ECT in Patients With Intracranial Masses

Electroconvulsive treatment for the patients with known intracranial masses has been considered a high-risk undertaking. There is a general consensus in case report literature, however, that if a lesion is relatively small, solitary, and not associated with significant mass effect, edema, or increased intracranial pressure, then ECT probably does not present greater than usual risk of neurological deterioration. 1 None of the patients in our series was known to have increased intracranial pressure or edema. Mass effect, when present, was invariably quite mild. Thus, our patients probably represented low-risk candidates for ECT. Nonetheless, in the absence of a large-scale series, such patients should still be approached with caution and ongoing consultation and evaluation by a neurologist or neurosurgeon. In particular, the necessity of daily neurological evaluation cannot be overstressed, as deterioration may initially be subtle and slow. The appearance of any new-onset focal neurological finding during a course of ECT in such patients should warrant immediate neuroimaging and expert consultation. Additionally, the informed consent process should include discussion of the possible extra risk of ECT.

A more problematic scenario is the presence of one of the complicating features mentioned above. The presence of a large mass, multiple masses (e.g., metastatic lesions), edema, increased intracranial pressure, or mass effect should probably be considered relative contraindications for ECT. Only in the case of a profoundly ill patient in which the psychopathological features cause the risk of suicide, prolonged psychomotor retardation, inanition, or agitation toward others should ECT be considered, and even then only when all other options have failed. Invariably, such patients have an attending neurologist or neurosurgeon with whom to consult regarding risk-reduction strategies in preparation for ECT. We recommend that it be considered standard of care in ECT practice that if a high-risk patient as defined herein is to be treated, then measures to reduce edema and the increase in intracranial pressure be undertaken. This may include diuretic agents (e.g., mannitol or furosemide), steroid medication such as dexamethasone or methylprednisolone, or hyperventilation, 7 depending on the preference of the patient’s attending neurologist or neurosurgeon, who is likely to be familiar with the dosing of such agents and the methods to document their efficacy. As is the case with the low-risk patient, meticulous daily neurological assessments should be conducted to detect subtle changes that might become fulminant unless the treatment series is terminated. Finally, if the patient is to receive maintenance treatments, then the clinician must take into account the rate of change of the lesion. A low-risk lesion may, over time, progress to a high-risk one, necessitating either discontinuation of ECT or institution of the strategies outlined above.

Received January 18, 2006; revised June 5, 2006; accepted June 12, 2006. Drs. Rasmussen, Perry, Sutor, and Moore are affiliated with the Mayo Clinic Department of Psychiatry and Psychology, Rochester, Minnesota. Address correspondence to Dr. Rasmussen, Mayo Clinic Department of Psychiatry, 200 First Street, Southwest, Rochester, MN 55905; [email protected] (e-mail).