Electroconvulsive therapy for medication-refractory depression in a patient with ruptured intracranial dermoid cyst, meningioma, and neurofibromatosis.

Electroconvulsive therapy (ECT) is considered relatively contraindicated in patients with intracranial space-occupying lesions. A 53-year-old male presented with a 5-year history of medication-refractory major depressive disorder. Brain imaging findings suggested the presence of a ruptured dermoid cyst in the transverse sinus and a calcified meningioma in the temporal lobe sulcal space. There was no evidence of mass effect. Neurofibromatosis was the only other clinical condition present. The patient had no clinical neurological deficits. Since the depression was severe and he was suicidal, ECT was advised. There was a substantial improvement after four bilateral and then eight right unilateral brief-pulse ECTs administered on alternate days, thrice weekly. There were no complications associated with ECT. The treatment gains were maintained with maintenance antidepressant medication at a 1-year follow-up. This is probably the first reported case of the use of ECT in a medication-refractory, severely depressed patient with a ruptured intracranial dermoid cyst and with a calcifying meningioma. The results testify to the safety of ECT even in high-risk patients.

INTRODUCTION

Dermoid cyst is a rare congenital tumor. While an unruptured intracranial dermoid may be symptomatic or nonsymptomatic, a ruptured intracranial dermoid can present with headache, focal neurological deficits, seizures, or even sudden death.[123]

A ruptured intracranial dermoid cyst is a rare incidental finding in brain imaging studies. Meningiomas are tumors, arising from meninges, that are usually benign and asymptomatic. Neurofibromatosis type 1 (NF1) is a genetic disorder, one of the visible signs of which is the prominent presence of soft, fleshy nodules under the skin. We present an unusual case of a patient who had a ruptured intracranial dermoid cyst, a calcifying meningioma, and neurofibromatosis NF1, who received a course of electroconvulsive therapy (ECT) for severe, medication-refractory depression.

CASE REPORT

S, a 53-year-old male, presented with a 5-year history of persistent sadness, loss of interest in everyday activities, feelings of hopelessness and helplessness, physical and mental slowing, and impairments in sleep and appetite. He had quit work 6 months earlier. He had made a serious suicide attempt in the previous month. There was no past history of hypomania or mania. The patient met criteria for a first major depressive episode (The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision).

Physical examination, including neurological examination, was unremarkable except for the presence of multiple nodules of varying sizes over the body, especially over the trunk, scalp, nape of the neck, and the extensor surface of the legs. One large nodule in the neck measured 3 cm × 1.5 cm × 1.5 cm, and one in the loin measured 4 cm × 3.5 cm × 1.5 cm. These nodules were diagnosed as neurofibromas [Figure 1].

Figure 1

Multiple neurofibromas

The patient had been trialled on most of the major antidepressant drugs available, both separately and in combination, and despite adequate trials, had failed to respond to any treatment regimen. Due to the severity of the depression, the occupational impairment, the recent suicide attempt, the strong ongoing suicidal ideation, and the failure to respond to multiple adequate antidepressant trials, he was advised ECT.

Baseline investigations, including hematology and thyroid, liver, and renal function tests, were all within normal limits. Brain computed tomography scan [Figure 2] showed multiple linear and oval foci of fat density areas in the posterior falx and an internal protuberance along the course of the transverse sinus, suggestive of a ruptured dermoid cyst. Brain MRI [Figure 3] showed a linear 1.6 mm × 4 mm × 4 mm hyperintense focus along the anterior part of the straight sinus and tissue with similar signal intensity near the confluence of sinuses, suggesting either a lipoma and prominent fat tissue along the sinuses or fatty tissue from a ruptured, resolving dermoid cyst. In addition, a 6 mm × 4 mm, well-defined T2 hypointense structure was seen in the left posterior temporal sulcal space, suggesting a calcifying meningioma. There were no mass effects.

Figure 2

Computed tomography brain images showing multiple foci of fat density areas

Figure 3

Magnetic resonance imaging brain images showing intracranial lesions

After a neurosurgical consultation and after discussion with the patient, the risk-benefit ratio was judged to be sufficiently acceptable to justify proceeding with ECT.

Informed consent was recorded, and brief-pulse ECT was administered on alternate days, thrice a week, using bitemporal electrode placement; antidepressant medication comprising escitalopram (20 mg/day), mirtazapine (45 mg/day), and amitriptyline (100 mg/day) was continued unchanged. After four ECTs, the patient reported subjective memory impairments. Treatment was therefore switched to right unilateral ECT, and eight more ECTs were administered. There was a progressive improvement across the course of ECT (dosing range, 60–240 mC) and Montgomery-Asberg Depression Rating Scale scores reduced from 40 before ECT to 15 at the end of the treatment course.

There were no clinical neurological changes apparent during or after the ECT course. The patient was followed up for 1 year. He remained well on maintenance antidepressant medication. His clinical neurological status did not change.

DISCUSSION

Dermoid cysts are among the rarest (<1%) of intracranial tumors; they most commonly occur in infratentorial areas. Case reports of dermoid cysts in the cavernous sinus have been published.[456] Intracranial dermoid cysts are slow growing and may cause symptoms due to mass effect.[7] A ruptured dermoid cyst is unusual in older persons.[8] Ruptured dermoids may present with headache, acute focal neurological deficits, seizures, hydrocephalus, or recurrent episodes of aseptic meningitis or encephalitis.[237]

To the best of our knowledge, this is the first case in medical literature where ECT was administered to a patient with refractory depression and ruptured intracranial dermoid cyst and meningioma. Our report adds to the small body of anecdotal literature that documents the safe use of ECT in patients with intracranial space-occupying lesions.[9101112]

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Conflicts of interest

There are no conflicts of interest.