Does electroconvulsive therapy (ECT) pose a risk of embolic stroke in patients with atrial fibrillation (AF)?

Acute embolic stroke in the setting of AF without anticoagulation after ECT has been reported in a single case report in the absence of conversion to normal sinus rhythm (1). Several cases of episodic or persistent conversion to normal sinus rhythm (NSR) in patients with AF undergoing ECT have also been reported (in the absence of embolic stroke), leading some to recommend anticoagulation therapy in such patients (2), though no firm data exist.

The mechanism by which ECT promotes cardioversion from AF to NSR is unclear as direct electrical influence of ECT on the heart is thought to be negligible (1). Arrhythmias such as atrial flutter and AF have also been reported after ECT (1). Curiously, ECT is associated with increased 5- hydroxytryptamine (5- HT2)-receptor densities of platelets in patients with depression which may enhance platelet reactivity and increase the risk of embolic stroke (3) even in the absence of cardioversion.

 

References

  1. Suzuki H, Takano T, Tominaga M, et al. Acute embolic stroke in a patient with atrial fibrillation after electroconvulsive therapy. J Cardiol Cases 2010; e12-e14.
  2. Petrides G, Fink M. Atrial fibrillation, anticoagulation, electroconvulsive therapy. Convulsive Therapy 1996;12:91-98.
  3. Stain-Malmgren R, Tham A, Ǻberg-Wistedt A. Increased platelet 5-HT2 receptor binding after electroconvulsive therapy in depression. J ECT 1998;14:15-24.
Does electroconvulsive therapy (ECT) pose a risk of embolic stroke in patients with atrial fibrillation (AF)?

Which motor test may be the most useful maneuver when examining a patient suspected of having a stroke?

When limited by the number of motor tests that can be performed on a patient suspected of having a stroke, the pronator drift may be your best bet! This test may be positive in as many as 94% of patients within a week of having a stroke (1).  An advantage of this maneuver is that it can point to subtle lesions in the corticospinal tract (CST) often missed by formal strength testing.

To perform the test, ask the patient to hold his or her arms straight out in front with palms facing upwards and eyes closed for 20-30 seconds. Slight pronation of one hand and flexion of the elbow suggests mild drift. Additional downward drift of the entire arm may also be present with more severe deficits (2). Interestingly, if one arm drifts upward this suggests a lesions outside the CST, possibly a cerebellar or parietal lesion, which may be equally concerning.

 

References

  1. Louis ED, King D, Sacco R, et al. Upper motor neuron signs in acute stroke: prevalence, interobserver reliability, and timing of initial examination. J Stroke Cerebrovasc Dis 1995;5:49-55.
  2. Campbell, WW. In DeJong’s The Neurologic Examination-6th Ed, p389-392, 2005. Lippincott Williams&Wilkins, Philadelphia.

 

 

 

Contributed by Alexis Roy, Harvard Medical Student, Boston, MA.

Which motor test may be the most useful maneuver when examining a patient suspected of having a stroke?