Recurrent Depression With Catatonic Excitement in a Patient With Moyamoya Disease: A Case Report

We report the case of a 76‑year‑old woman with a 25‑year history of neuropsychiatric symptoms and Moyamoya vasculopathy, first identified in 2016. She presented in March 2025 with severe catatonic excitement and began electroconvulsive therapy (ECT) starting in April, showing marked clinical improvement within 3 sessions. Genetic testing confirmed moyamoya disease (MMD) with a pathogenic RNF213 mutation, associated with increased risk of infarction or hemorrhage. After trials with several anesthetic agents, dexmedetomidine (DEX) combined with remifentanil was selected, enabling stable anesthesia with a consistent electrical dose of 192 mC across 35 sessions over 5 months. The main challenges included hemodynamic stability in MMD, prevention of post‑ictal agitation in advanced age and catatonia, and preservation of seizure quality despite repeated ECT. This case highlights the safe and effective use of ECT with DEX and remifentanil in a patient with genetically confirmed MMD with catatonic symptoms.