Abstract
Electroconvulsive therapy (ECT) is regarded as safe and effective with no absolute contraindications for its use [1]. Caution is warranted where there is raised intracranial pressure, a space-occupying lesion, unstable blood pressure, recent myocardial infarction, recent cerebrovascular accident or the presence of a skull defect [2]. Although there are increasing reports of ECT being used effectively for patients with head injuries [3] and even subdural haematoma [4,5], there have also been reports of subdural haematoma resulting from ECT [6]. We wish to present a case that illustrates that bilateral ECT can be used to effectively treat depression following the acute treatment of a subdural haematoma.
We report the case of a 77-year-old woman who sustained a significant subdural haematoma following a fall during her admission for a major depressive episode. The patient was admitted with profound psychomotor retardation, anhedonia, hopelessness and self-neglect with reduced oral intake. She had received ECT twice in the last 10 years for major depressive episodes with good effect and she was scheduled to receive ECT because she had poor response to oral medication. She slipped in the hospital bathroom, however, and sustained a large left frontoparietal acute subdural haemorrhage, which extended from the vertex down to the left temporal region. The depth of subdural haemorrhage was 1.2 cm. There was approximately 1 cm midline shift to the right side on non-contrast cerebral computed tomography (CT). There was another smaller subdural haemorrhage in the right frontal region with a maximum depth of 1.5 cm. There were no obvious neurological deficits after the head injury and she had an uneventful recovery following left frontal craniotomy and drainage of the subdural haemorrhage. Follow-up cerebral CT after craniotomy showed gradual reduction in the size of the subdural haemorrhages. After craniotomy the patient remained significantly depressed, with nihilism, hopelessness, anhedonia, marked psychomotor retardation and reduced oral intake. She had also been incontinent of urine, but this was attributed to her psychomotor retardation.
Seven weeks after craniotomy, a gradually resolving haematoma in the left frontal region was still apparent on scanning, but her severe depressive episode had not shown any improvement on oral medication. After extensive consultation the patient was commenced on bilateral ECT and received seven treatments over a 2 week period. She was closely monitored by the neurosurgical team and further scanning did not indicate any additional subdural bleeding. On successive Folstein mini-mental state examinations, the patient had no evidence of cognitive decline. ECT was effective with a response that was similar to her past treatments.
This case report adds to the limited literature concerning the safety and efficacy of ECT after subdural haematoma. With ageing populations one would expect that falls associated with depression and subsequent subdural haematomas are unlikely to be isolated events. Wijeratne and Shome reported two cases arising in similar settings involving less extensive haematomas and recommended unilateral ECT given contralateral to the side of the haematoma [4]. By administering ECT in this manner, it has been proposed that current flow would not concentrate at the site of the skull deficit and injury to the underlying cortex would be prevented [7]. There are likely, however, to be patients who do not respond to unilateral ECT. When a patient's depression is severe (as in this case), it is important that clinicians be aware that bilateral ECT has been given after subdural haemorrhage with positive consequences. We recommend extensive consultation and close follow up with a neurosurgeon, cerebral CT during the course of ECT and regular monitoring for neurological signs, of blood pressure and of cognition. We also urge other clinicians to report similar cases.