Journal of ECT • Volume 30, Number 4, December 2014
of its established antidepressant effects, tolerability, and safety (lack of proconvulsant properties).2 A meta-analysis by Schutter5 indicated that slow right-sided TMS was more effective than sham and was likely to be equally effective to fast-frequency TMS over the left DLPFC in treating depression. The cumulative effect size for the right-sided TMS was 0.63 in this meta-analysis encompassing 252 subjects.5 Only few studies have used TMS to treat cognitive and behavioral impairments in autism. Sokhadze et al4 applied TMS in children and adolescents with autism to improve executive functioning. They hypothesized that a low frequency (inhibitory) of TMS may restore the balance between cortical excitation and cortical inhibition and improve long-range cortical connectivity, which is a potential contributor of brain dysfunction in autism. They applied TMS at 1 Hz, 150 PPS, sequentially to the left DLPFC and then to the right DLPFC once weekly for 12 weeks. They evaluated error monitoring and post–error response correction during a visual task before and after TMS, demonstrating enhanced behavioral performance with improved error monitoring and correction in the visual attention task in TMS recipients compared with controls.4 For this patient, we implemented a protocol similar to that described by Sokhadze et al,4 applying TMS to the right and left DLPC. Improvements in our patient's behavior, social interactions, ability to cope with change, and ability to concentrate in schoolwork were noted. The main limitations of this report include low treatment parameters and lack of objective measures for depression and executive function. Nonetheless, this is the first report on TMS use in an adolescent with autistic disorder and comorbid depression that demonstrated improvement in mood and adaptive functioning. Randomized control trials are needed to test this potential TMS application.
Pilar Cristancho, MD Department of Psychiatry School of Medicine Washington University in St. Louis St Louis, MO [email protected]
Keerthi Akkineni, MD Department of Psychiatry School of Medicine Washington University in St. Louis St Louis, MO
John N. Constantino, MD Department of Pediatrics Washington University in St. Louis St Louis, MO © 2014 Lippincott Williams & Wilkins
Letters to the Editor
Alex R. Carter, MD, PhD Department of Neurology School of Medicine Washington University in St. Louis St Louis, MO
John P. O’Reardon, MD Department of Psychiatry University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine Stratford, NJ
The authors have no conflicts of interest or financial disclosures to report. ACKNOWLEDGMENTS The authors thank Dr Estate Sockhadze for providing guidance on repetitive transcranial magnetic stimulation parameters previously used in a similar subject population and Ms JoAnn Filla-Taylor for her help in treatment administration. The authors also thank the Barnes-Jewish Hospital Foundation for its support to the Transcranial Magnetic Stimulation Program at Washington University. REFERENCES 1. Magnuson KM, Constantino JN. Characterization of depression in children with autism spectrum disorders. J Dev Behav Pediatr. 2011;32:332–340. 2. Fitzgerald PB, Daskalakis ZJ. A practical guide to the use of repetitive transcranial magnetic stimulation in the treatment of depression. Brain Stimul. 2012;5:287–296. 3. Croarkin PE, Wall CA, McClintock SM, et al. The emerging role for repetitive transcranial magnetic stimulation in optimizing the treatment of adolescent depression. J ECT. 2010;26:323–329. 4. Sokhadze EM, Baruth JM, Sears L, et al. Prefrontal neuromodulation using rTMS improves error monitoring and correction function in autism. Appl Psychophysiol Biofeedback. 2012;37:91–102. 5. Schutter DJ. Quantitative review of the efficacy of slow-frequency magnetic brain stimulation in major depressive disorder. Psychol Med. 2010; 40:1789–1795.
Electroconvulsive Therapy and Cerebral Aneurysms To the Editor: 68-year-old woman with a history of bipolar disorder was admitted to our psychiatric unit for stabilization after a serious suicide attempt. She had responded well to electroconvulsive therapy (ECT) 6 years ago. Given this history and the need for rapid stabilization, we pursued a repeat course of ECT. Since her last course, cerebral imaging (computerized tomography
A
and magnetic resonance angiography) had revealed a 3-mm saccular aneurysm arising from the anterior communicating artery. She had no history of hypertension. After appropriate discussion and informed consent, she began bilateral ECT, administered 3 times weekly, using a Mecta Spectrum 5000Q machine. Succinylcholine (50 mg) and methohexital (70 mg) were used as anesthetic agents. Her blood pressure was treated prophylactically with 10 mg intravenous (IV) labetalol push 20 minutes before ECT. During the first treatment, peri-ictal blood pressure peaked at 190/99 mm Hg. An additional 10 mg IV labetalol push was given with acute hypertension resolving; post-ECT blood pressure was 145/69 mm Hg. For the remainder of her ECT sessions, she continued to be pretreated with 10 mg IV labetalol push with an additional 10 mg given peri-ictally as needed to control acute hypertension. Peri-ictal blood pressures for the remainder of her ECT sessions were more acceptable, with maximum systolic pressures generally ranging from 160 to 170 mm Hg. She was discharged after 8 ECT sessions, with 5 additional treatments as an outpatient. Because of clinical improvement, the frequency of ECT sessions was decreased to twice per month. Other than peri-ictal headache (treated adequately with IV ketorolac), she has not experienced any neurological signs or symptoms. Her psychiatric symptoms currently remain stable and are much improved compared with the time of admission. This represents the ninth reported case of administering ECT in a patient with an untreated aneurysm; 5 additional cases of ECTadministration in patients with ruptured or repaired aneurysm have also been reported (Table 1). Administering ECT to a patient with a cerebral aneurysm represents a clinical challenge that can be unnerving given the worst-case scenario. Electroconvulsive therapy triggers a transient surge in blood pressure, which can increase aneurysm wall stress and theoretically raise the possibility of rupture and lead to catastrophic outcomes. However, there are no case reports of ruptured cerebral aneurysms in association with ECT. Although this is reassuring, especially given the high periictal blood pressures recorded in the literature (Table 1), our understanding of the safety of ECT in patients with cerebral aneurysms remains limited. The decision of whether or not to administer ECT to a patient with cerebral aneurysm depends on multiple factors, including the urgency of the need for ECT, the size and location of the aneurysm, peri-ictal blood pressure management, and a full discussion with the patient of risks and benefits. www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e47
Journal of ECT • Volume 30, Number 4, December 2014
Letters to the Editor
TABLE 1. Previously Reported Cases of ECT Patients With Cerebral Aneurysms
Reference
Age, Sex
Diagnosis of HTN?
Cases with ≥1 untreated/unruptured cerebral aneurysm 70, Female Yes Drop et al,1 1988
Pre-Ictal HTN Treatment
Maximum Peri-Ictal Blood Pressure, mm Hg
Nitroprusside IV Timolol (by mouth) Esmolol IV
340/150
NR 190/100
Bader et al,2 1995
45, Female
NR
Hunt and Kaplan,3 1998
83, Female
No
66, Female Kolano et al,4 1997/ Najjar and Guttmacher,5 1998 Najjar and Guttmacher,5 1998 51, Male
No
Nadolol (by mouth) nightly Propranolol PO 1 h pre-ECT Esmolol IV
NR
Esmolol IV
210/115
Sublingual nitroglycerin Nitroprusside IV Esmolol/labetalol IV Labetalol IV
NR SBP
of its established antidepressant effects, tolerability, and safety (lack of proconvulsant properties).2 A meta-analysis by Schutter5 indicated that slow right-sided TMS was more effective than sham and was likely to be equally effective to fast-frequency TMS over the left DLPFC in treating depression. The cumulative effect size for the right-sided TMS was 0.63 in this meta-analysis encompassing 252 subjects.5 Only few studies have used TMS to treat cognitive and behavioral impairments in autism. Sokhadze et al4 applied TMS in children and adolescents with autism to improve executive functioning. They hypothesized that a low frequency (inhibitory) of TMS may restore the balance between cortical excitation and cortical inhibition and improve long-range cortical connectivity, which is a potential contributor of brain dysfunction in autism. They applied TMS at 1 Hz, 150 PPS, sequentially to the left DLPFC and then to the right DLPFC once weekly for 12 weeks. They evaluated error monitoring and post–error response correction during a visual task before and after TMS, demonstrating enhanced behavioral performance with improved error monitoring and correction in the visual attention task in TMS recipients compared with controls.4 For this patient, we implemented a protocol similar to that described by Sokhadze et al,4 applying TMS to the right and left DLPC. Improvements in our patient's behavior, social interactions, ability to cope with change, and ability to concentrate in schoolwork were noted. The main limitations of this report include low treatment parameters and lack of objective measures for depression and executive function. Nonetheless, this is the first report on TMS use in an adolescent with autistic disorder and comorbid depression that demonstrated improvement in mood and adaptive functioning. Randomized control trials are needed to test this potential TMS application.
Pilar Cristancho, MD Department of Psychiatry School of Medicine Washington University in St. Louis St Louis, MO [email protected]
Keerthi Akkineni, MD Department of Psychiatry School of Medicine Washington University in St. Louis St Louis, MO
John N. Constantino, MD Department of Pediatrics Washington University in St. Louis St Louis, MO © 2014 Lippincott Williams & Wilkins
Letters to the Editor
Alex R. Carter, MD, PhD Department of Neurology School of Medicine Washington University in St. Louis St Louis, MO
John P. O’Reardon, MD Department of Psychiatry University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine Stratford, NJ
The authors have no conflicts of interest or financial disclosures to report. ACKNOWLEDGMENTS The authors thank Dr Estate Sockhadze for providing guidance on repetitive transcranial magnetic stimulation parameters previously used in a similar subject population and Ms JoAnn Filla-Taylor for her help in treatment administration. The authors also thank the Barnes-Jewish Hospital Foundation for its support to the Transcranial Magnetic Stimulation Program at Washington University. REFERENCES 1. Magnuson KM, Constantino JN. Characterization of depression in children with autism spectrum disorders. J Dev Behav Pediatr. 2011;32:332–340. 2. Fitzgerald PB, Daskalakis ZJ. A practical guide to the use of repetitive transcranial magnetic stimulation in the treatment of depression. Brain Stimul. 2012;5:287–296. 3. Croarkin PE, Wall CA, McClintock SM, et al. The emerging role for repetitive transcranial magnetic stimulation in optimizing the treatment of adolescent depression. J ECT. 2010;26:323–329. 4. Sokhadze EM, Baruth JM, Sears L, et al. Prefrontal neuromodulation using rTMS improves error monitoring and correction function in autism. Appl Psychophysiol Biofeedback. 2012;37:91–102. 5. Schutter DJ. Quantitative review of the efficacy of slow-frequency magnetic brain stimulation in major depressive disorder. Psychol Med. 2010; 40:1789–1795.
Electroconvulsive Therapy and Cerebral Aneurysms To the Editor: 68-year-old woman with a history of bipolar disorder was admitted to our psychiatric unit for stabilization after a serious suicide attempt. She had responded well to electroconvulsive therapy (ECT) 6 years ago. Given this history and the need for rapid stabilization, we pursued a repeat course of ECT. Since her last course, cerebral imaging (computerized tomography
A
and magnetic resonance angiography) had revealed a 3-mm saccular aneurysm arising from the anterior communicating artery. She had no history of hypertension. After appropriate discussion and informed consent, she began bilateral ECT, administered 3 times weekly, using a Mecta Spectrum 5000Q machine. Succinylcholine (50 mg) and methohexital (70 mg) were used as anesthetic agents. Her blood pressure was treated prophylactically with 10 mg intravenous (IV) labetalol push 20 minutes before ECT. During the first treatment, peri-ictal blood pressure peaked at 190/99 mm Hg. An additional 10 mg IV labetalol push was given with acute hypertension resolving; post-ECT blood pressure was 145/69 mm Hg. For the remainder of her ECT sessions, she continued to be pretreated with 10 mg IV labetalol push with an additional 10 mg given peri-ictally as needed to control acute hypertension. Peri-ictal blood pressures for the remainder of her ECT sessions were more acceptable, with maximum systolic pressures generally ranging from 160 to 170 mm Hg. She was discharged after 8 ECT sessions, with 5 additional treatments as an outpatient. Because of clinical improvement, the frequency of ECT sessions was decreased to twice per month. Other than peri-ictal headache (treated adequately with IV ketorolac), she has not experienced any neurological signs or symptoms. Her psychiatric symptoms currently remain stable and are much improved compared with the time of admission. This represents the ninth reported case of administering ECT in a patient with an untreated aneurysm; 5 additional cases of ECTadministration in patients with ruptured or repaired aneurysm have also been reported (Table 1). Administering ECT to a patient with a cerebral aneurysm represents a clinical challenge that can be unnerving given the worst-case scenario. Electroconvulsive therapy triggers a transient surge in blood pressure, which can increase aneurysm wall stress and theoretically raise the possibility of rupture and lead to catastrophic outcomes. However, there are no case reports of ruptured cerebral aneurysms in association with ECT. Although this is reassuring, especially given the high periictal blood pressures recorded in the literature (Table 1), our understanding of the safety of ECT in patients with cerebral aneurysms remains limited. The decision of whether or not to administer ECT to a patient with cerebral aneurysm depends on multiple factors, including the urgency of the need for ECT, the size and location of the aneurysm, peri-ictal blood pressure management, and a full discussion with the patient of risks and benefits. www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e47
Journal of ECT • Volume 30, Number 4, December 2014
Letters to the Editor
TABLE 1. Previously Reported Cases of ECT Patients With Cerebral Aneurysms
Reference
Age, Sex
Diagnosis of HTN?
Cases with ≥1 untreated/unruptured cerebral aneurysm 70, Female Yes Drop et al,1 1988
Pre-Ictal HTN Treatment
Maximum Peri-Ictal Blood Pressure, mm Hg
Nitroprusside IV Timolol (by mouth) Esmolol IV
340/150
NR 190/100
Bader et al,2 1995
45, Female
NR
Hunt and Kaplan,3 1998
83, Female
No
66, Female Kolano et al,4 1997/ Najjar and Guttmacher,5 1998 Najjar and Guttmacher,5 1998 51, Male
No
Nadolol (by mouth) nightly Propranolol PO 1 h pre-ECT Esmolol IV
NR
Esmolol IV
210/115
Sublingual nitroglycerin Nitroprusside IV Esmolol/labetalol IV Labetalol IV
NR SBP
