Viguera A, Rordorf G, Schouten R, Welch C, Drop L J
Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
J Neurol Neurosurg Psychiatry. 1998 Jun;64(6):802-5. doi: 10.1136/jnnp.64.6.802.
This report describes successful anaesthesia and electroconvulsive therapy (ECT) in a patient with an unruptured basilar artery aneurysm. ECT is associated with a hyperdynamic state characterised by arterial hypertension, tachycardia, and considerably increased cerebral blood flow rate and velocity. These responses pose an increased risk for subarachnoid haemorrhage when an intracranial aneurysm coexists.
A 54 year old woman presented for ECT. She had a 20 year history of major depression which was unresponsive to three different antidepressant drugs. There was also an unruptured 5 mm saccular aneurysm at the basilar tip, which had been documented by cerebral angiography, but its size had remained unchanged for the previous four years. After she declined surgical intervention, she gave informed consent for ECT. During a series of seven ECT sessions middle cerebral artery flow velocity was recorded by a pulsed transcranial Doppler ultrasonography system. She was pretreated with 50 mg oral atenolol daily, continuing up to the day of the last ECT and immediately before each treatment, sodium nitroprusside was infused at a rate of 30 microg/min, to reduce systolic arterial pressure to 90-95 mm Hg.
Systolic flow velocity during the awake state ranged from 62-75 cm/s, remaining initially unchanged with sodium nitroprusside infusion. After induction of anaesthesia (0.5 mg/kg methohexitone and 0.9 mg/kg succinylcholine), flow velocities decreased to 39-54 cm/s, reaching maximal values of 90 cm/s (only 20% above baseline) after ECT. These flow velocities recorded post-ECT were considerably below the more than twofold increase recorded when no attenuating drugs were used. Systolic arterial blood pressure reached maximal values of 110-140 mm Hg and heart rate did not exceed 66 bpm. Rapid awakening followed each treatment, no focal or global neurological signs were apparent, and the patient was discharged in remission.
In a patient with major depression and a coexisting intracerebral saccular aneurysm who was treated with ECT, the combination of beta blockade with atenolol and intravenous infusion of sodium nitroprusside prevented tachycardia and hypertension, and greatly attenuated the expected increase in flow velocity in the middle cerebral artery.
本报告描述了一名患有未破裂基底动脉动脉瘤患者成功接受麻醉和电休克治疗（ECT）的情况。ECT与一种高动力状态相关，其特征为动脉高血压、心动过速以及脑血流速率和速度显著增加。当颅内动脉瘤并存时，这些反应会增加蛛网膜下腔出血的风险。
一名54岁女性前来接受ECT治疗。她有20年的重度抑郁症病史，对三种不同的抗抑郁药物均无反应。脑血管造影显示基底动脉尖有一个5毫米未破裂的囊状动脉瘤，在过去四年中其大小保持不变。在她拒绝手术干预后，她签署了ECT知情同意书。在一系列七次ECT治疗过程中，使用脉冲经颅多普勒超声系统记录大脑中动脉血流速度。她每天口服50毫克阿替洛尔进行预处理，一直持续到最后一次ECT治疗当天，并且在每次治疗前即刻，以30微克/分钟的速率输注硝普钠，将收缩压降至90 - 95毫米汞柱。
清醒状态下的收缩期血流速度范围为62 - 75厘米/秒，最初在输注硝普钠时保持不变。麻醉诱导（0.5毫克/千克美索比妥和0.9毫克/千克琥珀酰胆碱）后，血流速度降至39 - 54厘米/秒，ECT后达到最大值90厘米/秒（仅比基线高20%）。这些ECT后记录的血流速度明显低于未使用减效药物时记录的两倍以上的增加幅度。收缩期动脉血压达到最大值110 - 140毫米汞柱，心率未超过66次/分钟。每次治疗后患者迅速苏醒，未出现局灶性或全身性神经体征，患者出院时病情缓解。
在一名患有重度抑郁症且并存脑内囊状动脉瘤的患者接受ECT治疗时，阿替洛尔β受体阻滞与静脉输注硝普钠相结合可预防心动过速和高血压，并大大减轻大脑中动脉预期的血流速度增加。
