Electroconvulsive Therapy in the Presence of Cerebral Cavernous Hemangioma: A Case Report With Controlled Hemodynamic...

Electroconvulsive therapy (ECT) is an effective treatment for severe and treatment-resistant bipolar depression, yet intracranial vascular malformations such as cerebral cavernous malformations raise safety concerns due to transient ECT-induced increases in blood pressure and intracranial pressure, potentially elevating the risk of hemorrhage. We report a case of a woman in her mid-60s with treatment-resistant bipolar depression and severe symptom burden (MADRS 45; HAMD-17 35; HAMD-21 39) in whom brain MRI incidentally revealed a 6×4 mm cavernous hemangioma in the left precentral gyrus without signs of prior hemorrhage. Following interdisciplinary consultation with neurosurgery and anesthesiology, an index course of ECT was initiated with careful hemodynamic monitoring and pharmacological blood pressure control. The patient received 16 sessions; initial bifrontal stimulation yielded insufficient seizure quality despite maximal stimulus intensity, prompting a switch to right unilateral electrode placement, which produced adequate seizures. Hypertensive peaks up to 210/150 mmHg were successfully managed with metoprolol and intravenous urapidil. Apart from transient anisocoria after the first session with unremarkable cranial CT findings, no neurological complications occurred. Depressive symptoms markedly improved by the end of treatment (MADRS 12; HAMD-17 15; HAMD-21 17). This case suggests that ECT can be performed safely and effectively in patients with cerebral cavernous hemangioma when multidisciplinary assessment and targeted hemodynamic management are implemented, and that the combination of metoprolol and urapidil may represent a useful strategy to mitigate blood pressure surges during ECT.