Electroconvulsive Therapy in the Presence of Intracranial Pathology

Electroconvulsive therapy (ECT) is a well-established method to treat various psychiatric disorders. However, ECT is not without risk; as such, all patients undergo a thorough workup to ensure appropriate patient selection. An important physiological event during ECT is the transient increase in intracranial pressure (ICP), which raises the question of intracranial contraindications to this treatment modality. A literature review was conducted to explore the safety of ECT in the presence of various intracranial pathologies to establish a summary of recommendations. Neuropathologies considered include malignant or benign brain tumours, arachnoid cysts, neurovascular conditions, neurotrauma, hydrocephalus, idiopathic intracranial hypertension, and Chiari 1 malformations. The literature remains very sparse on this topic, mostly including case series or short retrospective studies. However, there have not been any established absolute contraindications to ECT. Available evidence describes lower risks following ECT in clinically asymptomatic tumors, arachnoid cysts, treated hydrocephalus, and asymptomatic Chiari 1 malformation. Several strategies have been proposed to mitigate the risks of transient rise of intracranial pressure in certain conditions, including the administration of steroid medications and intravenous antihypertensives. The decision to proceed with ECT in the presence of intracranial pathology should be made on a case-by-case basis by a multidisciplinary team involving both psychiatric and neurosurgical teams.