A recent review of the literature and case reports outlines 8 cases of ECT performed in patients with IVMs, none of whom had adverse outcome (105). While these numbers do not establish unequivocal safety in this population, the individual practitioner must continue to perform risk–benefit analysis on a case-by-case basis.

In patients with intracranial aneurysms, the primary anesthetic goal is to try to control the systemic blood pressure. Abrupt changes in transmural pressure from either increases in systemic pressure or decreases in ICP may cause rupture. In contrast to patients with mass lesions (that is, with brain tumours), maneuvers such as hyperventilation to decrease ICP are detrimental. In these patients, safe ECT administration has been reported by avoiding hyperventilation, with close attention to control of blood pressure and heart rate (106). Several publications show that esmolol alone, especially in low doses, may not be sufficient to control hypertension during ECT in patients with intracranial aneurysm (104). These patients have been treated successfully with a combination of atenolol, a beta blocker, and intravenous infusion of sodium nitroprusside to prevent tachycardia and hypertension (107). Atenolol use has been associated with severe confusion in 1 case when used in this context (108). Pretreatment does not totally block hypertensive surges but seems to reduce morbidity (109).

Stroke. Depression develops in 30% to 60% of patients within 2 years after a stroke (110–112) and impedes recovery and rehabilitation of stroke patients (113). In antidepressant-resistant patients with poststroke depression, ECT is effective, but there is no generally accepted recommendation on how long to wait after a stroke before administering ECT (114). Although the risk in patients with stable lesions is thought to be small, fresh lesions— particularly hemorrhagic lesions—may be more likely than ischemic infarctions to rebleed with ECT (115–117). One patient was treated 4 days after a documented cerebral infarction (44). More recently, a well-documented report describes a 79-year-old patient with depression successfully treated with ECT about 7 to 14 days after a cerebellar ischemic stroke (117).

Some experts believe that ECT after a fresh stroke may worsen the effects of the original stroke (114) or may be associated with an increased incidence of delirium or cardiac complication (118–120). Because of the potential rebleeding risk with ECT—especially with hemorrhagic lesions (117,119)—careful pharmacologic blunting of the hypertensive surge must be undertaken (107,109). In contrast, patients with ischemic strokes generally do not require aggressive control due to risk of hypotension morbidity (7). ECT is very effective and generally well tolerated in poststroke patients, but they show a high risk of relapse, despite a robust ECT response and maintenance antidepressant therapy (121). It is recommended that caution be used, treatment carefully monitored, and ECT administered in the acute poststroke period only in settings where adequate medical, neurologic, and radiologic consultations are available (117).

Patients with MRI evidence of subcortical hyperintensities, but without cognitive impairment (silent cerebrovascular disease), generally respond as well as patients who have depression without dementia and do not appear to be at increased long-term cognitive risk with ECT use (122,123). These patients, however, along with others suffering from strokes with dementia, may be at increased risk for confusion or transient cognitive worsening post-ECT (120,125). Table 2 outlines ECT use in other CNS conditions.

ECT Use in Patients with Cardiovascular Disorders

The most frequent complications during ECT (145) prior to modern anesthetic techniques (146) and effective medical management (147) were cardiovascular. These have reduced dramatically in patients with and without prior cardiac history (148,156). ECT is increasingly being considered for patients with medication-resistant or medication-intolerant psychiatric conditions and significant cardiovascular disease, many of whom are also elderly (149).