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Rethinking Restimulation: A Case Report

Kranaster, Laura MD*; Janke, Christoph MD; Lewien, Antje MD*; Hoyer, Carolin MD*; Lederbogen, Florian MD*; Sartorius, Alexander MD, PhD*

doi: 10.1097/YCT.0b013e318254f437
Case Reports

The individual time-course of the seizure threshold (ST) in electroconvulsive therapy is mostly unknown. It is assumed that a typical seizure is followed by a short refractory period and that ST increases in the long run. We hypothesize ST to be lowered immediately after the refractory period, particularly after inadequate or abortive seizures where risk for prolonged seizures is generally higher. Ketamine anesthesia does not possess pronounced anticonvulsive properties like propofol, etomidate, thiopental, or methohexital. It is therefore ideal to test such a hypothesis. We report the case of a geriatric patient with a major depressive episode, who received 5 consecutive electroconvulsive therapies with S-ketamine, all with identical right unilateral high-energy stimulation and restimulation. Whereas all primary stimulations were inadequate, all restimulations showed significantly improved seizure parameters such as midictal amplitude, maximal postictal heart rate, and average seizure energy index. In this patient, the refractory period turned out to be longer than 1 minute, and ST was lower in all 5 instances of restimulation. This ST decrease could be clinically useful in one-session restimulations.

From the *Department of Psychiatry and Psychotherapy, Central Institute of Mental Health and †Department of Anaesthesiology and Critical Care Medicine, Medical Faculty Mannheim, Heidelberg University, Germany.

Received for publication February 10, 2012; accepted March 9, 2012.

Reprints: Alexander Sartorius, MD, PhD, Central Institute of Mental Health, Ruprecht-Karls-University Heidelberg, J5, 68159 Mannheim, Germany (e-mail:

The authors have no conflicts of interest or financial disclosures to report.

© 2012 Lippincott Williams & Wilkins, Inc.