From the Guidelines
A history of intracranial hemorrhage is not an absolute contraindication for TMS treatment for depression, but it requires cautious assessment and consideration of individual risk factors. The provided evidence primarily discusses the use of electroconvulsive therapy (ECT) in patients with various neurological conditions, including intracranial tumors and a history of craniotomy 1. While ECT and TMS are different treatments, the principles of cautious assessment and individualized risk evaluation can be applied to TMS as well.
Key Considerations
- The presence of structural abnormalities in the central nervous system, such as those resulting from intracranial hemorrhage, may affect treatment outcomes but does not necessarily preclude the use of TMS or ECT 1.
- Successful use of ECT in patients with cerebral lesions, including tumors and a history of craniotomy, has been reported, suggesting that with proper assessment and caution, similar treatments might be safely administered in patients with a history of intracranial hemorrhage 1.
- The primary concern with TMS in patients with a history of intracranial hemorrhage is the potential for the magnetic fields to interact with damaged brain tissue or vulnerable blood vessels, which could increase the risk of adverse effects or new bleeding events.
Clinical Approach
- A thorough neurological assessment and review of the patient's medical history are essential before initiating TMS therapy, especially in patients with a history of seizures, head trauma, or intracranial pathology.
- Alternative depression treatments, such as medication adjustments, psychotherapy, or other neuromodulation approaches, should be considered for patients with a history of intracranial hemorrhage, weighing the potential benefits against the risks.
- The decision to use TMS in a patient with a history of intracranial hemorrhage should be made on a case-by-case basis, considering the individual's specific condition, the severity of their depression, and the potential risks and benefits of the treatment.
From the Research
History of Intracranial Hemorrhage and TMS Treatment for Depression
- The provided studies do not directly address the question of whether a history of intracranial hemorrhage is a contraindication for TMS treatment for depression 2, 3, 4, 5, 6.
- However, the studies suggest that a history of intracranial hemorrhage may be associated with an increased risk of recurrent hemorrhagic stroke, particularly in patients taking selective serotonin reuptake inhibitors (SSRIs) 3, 4.
- One study found that SSRI exposure was associated with both ICH recurrence and resolution of post-ICH depression, but the association with ICH recurrence was stronger in individuals at high risk for recurrent ICH 3.
- Another study found that the use of SSRIs was associated with an increased risk of ICH, but the association was partly accounted for by biases and methodological limitations in the available observational data 4.
- Studies on intravenous thrombolysis in ischemic stroke patients with a prior intracranial hemorrhage suggest that a history of ICH may not increase the risk of symptomatic hemorrhagic transformation, but may be associated with a higher risk of death and poor functional outcomes 5, 6.
- Overall, while there is no direct evidence on the safety of TMS treatment for depression in patients with a history of intracranial hemorrhage, the available studies suggest that such a history may be associated with increased risks and should be carefully considered in treatment decisions.