NCSE After ECT: Case Report in Cureus
Out on PubMed, from clinicians in the US, is this case report:
Non-convulsive Status Epilepticus in a Patient With Schizoaffective and Seizure Disorder on Clozapine and Electroconvulsive Therapy: A Case Report.
Cureus. 2022 May 25;14(5):e25337. doi: 10.7759/cureus.25337. eCollection 2022 May.
PMID: 35761918
The abstract is copied below:
There is limited literature on electroconvulsive therapy (ECT) in patients with a severe schizophrenia spectrum illness and concomitant seizure disorder. In addition, it is unclear whether it is safe to perform ECT in a patient with these comorbidities and a history of status epilepticus. This is the case of a 48-year-old patient with a history of schizoaffective disorder, bipolar type, refractory psychosis on clozapine and ECT, and seizure disorder on carbamazepine. She presented to the emergency department with suspected post-ECT delirium four days after her last ECT treatment, was found to be in non-convulsive status epilepticus, and was admitted to the neuroscience intensive care unit. Coma induction was required for seizure control. As she stabilized, her psychosis worsened, and she required psychiatric hospitalization. Multiple factors may have contributed to the development of status epilepticus in this patient. She was on clozapine, which has a time- and dose-dependent risk of seizure that prescribers should be wary of. She had also been prescribed the antiepileptic drug carbamazepine, which induces clozapine and itself, decreasing their effectiveness. Upon the patient's discharge, ECT was suspended indefinitely due to concern that it may have led to status epilepticus. However, case reports suggest that intractable seizures following ECT are rare. We found no reports of status epilepticus occurring more than 60 minutes after the completion of ECT. If the benefits of ECT are significant, then it should remain a treatment option for the patient.
Keywords: antiepileptic drug; carbamazepine; clozapine; cytochrome p450; electroconvulsive therapy; non-convulsive status epilepticus; schizoaffective disorder; schizophrenia spectrum illness; seizure disorder; serious mental illness.
Not sure what to say about this one, except I don't put much store in it. Complicated case, with several unresolved questions. It is not clear at what hospital the patient was treated, and the ECT details are absent.
I hope some blog readers will comment with their opinions, thanks.
This Case Report is certainly not appropriate for contributing to the relevant literature.
ReplyDeleteA tardive seizure days after is reported, but the authors also offer an alternative etiology as an explanation in the text:
"Likely for this reason, the level of carbamazepine was reduced, and
seizure prophylaxis was subtherapeutic at the time status epilepticus occurred."
This really says it all.
On top, "a lowered seizure threshold" is mentioned as a risk factor, but stimulation just above the seizure threshold (regardless of the level of the seizure threshold) would be correct as a risk factor.
Unfortunately, neither the seizure threshold nor the amount of charge applied nor the anesthetic nor anything else about ECT is reported. Only the seizure length. The easily calculated concordance of 34/46=0.74 is certainly suboptimal and may indicate a stimulation too close to the seizure threshold in a patient only 48 years young, which is still not convincing enough for a tardive seizure.