Electroconvulsive therapy in an elderly patient with recurrent meningiomas

Electroconvulsive therapy (ECT) is widely accepted as a safe and effective treatment for severe depressive disorders with ECT mortality reported as 1–2 death per 100,000 patients. Large intracranial masses constitute a high-risk situation with the potential for profound neurological deterioration (Tiller and Lyndon, 2013).

We report the administration of ECT in an elderly patient with significant medical comorbidity, including previous intracranial surgery and the presence of a large meningioma. There is conflicting evidence regarding the use of ECT in patients with intracranial pathology. Some studies observed ECT in these patients without incident and resolution of depressive symptoms (Hsiao et al., 1987). However, there were reviews that concluded this to be absolute contraindications to ECT (Gassel, 1960).

Our patient is a 76-year-old lady living in an aged care facility with a longstanding history of a recurrent treatment-resistant major depressive disorder with mood congruent psychotic features. She had prolonged hospital admissions with modest symptom improvement despite aggressive pharmacotherapy. Her family was resistant to ECT due to concerns about anaesthetic risk. Apart from recurrent meningiomas, other medical comorbidities included congestive cardiac failure, osteoarthritis and non-epileptiform seizures. The meningioma was first diagnosed 30 years ago requiring multiple neurosurgical operations and radiotherapy.

She was admitted to the aged psychiatry unit with worsening depressive symptoms with melancholic features as well as prominent persecutory delusions and nihilistic delusions. During the most recent admission, her family was again consulted about the role of ECT given her poor response to pharmacotherapy and worsening depressive illness with psychosis. The family consented to ECT which they viewed as a last resort. A thorough medical work up included an anaesthetic, neurology and neurosurgical opinion. A magnetic resonance imaging (MRI) demonstrated the presence of a 23 mm left posterior parietal parafalcine meningioma, no evidence of disease recurrence and residual effects of past frontotemporal craniectomy. The consensus was that despite the medical complexity, the ECT was a reasonable option given the poor response to other treatments and her declining mental state.

ECT was performed under the Mental Health Act (MHA). The patient received 11 bilateral treatments. It was decided to stimulate dose at half age at the initial treatment in an attempt to minimise the number of ECT treatments given. ECT was uncomplicated. There was gradual improvement in mood noted, with greater reactivity, a reduction in her anxiety and resolution of her delusional beliefs by the 11th treatment. She did not experience any adverse neurological events or any other physical health issues during her ECT treatment. She was discharged on maintenance ECT in the community setting with assertive outpatient follow-up. Our experience adds to the limited literature in this area and demonstrates that ECT can be safely given with good clinical outcomes in these high-risk individuals.