Is ECT contraindicated in brain tumor?

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Electroconvulsive Therapy

MDD is the most common indication for ECT. The mechanisms by which this procedure alleviates depressive symptoms are not fully understood. Remission rates of 70%–90% have been reported in clinical trials of ECT for MDD (Popeo, 2009). It is also an effective treatment for bipolar disorder but may uncommonly precipitate hypomania or mania. Suicidal thoughts respond favorably to ECT and are an indication for early transition from drug therapy. ECT is not routinely used for the treatment of schizophrenia. When combined with antipsychotic medications, however, it may result in improvement in 80% of patients with drug-resistant chronic schizophrenia. Patients with mania also respond favorably to ECT. There are few absolute contraindications to ECT, but cardiac conditions may worsen and should be addressed. Conditions such as vascular aneurysms and aortic stenosis should preferably be repaired prior to ECT, but persons with such conditions have been reported to tolerate the procedure. Those with properly functioning cardiac pacemakers generally tolerate ECT well. Case reports of ECT performed on individuals with a recent cerebral infarction suggest a low complication rate and a favorable response to treatment. ECT has been successfully used in persons with mental retardation, MS, HD, arteriovenous malformations, and hydrocephalus (Ducharme et al., 2015). Patients with depression and PD may experience improvement of mood and motor symptoms with ECT. Some research supports the effectiveness of ECT for treatment of the core motor symptoms of PD (Popeo and Kellner, 2009). There is no evidence of structural brain damage due to ECT. Posttreatment memory difficulty (anterograde amnesia) is usually experienced during the course of ECT treatments but normally resolves within 1 month after the last treatment. Retrograde amnesia is more prominent for the events closer to the time of ECT treatment. Posttreatment confusion is variable and may be associated with bilateral electrode placement, high stimulus intensity, prolonged seizure activity, and inadequate oxygenation. There is controversy about whether unilateral electrode placement for ECT is as effective as bilateral placement. Several studies have shown equal efficacy as long as unilateral ECT is performed with a stimulus intensity well above seizure threshold (Lisanby, 2007). Studies also indicate a lower incidence of cognitive side effects with right unilateral electrode placement and electrical brief pulse waveform stimulus. There is uncertainty about the efficacy of ultrabrief pulse stimulus, but preliminary evidence suggests that it is associated with a significant reduction in memory-related side effects (Peterchev et al., 2010).

Abstract

Electroconvulsive therapy (ECT) is the oldest and most effective nonpharmacological therapies currently available for psychiatric disease. ECT is performed under general anesthesia, electrodes are placed either unilaterally or bilaterally with electric pulses of 500–800 mA, 0.3–2.0 ms duration at 20–120 Hz for 0.5–8 s. Muscle movement and EEG activity are monitored. Mechanisms of the therapeutic effect of ECT are not known. ECT is frequently associated with retrograde and anterograde amnesia, and relapse after a successful ECT course is a major limitation of the therapy.

Electroconvulsive Therapy

Electroconvulsive therapy is the transcutaneous application of small electrical stimuli to the brain for treatment of selected psychiatric disorders like major depression. The tonic-clonic convulsions associated with electroconvulsive therapy can result in injuries such as limb fractures and compression fractures of vertebral bodies. The introduction of anesthesia, especially neuromuscular blockade, can mitigate tonic-clonic motor activity and reduce the physiologic trauma associated with uncontrolled tetanic muscle contractions.216 Succinylcholine is commonly used as a NMBD in these patients, and its use is associated with well-known unwanted side effects.216 Rocuronium has similar efficacy as succinylcholine in electroconvulsive therapy, making it an appropriate alternative to succinylcholine.217 However, the increased doses of rocuronium required to decrease the onset time are associated with a prolonged duration of neuromuscular blockade. Several reports have evaluated the use of sugammadex in electroconvulsive therapy. These investigations demonstrated that sugammadex produced a complete and rapid reversal of neuromuscular blockade induced by rocuronium, without signs of residual blockade or other safety concerns.217-220 Therefore the combination of rocuronium and sugammadex may be an alternative to succinylcholine for electroconvulsive therapy. However, the required dose of sugammadex in this clinical situation is not well established.

Historically, an important strategy in anesthesia has been to ensure that neuromuscular blockade is sufficiently recovered to achieve adequate antagonism by neostigmine. Having an intense neuromuscular blockade at the end of surgery would more likely result in residual blockade. With the availability of sugammadex, a profound, or deep, neuromuscular blockade has been recommended for the entire duration of laparoscopy. A profound neuromuscular blockade increases surgical space with smaller pressures for the pneumoperitoneum.221 It is even possible that reducing insufflation pressures may improve patient outcomes.221 Furthermore, Staehr-Rye and associates222 have postulated that a deep or profound neuromuscular blockade is associated with more optimal surgical conditions, which leads to less postoperative pain and nausea and vomiting. A recent review and metaanalysis has shown that deep neuromuscular blockade during laparoscopic surgical procedures allows lower insufflation pressure, thereby improving surgical conditions and reducing postoperative pain.223 Sugammadex, at doses of 2 to 8 mg/kg, was given to reverse the blockade when the TOF ratio was less than 0.90.

OVERVIEW

Electroconvulsive therapy (ECT) remains an indispensable treatment because of the large number of depressed patients who are unresponsive to drugs or who are intolerant to their side effects. In the largest clinical trial of antidepressant medication, only 50% of depressed patients achieved a full remission, while an equal percentage were nonresponders or achieved only partial remission.1 On the other hand, remission rates of 70% to 90% have been reported in clinical trials of ECT.2,3 Depression requires effective treatment because it is associated with increased mortality risk (mainly due to cardiovascular events or suicide).4 Furthermore, among all diseases, depression currently ranks fourth in global disease burden, and is projected to rank second by the year 2020.5 ECT is currently the most promising prospect for addressing the unmet worldwide need for effective treatment of individuals suffering from depression.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is considered an important treatment option in the pregnant patient with psychiatric disease, especially when balancing the risk for morbidity from psychiatric illness and the potential adverse effects of psychiatric drugs. Indications include major unipolar or bipolar depressive episodes, mania, and certain acute schizophrenia exacerbations. Acute suicide risk, poor response to medications, and patient preference may also affect the decision to use ECT.40 Contraindications include anticipated intolerance of associated physiologic changes that result from autonomic activation during ECT (e.g., increased intracranial pressure). Relative contraindications include hypertensive disease and impaired uteroplacental perfusion.

There is a paucity of controlled data evaluating the use of ECT in pregnancy, with most information coming from case series. The APA has endorsed the use of ECT in all three trimesters of pregnancy.41 The use of ECT in pregnancy has been considered effective with low risk to the mother and fetus.42 However, a recent systematic review reported that adverse events such as decreased fetal heart rate, uterine contractions, and preterm labor occurred in 29% of cases.43

ECT for pregnant patients should be administered in a facility that can handle fetal emergencies. Anesthetic agents that have been used include thiopental, methohexital, propofol, succinylcholine, and anticholinergics.43 Suggested guidelines for ECT during pregnancy are summarized inBox 50.2. Denitrogenation (preoxygenation), left uterine displacement, and fetal heart rate and uterine contraction monitoring should be used. Pharmacologic aspiration prophylaxis and tracheal intubation should be considered in patients with symptoms of gastroesophageal reflux. Some anesthesia providers contend that tracheal intubation should be performed after 20 weeks’ gestation, when the enlarging uterus has arisen out of the pelvis.

14 What are some of the adverse effects of electroconvulsive therapy?

An induced seizure lasting longer than 2 or 3 minutes is considered prolonged and can result in increased cognitive deficits. Prolonged apnea is said to occur if it takes longer than 5 minutes to regain spontaneous ventilations after ECT treatment and may be caused by a pseudocholinesterase deficiency, resulting in prolonged succinylcholine activity. Emergence delirium is characterized by restless agitation, aimless repetitive movements, grasping objects in view, or restless attempts to remove the monitors and intravenous line. It usually lasts from 10 to 45 minutes or more after the seizure and responds to benzodiazepines. Anterograde amnesia may occur immediately after an ECT treatment but tends to resolve usually within an hour. Retrograde amnesia is the most common persistent adverse effect of ECT. It is more commonly seen in elderly patients and those with preexisting cognitive impairment. Memory loss of events several months or years in the past can occur. Usually retrograde amnesia improves during the first few months after ECT, although many patients have incomplete recovery. Other adverse effects include headache, muscle aches, nausea, and fatigue.

KEY POINTS:

Electroconvulsive Therapy

ECT treatment is recommended for patients with depression with psychotic features, manic delirium, and catatonia and patients who cannot tolerate the side effects of antidepressant medications.

Typical physiologic responses to ECT include transient parasympathetic discharge resulting in bradyarrhythmias, followed by a sympathetic stimulus resulting in hypertension and tachycardia. Increases in cerebral blood flow and ICP are also noted.

Methohexital is the most common induction agent used during ECT because it has minimal anticonvulsant properties, a rapid onset, short duration of action, and low cardiac toxicity.

Succinylcholine is the most common muscle relaxant used during ECT because of its short duration of action.

Electroconvulsive Therapy (ECT)

ECT is a recommended option for patients with depression and psychotic features who have not responded to antipsychotic and antidepressant medications and for patients with severe nonpsychotic depression who have not responded to adequate trials of at least two antidepressants. ECT is used most often in patients older than age 60. Patients with delusions, psychomotor retardation, early morning awakening, and a family history of depression are most likely to benefit from ECT. ECT may reverse the memory loss and confusion associated with pseudodementia.

Contraindications include recent myocardial infarction, brain tumor, cerebral aneurysm, and uncontrolled heart failure.

ECT is an effective short-term therapy but has higher relapse rates over 6 to 12 months; patients with a history of medication resistance have higher relapse rates following ECT.

Electroconvulsive therapy

ECT is discussed in detail in Chapter 40. Patients with severe depression in whom a rapid response is needed, such as life-threatening states (dehydration, physical complications, stupor or suicidal behaviour) or postpartum, should be considered early for ECT. Otherwise, ECT is reserved for patients resistant to other treatments. Unlike antidepressants, ECT causes upregulation of postsynaptic 5HT2 receptors. Other effects (e.g. normalization of the reduced prolactin response to fenfluramine) are the same. ECT is clearly efficacious for the short-term treatment of depression (Geddes 2003). However, the caveats to ECT use include a number of contraindications, side-effects, patient acceptability and the tendency to relapse.

Electroconvulsive therapy (ECT)

ECT is an effective treatment for mood disorders despite the negative public perception. The effectiveness of ECT has recently been demonstrated in a meta-analysis of the efficacy and safety in depressive disorders (UK ECT Review Group 2003). NICE has recently published guidelines on the use of ECT. These recommendations state that ECT should be used only in patients with severe depressive illness, catatonia or a prolonged or severe manic episode, and only then after an adequate trial of other treatment has proven ineffective and/or when the condition is considered to be potentially life-threatening (NICE 2003b).

ELECTROCONVULSIVE THERAPY

Electroconvulsive therapy (ECT) is discussed in detail elsewhere in this volume (see Chapter 45). ECT has been used to treat depression since the 1930s, and many consider it the “gold standard” of antidepressant treatment. ECT involves delivery of an electrical current to the brain through the scalp and skull in order to induce a generalized seizure. While the mechanism by which generalized seizures alleviate depressive symptoms is not fully understood, the efficacy of ECT for depression has been demonstrated in a large number of clinical trials. A recent meta-analysis that included most of these clinical trials found that active ECT was significantly more effective than sham ECT and more effective than pharmacotherapy.4 However, many patients relapse unless they receive periodic maintenance treatments and there are common side effects, such as memory loss, that are associated with ECT.5