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.
SalzmanCWongEWrightBC. Drug and ECT treatment of depression in the elderly, 1996-2001: a literature review. Biol Psychiatry. 2002;52(3):265–284.
5.
TørringNSanghaniSNPetridesGKellnerCHØstergaardSD. The mortality rate of electroconvulsive therapy: a systematic review and pooled analysis. Acta Psychiatr Scand. 2017;135(5):388–397.
HishikawaTDateI. Unruptured cerebral aneurysms in elderly patients. Neurol Med Chir (Tokyo). 2017;57(6):247–252.
8.
WiebersDWhisnantJForbesGMeissnerI. Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. N Engl J Med Boston. 1998;339(24):1725–1733.
9.
MoherDLiberatiATetzlaffJAltmanDG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLOS Med. 2009;6(7):e1000097.
10.
HuntSAKaplanE. ECT in the presence of a cerebral aneurysm. J ECT. 1998;14(2):123–124.
11.
GuggerJJDunnLE. Subarachnoid hemorrhage in the setting of electroconvulsive therapy in a patient with an unsecured cerebral aneurysm: a case report and review of the literature. J ECT. 2019;35(3):212–214.
12.
GardnerMWKellnerCH. Safe use of ECT with an intracranial aneurysm. J ECT. 1998;14(4):290–292.
13.
FarahAMcCallWVAmundsonRH. ECT after cerebral aneurysm repair. Convuls Ther. 1996;12(3):165–170.
14.
NajjarFGuttmacherLB. ECT in the presence of intracranial aneurysm. J ECT. 1998;14(4):266–271.
15.
SharmaARamaswamySBhatiaSC. Electroconvulsive therapy after repair of cerebral aneurysm. J ECT. 2005;21(3):180–181.
16.
RasmussenKGPerryCLSutorBMooreKM. ECT in patients with intracranial masses. J Neuropsychiatry Clin Neurosci. 2007;19(2):191–193.
17.
KolanoJEChhibberACalalangCC. Use of esmolol to control bleeding and heart rate during electroconvulsive therapy in a patient with an intracranial aneurysm. J Clin Anesth. 1997;9(6):493–495.
18.
SalarisSSzubaMPTraberK. ECT and intracranial vascular masses. J ECT. 2000;16(2):198–203.
19.
Ogawa-OkamotoCSaitoSNishiharaFYukiNGotoF. Blood pressure control with glyceryl trinitrate during electroconvulsive therapy in a patient with cerebral aneurysm. Eur J Anaesthesiol. 2003;20(1):70–72.
20.
WilkinsonSTHelgesonLOstroffRB. Electroconvulsive therapy and cerebral aneurysms. J ECT. 2014;30(4):47–49.
TadaYWadaKShimadaK, et al.Roles of hypertension in the rupture of intracranial aneurysms. Stroke. 2014;45(2):579–586.
23.
NahedBVDiLunaMLMorganT, et al.Hypertension, age, and location predict rupture of small intracranial aneurysms. Neurosurgery. 2005;57(4):676–683.
24.
AndradeCArumughamSSThirthalliJ. Adverse effects of electroconvulsive therapy. Psychiatr Clin North Am. 2016;39(3):513–530.
25.
PetitoCKSchaeferJAPlumF. Ultrastructural characteristics of the brain and blood-brain barrier in experimental seizures. Brain Res. 1977;127(2):251–267.
ZielinskiRJRooseSPDevanandDPWoodringSSackeimHA. Cardiovascular complications of ECT in depressed patients with cardiac disease. Am J Psychiatry. 1993;150(6):904.
28.
KujalaIRosenvingeBBekkelundSI. Clinical outcome and adverse effects of electroconvulsive therapy in elderly psychiatric patients. J Geriatr Psychiatry Neurol. 2002;15(2):73–76.
29.
RumiDOSolimeneMCTakadaJY, et al.Electrocardiographic and blood pressure alterations during electroconvulsive therapy in young adults. Arq Bras Cardiol. 2002;79(2):155–160.
30.
KurupVOstroffR. When cardiac patients need ECT—challenges for the anesthesiologist. Int Anesthesiol Clin. 2012;50(2):128–140.
31.
BoereEBirkenhägerTKGroenlandTHNvan den BroekWW. Beta-blocking agents during electroconvulsive therapy: a review. Br J Anaesth. 2014;113(1):43–51.
32.
ShresthaSShresthaBRThapaCPradhanSNThapaRAdhikariS. Comparative study of esmolol and labetalol to attenuate haemodynamic responses after electroconvulsive therapy. Kathmandu Univ Med J. 2007;5(19):318–323.
33.
WulfsonHDAskanaziJFinckAD. Propranolol prior to ECT associated with asystole. Anesthesiology. 1984;60(3):255–256.
34.
McCallWVShelpFEWeinerRDAustinSRNHarrillARN. Effects of labetalol on hemodynamics and seizure duration during ECT. Convuls Ther. 1991;7(1):5–14.
35.
AvramovMNStoolLAWhitePFHusainMM. Effects of nicardipine and labetalol on the acute hemodynamic response to electroconvulsive therapy. J Clin Anesth. 1998;10(5):394–400.
36.
WajimaZYoshikawaTOguraA, et al.The effects of diltiazem on hemodynamics and seizure duration during electroconvulsive therapy. Anesth Analg. 2001;92(5):1327–1330.
37.
WajimaZYoshikawaTOguraA, et al.Intravenous verapamil blunts hyperdynamic responses during electroconvulsive therapy without altering seizure activity. Anesth Analg. 2002;95(2):400–402.
38.
MarikPERiveraR. Hypertensive emergencies: an update. Curr Opin Crit Care. 2011;17(6):569–580.
39.
ParabALChaudhariLSApteJ. Use of nitroglycerin ointment to prevent hypertensive response during electroconvulsive therapy—a study of 50 cases. J Postgrad Med. 1992;38(2):55–57.
40.
LeeJTErbguthPHStevensWCSackRL. Modification of electroconvulsive therapy induced hypertension with nitroglycerin ointment. Anesthesiology. 1984;61(3).
41.
HottingerDGBeebeDSKozhimannilTPrielippRCBelaniKG. Sodium nitroprusside in 2014: a clinical concepts review. J Anaesthesiol Clin Pharmacol. 2014;30(4):462–471.
42.
CirauloD. Sodium nitroprusside treatment of ECT-induced blood pressure elevations. Am J Psychiatry. 1978;135(9):1105.
43.
DevanandDPMalitzSSackeimHA. ECT in a patient with aortic aneurysm. J Clin Psychiatry. 1990;51(6):255–256.
44.
RecartARawalSWhitePFByerlySThorntonL. The effect of remifentanil on seizure duration and acute hemodynamic responses to electroconvulsive therapy. Anesth Analg. 2003;96(4):1047–1050.
45.
WeingerMBPartridgeBLMHaugerRMirowA.Prevention of the cardiovascular and neuroendocrine response to electroconvulsive therapy: I. Effectiveness of pretreatment regimens on hemodynamics. Anesth Analg. 1991;73(5):556–562.
46.
FigielGSDeLeoBZorumskiCF, et al.Combined use of labetalol and nifedipine in controlling the cardiovascular response from ECT. J Geriatr Psychiatry Neurol. 1993;6(1):20–24.
47.
LanzinoGKassellNFGermansonTP, et al.Age and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse?J Neurosurg. 1996;85(3):410–488.
48.
WermerMJHvan der SchaafICAlgraARinkelGJE. Risk of rupture of unruptured intracranial aneurysms in relation to patient and aneurysm characteristics: an updated meta-analysis. Stroke. 2007;38(4):1404–1410.
49.
VegaCKwoonJVLavineSD. Intracranial aneurysms: current evidence and clinical practice. Am Fam Physician. 2002;66(4):601.
50.
Bederson JoshuaBAwad IssamAWiebers DavidO, et al.Recommendations for the management of patients with unruptured intracranial aneurysms. Circulation. 2000;102(18):2300–2308.
51.
WangG-XZhangDWangZ-PYangL-QYangHLiW. Risk factors for ruptured intracranial aneurysms. Indian J Med Res. 2018;147(1):51–57.
52.
DharSTremmelMMoccoJ, et al.Morphology parameters for intracranial aneurysm rupture risk assessment. Neurosurgery. 2008;63(2):185–196. Discussion 196-197.
53.
VarbleNTutinoVMYuJ, et al.Shared and distinct rupture discriminants of small and large intracranial aneurysms. Stroke. 2018;49(4):856–864.
54.
PorquezJMThompsonTRMcDonaldWM. Administration of ECT in a patient with an inoperable abdominal aortic aneurysm: serial imaging of the aorta during maintenance. J ECT. 2003;19(2):118–120.
55.
MuellerPSAlbinSMBarnesRDRasmussenKG. Safety of electroconvulsive therapy in patients with unrepaired abdominal aortic aneurysm: report of 8 patients. J ECT. 2009;25(3):165–169.
56.
GoumenioukADMDFryPDZisAP. Abdominal aortic aneurysm and ECT administration. Convuls Ther. 1990;6(1):55–56.
57.
PascoeNGrayHAldousSPorterR. Electroconvulsive therapy in a patient with pulmonary aneurysm. J ECT. 2014;30(3):e22–23.
