IMAGES IN CLINICAL ECT
Electroconvulsive Therapy After Maxillofacial Metallic Implants G. Mark Freeman, Jr, MD, PhD, Matthew T. Perry, MD, George S. Manatt, MD, and Pilar Cristancho, MD Abstract: A growing body of literature suggests that electroconvulsive therapy (ECT) can be safely utilized in patients with craniofacial metallic implants. Here we provide radiographic images and the clinical course of a 49-year-old woman with both maxillary and mandibular metallic implants who safely received ECT. Key Words: electroconvulsive therapy, maxillofacial, metallic implant (J ECT 2014;30: 3–4)
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ccumulating evidence suggests that electroconvulsive therapy (ECT) can be both safe and effective in the setting of intracranial or craniofacial metallic implants.1–6 We present a case where ECT was successfully used to treat a 49-year-old woman with major depressive disorder resistant to medication management. The patient underwent maxillofacial surgery for temporomandibular joint disorder 25 years before ECT. Before initiation of ECT, anteroposterior and lateral skull radiographs revealed the presence of malleable plates along the anterior walls of the right and left maxillary sinuses, cerclage wires in the anterior mandible, and 2 screws within the right and 2 screws within the left mandibular rami. Potential heating of the metallic hardware was a theoretical concern in this case. However, it has been previously documented that the levels of electrical current used in ECT may be insufficient to cause heating of metallic implants.2 This concern can be addressed further by increasing the distance between electrode and implants, as electrical field strength decreases exponentially with distance.2,5 We
administered treatment using a modified d’Elia placement to increase the distance between the lateral electrode and mandibular screws. The right electrode was placed 2 cm above the midpoint of a line running between the outer canthus of the eye and the external auditory meatus, and the second electrode was placed, as usual, just to the right of the vertex. Electrode placement determines the geometrical brain volume exposed to the highest current density and affects seizure generalization, efficacy, and adverse effects.7,8 Our modified d’Elia placement decreased both the distance between the 2 electrodes and geometrical brain volume receiving maximum current. Nevertheless, seizure threshold was achieved using a charge of 25 mC (pulse width, 0.3 milliseconds [ms]; frequency, 10 Hz) with a Thymatron IV, Somatics, LLC device (Lake Bluff, IL). Subsequent treatments at 6 times the seizure threshold were administered using a charge of 151 mC (pulse width, 0.3 ms; frequency, 40 Hz). At treatment 6, the charge was increased to 504 mC to achieve maximum benefit (pulse width, 0.3 ms; frequency, 120 Hz). Mean central seizure duration over 9 treatments was 50.7 seconds (range, 24–68 seconds) and mean peripheral seizure duration was 24.4 seconds (range, 10–45 seconds). Despite adequate dosing, the patient’s clinical response was limited. The Clinical Global Impression of Improvement at treatment 9 was rated at 3 (minimally improved). Treatments were uneventful except for postprocedure headaches. No discomfort or pain was noted in the areas where the plates or screws were located. This case emphasizes the safety of ECT in patients with maxillofacial metallic hardware and suggests that modified placement of electrodes remains associated with adequate dosing.
From the Department of Psychiatry, Washington University School of Medicine, St. Louis, MO. Received for publication May 31, 2013; accepted June 4, 2013. Reprints: George Mark Freeman Jr, MD, PhD, Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO 63110 (e-mail: [email protected]). The authors declare no financial conflicts of interest. Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/YCT.0b013e3182a2706f
Journal of ECT • Volume 30, Number 1, March 2014
www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Journal of ECT • Volume 30, Number 1, March 2014
Freeman et al
REFERENCES 1. Baker M, Turner M. Use of ECT after maxillofacial repair. J ECT. 2000;16:421–422. 2. Madan S, Anderson K. ECT for a patient with a metallic skull plate. J ECT. 2001;17:289–291. 3. Glezer A, Murray E, Price B, et al. Effective use of electroconvulsive therapy after craniofacial reconstructive surgery. J ECT. 2009;25:208–209. 4. Lin T, Manepalli J, Grossberg G. Electroconvulsive therapy in the presence of a metallic skull plate after meningioma resection. J ECT. 2010;26:136–138.
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www.ectjournal.com
5. Kaido T, Noda T, Otsuki T, et al. Titanium alloys as fixation device material for cranioplasty and its safety in electroconvulsive therapy. J ECT. 2011;27:e27–e28. 6. Kar N, Mannix J, Sichel M, et al. Electroconvulsive therapy for a patient with metallic internal fixation in mandible. J ECT. 2012;28:e3–e4. 7. Kellner C, Tobias K, Wiegand J. Electrode placement in electroconvulsive therapy (ECT). J ECT. 2010;26:175–180. 8. Swartz CM, Nelson AI. Rational electroconvulsive therapy electrode placement. Psychiatry. 2005;2;37–43.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Electroconvulsive Therapy After Maxillofacial Metallic Implants G. Mark Freeman, Jr, MD, PhD, Matthew T. Perry, MD, George S. Manatt, MD, and Pilar Cristancho, MD Abstract: A growing body of literature suggests that electroconvulsive therapy (ECT) can be safely utilized in patients with craniofacial metallic implants. Here we provide radiographic images and the clinical course of a 49-year-old woman with both maxillary and mandibular metallic implants who safely received ECT. Key Words: electroconvulsive therapy, maxillofacial, metallic implant (J ECT 2014;30: 3–4)
A
ccumulating evidence suggests that electroconvulsive therapy (ECT) can be both safe and effective in the setting of intracranial or craniofacial metallic implants.1–6 We present a case where ECT was successfully used to treat a 49-year-old woman with major depressive disorder resistant to medication management. The patient underwent maxillofacial surgery for temporomandibular joint disorder 25 years before ECT. Before initiation of ECT, anteroposterior and lateral skull radiographs revealed the presence of malleable plates along the anterior walls of the right and left maxillary sinuses, cerclage wires in the anterior mandible, and 2 screws within the right and 2 screws within the left mandibular rami. Potential heating of the metallic hardware was a theoretical concern in this case. However, it has been previously documented that the levels of electrical current used in ECT may be insufficient to cause heating of metallic implants.2 This concern can be addressed further by increasing the distance between electrode and implants, as electrical field strength decreases exponentially with distance.2,5 We
administered treatment using a modified d’Elia placement to increase the distance between the lateral electrode and mandibular screws. The right electrode was placed 2 cm above the midpoint of a line running between the outer canthus of the eye and the external auditory meatus, and the second electrode was placed, as usual, just to the right of the vertex. Electrode placement determines the geometrical brain volume exposed to the highest current density and affects seizure generalization, efficacy, and adverse effects.7,8 Our modified d’Elia placement decreased both the distance between the 2 electrodes and geometrical brain volume receiving maximum current. Nevertheless, seizure threshold was achieved using a charge of 25 mC (pulse width, 0.3 milliseconds [ms]; frequency, 10 Hz) with a Thymatron IV, Somatics, LLC device (Lake Bluff, IL). Subsequent treatments at 6 times the seizure threshold were administered using a charge of 151 mC (pulse width, 0.3 ms; frequency, 40 Hz). At treatment 6, the charge was increased to 504 mC to achieve maximum benefit (pulse width, 0.3 ms; frequency, 120 Hz). Mean central seizure duration over 9 treatments was 50.7 seconds (range, 24–68 seconds) and mean peripheral seizure duration was 24.4 seconds (range, 10–45 seconds). Despite adequate dosing, the patient’s clinical response was limited. The Clinical Global Impression of Improvement at treatment 9 was rated at 3 (minimally improved). Treatments were uneventful except for postprocedure headaches. No discomfort or pain was noted in the areas where the plates or screws were located. This case emphasizes the safety of ECT in patients with maxillofacial metallic hardware and suggests that modified placement of electrodes remains associated with adequate dosing.
From the Department of Psychiatry, Washington University School of Medicine, St. Louis, MO. Received for publication May 31, 2013; accepted June 4, 2013. Reprints: George Mark Freeman Jr, MD, PhD, Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO 63110 (e-mail: [email protected]). The authors declare no financial conflicts of interest. Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/YCT.0b013e3182a2706f
Journal of ECT • Volume 30, Number 1, March 2014
www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3
Journal of ECT • Volume 30, Number 1, March 2014
Freeman et al
REFERENCES 1. Baker M, Turner M. Use of ECT after maxillofacial repair. J ECT. 2000;16:421–422. 2. Madan S, Anderson K. ECT for a patient with a metallic skull plate. J ECT. 2001;17:289–291. 3. Glezer A, Murray E, Price B, et al. Effective use of electroconvulsive therapy after craniofacial reconstructive surgery. J ECT. 2009;25:208–209. 4. Lin T, Manepalli J, Grossberg G. Electroconvulsive therapy in the presence of a metallic skull plate after meningioma resection. J ECT. 2010;26:136–138.
4
www.ectjournal.com
5. Kaido T, Noda T, Otsuki T, et al. Titanium alloys as fixation device material for cranioplasty and its safety in electroconvulsive therapy. J ECT. 2011;27:e27–e28. 6. Kar N, Mannix J, Sichel M, et al. Electroconvulsive therapy for a patient with metallic internal fixation in mandible. J ECT. 2012;28:e3–e4. 7. Kellner C, Tobias K, Wiegand J. Electrode placement in electroconvulsive therapy (ECT). J ECT. 2010;26:175–180. 8. Swartz CM, Nelson AI. Rational electroconvulsive therapy electrode placement. Psychiatry. 2005;2;37–43.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
