Successful Use of Electroconvulsive Therapy for Catatonia After Hypoxic-Ischemic Brain Injury

Objective Report on the first known successful use of ECT for treatment of catatonia in a patient with hypoxic-ischemic brain injury. Background Catatonia is a psychomotor disorder characterized by difficulty initiating or inhibiting volitional behavior. Catatonia is likely underdiagnosed in medically ill patients, whose features may be misinterpreted as delirium or static brain injury-related deficits. While catatonia itself is rarely described after hypoxic-ischemic brain injury, its features are commonly reported in the context of delayed post-hypoxic leukoencephalopathy. To date, there are no reports of successful use of ECT for catatonia in this population. Methods Case Report. 32-year-old man with opioid and cocaine use disorders suffered hypoxic-ischemic brain injury after heroin overdose. He recovered well though reported depressive symptoms. Seven months later, he developed progressive mutism, rigidity, stupor, catalepsy, and dysautonomia consistent with catatonia, unspecified. MRI at that time did not show leukoencephalopathy. Results Twenty-four months after initial injury, lorazepam trial for suspected catatonia produced dramatic improvement but he required increasing doses to maintain effect. Right unilateral ECT was initiated for benzodiazepine-resistant catatonia and the patient received 12 treatments during an inpatient admission with complete resolution of catatonia. He reported no adverse effects. Catatonic symptoms re-emerged after discharge, and he received 21 outpatient ECT treatments (9 right unilateral and 12 bilateral) with overall improvement in catatonia. Conclusions The following factors may underlie the successful use of ECT for treatment of catatonia in this patient with hypoxic-ischemic brain injury: mood symptoms prior to onset of catatonia; initial response to lorazepam; absence of neuroimaging evidence of leukoencephalopathy; and longer length of time between the hypoxic-ischemic brain injury and initiation of ECT. Despite literature suggesting ECT can be detrimental after hypoxic-ischemic brain injury, stringent case selection criteria may allow for safe and effective use of ECT for catatonia in these patients.