review of literature.
Int J Neurosci. 2022 Mar 14:1-11. doi: 10.1080/00207454.2022.2050371. Online ahead of print. PMID: 35287528
The abstract is copied below:Objective: We aim to describe use of electroconvulsive therapy (ECT) to treat super refractory status epilepticus (SRSE) in pregnancy and review the literature regarding utility and safety of ECT in refractory status epilepticus.
Background: Status epilepticus (SE) is a commonly encountered emergency in neuro-critical care world. Pharmacotherapy of status epilepticus in pregnancy is very challenging given the effect of the majority of antiepileptic drugs (AEDs) on fetal development. Although there has been growing evidence for use of ECT in status epilepticus, data about its utility in pregnancy is lacking.
Design/method: A twenty-one year old Caucasian female with history of epilepsy presented at 8 weeks of gestation as status epilepticus (SE) after abrupt discontinuation of her AEDs. Treatment was initiated with standard regimen of benzodiazepine and levetiracetam, which was progressively expanded to include approximately 10 anti-epileptic drugs over the course of 30 days. The status epilepticus was super refractory to sedation. She underwent ECT on day 31 with remarkable improvement in electroencephalogram (EEG) pattern and resolution of status epilepticus following a single ECT session. We reviewed PubMed and collated case reports involving the use of ECT in status epilepticus with emphasis on differences in various confounding factors esp. etiology of status and age group.
Conclusion: Our case is the first reported case of ECT for successful treatment of SRSE in pregnancy. While majority AEDs pose a significant maternal and fetal risk during pregnancy, ECT could be a potential frontline therapy for SE in pregnancy.
Keywords: Electroconvulsive therapy; Status epilepticus; pregnancy; seizure.
The abstract is copied below:Objective: We aim to describe use of electroconvulsive therapy (ECT) to treat super refractory status epilepticus (SRSE) in pregnancy and review the literature regarding utility and safety of ECT in refractory status epilepticus.
Background: Status epilepticus (SE) is a commonly encountered emergency in neuro-critical care world. Pharmacotherapy of status epilepticus in pregnancy is very challenging given the effect of the majority of antiepileptic drugs (AEDs) on fetal development. Although there has been growing evidence for use of ECT in status epilepticus, data about its utility in pregnancy is lacking.
Design/method: A twenty-one year old Caucasian female with history of epilepsy presented at 8 weeks of gestation as status epilepticus (SE) after abrupt discontinuation of her AEDs. Treatment was initiated with standard regimen of benzodiazepine and levetiracetam, which was progressively expanded to include approximately 10 anti-epileptic drugs over the course of 30 days. The status epilepticus was super refractory to sedation. She underwent ECT on day 31 with remarkable improvement in electroencephalogram (EEG) pattern and resolution of status epilepticus following a single ECT session. We reviewed PubMed and collated case reports involving the use of ECT in status epilepticus with emphasis on differences in various confounding factors esp. etiology of status and age group.
Conclusion: Our case is the first reported case of ECT for successful treatment of SRSE in pregnancy. While majority AEDs pose a significant maternal and fetal risk during pregnancy, ECT could be a potential frontline therapy for SE in pregnancy.
Keywords: Electroconvulsive therapy; Status epilepticus; pregnancy; seizure.
The case report is here.
Here is a figure from the text:
While the report is rambling and imperfectly edited, the clinical message is clear and important. While it is hard to argue with such success, the RUL electrode placement was a potentially risky selection, and one that may not be optimal for other such cases.
I recommend a full read to all ECT practitioners, ~15 minutes.
Thank you, Dr. Kellner for your citation of our paper. The treatment of status epilepticus is always an nice departure for the ECT practitioner working in a university or general hospital setting. It always seems to come as a grand revelation to the neurologists, especially trainees who have no experience with the treatment. It's important to get the word out. The next step in the algorithm for our neurology team (before ECT it seems) is whole body cooling. This would most certainly have resulted in a loss of the pregnancy and so I had no difficulty convincing the family that ECT would be the safer option.
ReplyDeleteI have treated a number of cases in my career, not uniformly successful, but this was the first time that a single treatment resulted in immediate and lasting resolution.
My rationale for the right unilateral electrode placement is as follows. First, we are frequently faced with trying to induce a seizure in the presence of a host of anticonvulsants, and RUL thresholds are lower than bilateral thresholds. Second, the nonconvulsive seizure focus was in the right temporal lobe in this case. While we certainly have no certitude about the mechanism of ECT in dampening excitatory activity within the brain, it stands to reason that directing charge towards that region we might anticipate that the direct effect of the stimulus is maximized.
In a case of pediatric status epilepticus (without a clear focus) we reported on in 2011, we struggled to achieve even the most rudimentary generalized seizure when stimulating with bitemporal placement at maximum device intensity. And yet, with repeated stimulation the treatment was successful (we tried every possible combination of brief pulse stimulus and even one ultrabrief stimulus). These experiences highlight for me the possibility that it may be the electrical charge density, rather than the induced seizure itself that brings about the end of status.
Shin HW, O'Donovan CA, Boggs JG, Grefe A, Harper A, Bell WL, McCall WV, Rosenquist P. Successful ECT treatment for medically refractory nonconvulsive status epilepticus in pediatric patient. Seizure. 2011 Jun;20(5):433-6.