Left unilateral electroconvulsive therapy in the presence of intracranial stainless steel wire

To the Editor

Electroconvulsive therapy (ECT) is a safe and effective therapy for catatonia with a risk of adverse effects comparable to other procedures performed under general anaesthesia (Waite and Easton, 2013). It is standard practice to deliver the therapy using either bitemporal or bifrontal electrode placement (bilateral ECT) or the d’ Elia electrode placement most often right unilateral (RUL) ECT (Kellner et al., 2010). In cases where the patient has intracranial metal or a skull defect, it is advisable to avoid placement directly over the metallic object or defect (Gahr et al., 2014). This is done to minimize the theoretical risk of bleeding, prolonged seizure and abnormal warming of surrounding brain tissue due to aberrant conduction associated with ECT in the presence of intracranial metallic objects (Gahr et al., 2014). Left unilateral (LUL) electrode placement is an alternative and is comparable to RUL in terms of efficacy and side effect profile (Kellner et al., 2010).

We report the case of a 72-year-old man with a bipolar disorder presenting twice with major depressive relapses and catatonic features. Of significance was a head injury in a motor vehicle accident at age 10, managed with a right parietal craniotomy and craniotomy. An X-ray revealed nine metallic surgical sutures overlying the right anterior temporal and frontal skull vault. A computed tomography (CT) brain revealed stable encephalomalacia in the anterior right temporal lobe and right frontal lobe. ECT was raised as treatment option early in his index presentation, but there was reluctance from his next of kin. In addition, ECT staff and the anaesthetic department were apprehensive due the skull defect with metallic sutures which constituted high-risk procedure (Waite and Easton, 2013). Our patient did not respond pharmacotherapy including use of lorazepam. A decision was made to proceed with LUL ECT with the initial treatment performed in the main theatre. ECT was uncomplicated both from an anaesthetic and cognitive perspective. He achieved symptom remission after 18 ECT treatments and discharged on maintenance pharmacotherapy. Unfortunately, he relapsed 7 months later. On readmission, we proceeded quickly to ECT with good response to 19 LUL ECT treatments with a plan for maintenance ECT on discharge. Treatment was uncomplicated.

A review of the literature identified a study reporting 24 cases of patients with intracranial metal receiving ECT with no adverse effect, of which 10 had modification of electrode placement including one LUL placement (Gahr et al., 2014).

Not surprisingly, there is limited clinical experience of ECT in the presence of intracranial metal with non-standard electrode placement. The evidence thus far provides reassurance that ECT in this subgroup of patient is safe and effective. Our case adds to the limited literature in this clinical scenario and hopes that this case provides guidance to clinicians managing similar patients.