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Transcranial Magnetic Stimulation Allyson Rosen, Ph.D., ABPP-Cn VA Palo Alto MIRECC [email protected]
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Page 1: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Transcranial Magnetic Stimulation

Allyson Rosen, Ph.D., ABPP-Cn

VA Palo Alto MIRECC

[email protected]

Page 2: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Transcranial Magnetic Stimulation (TMS)

*Magventure

Page 3: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Examples of Applications

• Treatment

– Depression,

– Pain/migraine

– Movement Disorders

– Bipolar Disorder

• Surgical Planning: Prediction of

Response

– Pain (rTMS correlates with MCS)

– Speech and Motor Localization

(Nexstim-FDA approved)

Page 4: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Induced Electrical Current

Electrical current

In Coil

Magnetic Field

Pass through Scalp

Action Potentials

Page 5: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Focal Cortical Stimulation

(limited depth)

Wagner et al., 2009

Page 6: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Parameters

• Frequency

– High (fast->5 Hz.) -> excitatory

– Low (slow- 1 Hz. or less) -> suppressive

• Intensity Metrics

– % Maximum Device Output

– % Motor Cortex Threshold

• Duration

• Pattern of Pulses

Page 7: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Motor Hot Spot

Fregni, Freedman, Pascual-Leone, 2007

Page 8: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Frontal Cortex

(Dorsolateral Prefrontal Cortex)

Page 9: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Parameters

• Frequency

– High (fast->5 Hz.) -> excitatory

– Low (slow- 1 Hz. or less) -> suppressive

• Intensity Metrics

– % Maximum Device Output

– % Motor Cortex Threshold

• Duration

• Pattern of Pulses

– Single, paired pulse, repetitive, theta

burst

Page 10: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Pattern of Pulses

Page 11: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Pattern of Pulses

Intertrain Interval

Page 12: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

TMS Papers Published

Rossi et al., 2009

Page 13: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Current Guidelines 1. Safety, ethical considerations, and application

guidelines for the use of transcranial magnetic stimulation

in clinical practice and research.

Rossi S, Hallett M, Rossini PM, Pascual-Leone A; Safety

of TMS Consensus Group.

Clin Neurophysiol. 2009 Dec;120(12):2008-39.

2. Safety of different inter-train intervals for repetitive

transcranial magnetic stimulation and recommendations

for safe ranges of stimulation parameters.

Chen R, Gerloff C, Classen J, Wassermann EM, Hallett

M, Cohen LG.

Electroencephalogr Clin Neurophysiol 1997;105:415–21.

Page 14: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Safety of TMS

Side Effects

Mild Headache

Mild Discomfort at sight of stimulation

Temporary increase in auditory threshold

(without ear plugs)

Syncope

Induce Mania (rare)

Induce Seizure (rare)

Page 15: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Contraindications

Cochlear implant

Aneurysm clips

Brain electrodes

Ferromagnetic material in their head or neck

Stroke

Head trauma

Pregnancy

Cardiac pacemaker

Safety of TMS

Page 16: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Frontal Lobe Target

http://www.mrc-

cbu.cam.ac.uk/people/jessica.grahn/neuroanatomy.

html

Page 17: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Talairach Atlas

Page 18: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Current Practice: 5 cm Rule

Page 19: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

5 cm rule

M1 M1

Page 20: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

EEG

Beam F3 method is better and more efficient

http://www.clinicalresearcher.org/software.htm

Page 21: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Why Should Do Both

Imaging and Stimulation?

Page 22: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Fiducial Marker of TMS

Herbsman et al., 2009

Page 23: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Anterior and Lateral Remitted

from Depression

Herbsman et al., 2009

Yellow=remit

Page 24: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Feedback On Location

Page 25: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Image Guided TMS

eXimia NBS system

Picht et al., 2011

Page 26: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

TMS Distance From Brain

Page 27: Transcranial Magnetic Stimulation - Veterans Affairs · transcranial magnetic stimulation and recommendations for safe ranges of stimulation parameters. Chen R, Gerloff C, Classen

Summary

• TMS is FDA approved for depression and

there are many other off label applications

with promise

• Know the safety guidelines!!!

• The temporal pattern of rTMS is crucially

important for the effect on the brain

• MRI guided TMS is most accurate for brain

targeting and EEG based landmarks are

next best but fixed distance is worst (e.g.

5 cm rule)


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