Electroconvulsive Therapy for Postoperative Catatonia in a Patient With Intellectual Disability: Successful Seizure Induction After Multimodal Technical and Anesthetic Optimization.

Abstract

Catatonia is a neuropsychiatric syndrome that may complicate medical and surgical conditions but is often underrecognized, particularly in patients with intellectual disability. Electroconvulsive therapy (ECT) is an established treatment for benzodiazepine-resistant catatonia, although seizure induction can be difficult in some cases. We report a 52-year-old man with intellectual disability who developed postoperative catatonia after laparoscopic pancreaticoduodenectomy for insulinoma. Despite prolonged agitation, echolalia, mutism, rigidity, and catalepsy, catatonia was not recognized at multiple hospitals, and he was repeatedly discharged without appropriate treatment. After transfer to our facility, catatonia was confirmed. Because of recurrent aspiration pneumonia and oversedation with lorazepam, ECT was initiated promptly. Seizure induction was exceptionally difficult. Bilateral electrode placement with standard pulse width required escalation to the maximum charge output (200%, 1008 mC), and adequate seizures remained inconsistent. Sequential modifications included right unilateral electrode placement, ultrabrief pulse width, and later extension of pulse width to 1.50 ms at 50 Hz. Even then, consistent seizure induction was not achieved until the anesthetic was changed from propofol to thiamylal and flumazenil pretreatment was added, which suggests a synergistic effect of extended pulse width with right unilateral electrode placement, together with thiamylal and flumazenil. This case underscores that catatonia in patients with acute medical illness or intellectual disability is easily overlooked and that delayed recognition can result in serious medical complications; early diagnosis and prompt treatment are therefore essential. It further suggests that multimodal optimization of ECT parameters and anesthetic management may be required for reliable seizure induction in refractory cases.