Status Epilepticus Related to Maintenance Electroconvulsive Therapy

Prolonged seizures (PS), tardive seizures (TS), and status epilepticus (SE) are rare but severe complications related to electroconvulsive therapy (ECT). Factors increasing the risk for these conditions and measures making ECT safe after PS, TS, and SE are insufficiently studied. Therefore, we report and discuss the case of a 43-year-old woman with recurrent major depressive disorder and a history of epilepsy who developed SE during maintenance ECT. Factors possibly associated with SE in the present case were previous PS, discontinuation of oxcarbazepine during ECT, an implanted vagus nerve stimulator, and low stimulus intensity, presumably near the individual seizure threshold. Following comprehensive neurological diagnostics with unremarkable findings, maintenance ECT was resumed with an increased stimulus charge with good efficacy, safety, and tolerability. Based on the present case and the available evidence from the literature, resuming ECT after ECT-associated SE appears to be safe under the following conditions: (1) First, pre-ECT medical history and clinical investigation have to address risk factors for PS, TS, and SE (eg, substance withdrawal and medication/substances lowering seizure threshold). (2) Establishment of an anticonvulsant in order to reduce the risk of PS, TS, and SE cannot be recommended in general. (3) If available, characteristics of previous ECTs regarding charge, type, and dosing of anesthetics, concurrent medication, seizure duration, and tolerability of ECT should be considered. In particular, we recommend an increase in stimulus intensity (charge) to induce robust seizure termination.