Blood pressure control with glyceryl trinitrate during electroconvulsive therapy in a patient with cerebral aneurysm.

Electroconvulsive therapy (ECT) induces abrupt changes in systemic and cerebral haemodynamics that are problematical for patients with cardiovascular or cerebrovascular complications. Although there are no reports of ECT causing rupture of a cerebral aneurysm, excessive haemodynamic changes in such patients must be avoided. Short-acting -adrenoceptorblocking agents, e.g. esmolol, are suitable to attenuate hyperdynamic states after ECT. However, this type of drug is sometimes inapplicable for medical or social reasons. We describe a patient with a cerebral aneurysm who was successfully treated with glyceryl trinitrate before undergoing ECT. A 68-yr-old female diagnosed with endogenous depression and resistant to medication needed ECT. Preoperative evaluation with computed tomography revealed a cerebral aneurysm (6 mm in diameter) with a bleb in the middle section of the anterior communicating artery. Her family refused to have surgical clipping performed before the series of ECT. They understood the risks of both the procedure and cerebral aneurysm rupture, and written informed consent was obtained. Atropine 0.01 mg kg 1 intramuscularly (i.m.) was given as a vagolytic premedication. Arterial blood pressure was measured continuously at the right radial artery using a tonometric BP monitor (CBM-7000®; Colin Co Ltd, Komaki, Japan). The tc-Doppler probe (Sonos 5500®; Agilent Technology, Palo Alto, CA, USA) was adjusted to detect the middle cerebral artery flow (right temporal side) using a 2 MHz ultrasonic wave. The Doppler signals were obtained at a depth of 45–55 mm from the surface and the velocity was calculated automatically by tracing the waveforms. General anaesthesia was induced with propofol, 1 mg kg 1, over 15 s through an indwelling intravenous (i.v.) cannula. After consciousness had been lost, succinylcholine chloride (1 mg kg 1) was administered and the lungs inflated with 100% oxygen via a facemask. Glyceryl trinitrate (0.01–0.02 mg kg 1) was administered i.v. immediately after the succinylcholine to prevent excessive hypertension during the ECT. One minute later, an electrical current was applied bilaterally for 5 s at the minimal stimulus intensity, which had been determined in a first ECT trial by increasing the electrical intensity stepwise. The electroshock was delivered by a trained psychologist using an ECT stimulator (CS-1®; Sakai Iryo Co Ltd, Tokyo, Japan). The efficacy of electrical stimulation was determined using a tourniquet. The lungs were then gently inflated and PETCO2 at the nostrils was maintained at 4.0–4.7 kPa and SPO2 98%. The patient received ECT three times a week for a total of 20 treatments. Heart rate and blood pressure were largely unchanged after the ECT stimulus. Maximum changes of the averages (average of the 20 ECT sessions) were a 13.6% increase in heart rate (preanaesthesia 109 12 beats min 1, pre-electrical stimulus 107 10 beats min 1, maximum after the shock 122 10 beats min 1, respectively). The increase in mean blood pressure was 8.4% (preanaesthesia 81 12 mmHg, pre-electrical stimulus 71 11 mmHg, maximum after the shock 77 18 mmHg, respectively), 30 s after the electrical stimulus. The mean flow velocity in the middle cerebral artery was increased to a maximum of 12.7% at 30 s after the electrical stimulus (preanaesthesia 67 8 cm s 1, pre-electrical stimulus 65 7 cm s 1, maximum after the shock 73 10 cm s 1, respectively). The patient’s mental condition improved gradually, and she was discharged after the completion of the course of treatment without any physical problems. An intracranial aneurysm is listed as a contraindication of ECT, since the abrupt haemodynamic changes during therapy may cause aneurysmal rupture. However, there are several reports describing safe ECT management of patients with a cerebral aneurysm [1,2]. In all reports, some kind of antihypertensive drug was given to prevent excessive hypertension. Esmolol is the antihypertensive agent most used since short-acting -adrenoceptor-blocking European Journal of Anaesthesiology 2003; 20: 70–78 © 2003 European Academy of Anaesthesiology ISSN 0265-0215