TRANSCRANIAL

MAGNETIC STIMULATION

Faten Alzaben PGY5 RESIDENT

What is it?

TMS is a non-invasive method of brain

stimulation in which magnetic fields are
used to induce electric currents in the
cerebral cortex, thereby depolarizing
neurons.

Early Attempts!

Modern Application

Even More Modern

History

the idea of using TMS goes back to the

early 1900s.

1985 tony barker and colleagues .

1984 David Cohen, 1988 Shoogo Ueno :

the idea and realization of the figure-ofeight coil .

Mechanism of action of TMS

Electrical energy is converted to

magnetic fields ,which are then
converted back into electrical currents in
the brain.

TMS is sometimes calledelectrodeless

electrical stimulation

Applications of TMS

A research tool to study aspects of the

human brain physiology
Therapeutic application:

Neurological disorders
Psychiatric disorders

TMS as a research tool

A research tool to study aspects of the

human brain physiology including motor
function,vision,language and the
pathophysiology of brain disorders
TMS can excite or inhibit the brain
allowing functional mapping of cortical
regions and creation of transient
functional lesions.

Examples:

rTMS over the occipital lobe impaired

detection of visual stimuli
rTMS delivered to discrete areas in the
language-dominant hemisphere can
disrupt speech.

Therapeutic Application in
Neurological Disorders

Movement disorders:

Therapeutic applications of TMS in movement disorders

are preliminary.

Fast rTMS of the motor cortex has been reported to

improve performance on several motor measures in
Parkinson disease.

a recent meta-analysis included 12 studies and

concludes that the overall literature does show a
positive effect of r TMS on Parkinson motor function.
Slow rTMS has been reported to improve dystonia.

George, linsbey ,and sackiem

Fregni et al. 2005

Neuro-rehabilitation

TMS to evaluate the functional

properties of the motor cortex after
lesions like stroke is of special interest in
the field of neurorehabilitation.

Brain stimulation have been proposed to

enhance motor function when combined
with conventional neurorehabilitative
interventions after stroke

Chronic Pain
(rTMS) of the cortex induces analgesic
effects in focal chronic pain syndromes.

Therapeutic Application
in Psychiatric Disorders

Mood Disorders

Several studies demonstrated that

repetitive transcranial magnetic
stimulation (rTMS) is an
efficacious treatment for treatmentresistant major depression.
its efficacy has often been shown to be
modest, compared with sham
stimulation.

Mechanisms of rTMSInduced Antidepressant

Response

evidence suggests that MDD is most

commonly associated with
hypoexcitability over the left prefrontal
cortex and hyperexcitability over the
right prefrontal cortex

Evidence in support left

prefrontal hypoexcitablity in
Brain injury:
depression:

patients with left-sided strokes

(hypoexcitability) experience depression
Patients with right-sided strokes experience
manic symptoms

Imaging studies demonstrated that

MDD may involve lower activity in the
left DPLFC and higher activity in the
right DPLFC.

rTMS treatment in MDD has often been

shown to be associated with a
normalization of hypoexcitability over
the left prefrontal cortex and
normalization of hyperexcitability over
the right hemisphere.

Studies have demonstrated that when

10 Hz rTMS is applied to the right
DLPFC , dysphoric symptoms occur.

Review of Studies of rTMS in

Depression

Studies in the review were summarized into 5 broad

categories:
1- first-generation studies that have evaluated the efficacy of 10
rTMS sessions (that is, 2 weeks) for TRD.

2-second-generation studies that have evaluated the efficacy of

rTMS for more than 10 rTMS sessions.

3-third-generation studies that evaluate the efficacy of rTMS

using several novel treatment approaches (for example, bilateral
rTMS).

4- metaanalytic studies of rTMS for TRD.

5-future studies proposing novel methods to optimize the

efficacy of rTMS for TRD.
The Canadian Journal of Psychiatry, Vol 53, No 9, September 2008

First-Generation Studies

rTMS studies applied at high frequencies (10

to 20 Hz) over the left prefrontal cortex have
demonstrated efficacy in the treatment of
depression.

Other studies also demonstrated right lowfrequency rTMS to be useful in depression.

Other first-generation studies were
equivocal or showed lack of efficacy.

Other studies have also reported negligible

results.

Explanations :
1- most patients included in these studies were
treatment resistant.

2- stimulation parameters including frequency,

intensity, and duration vary from study to
study.
3- concomitant use of medications .
4- no consistent method for precisely localizing
the prefrontal cortex.

Second-Generation
Studies

20 or more treatments.

The results demonstrate that both HFLand LFR-rTMS have substantial

therapeutic efficacy.

Third-Generation Studies

bilateral rTMS.
The studies showed no difference
between the groups.
Limitations of these studies:

First, bilateral rTMS was not compared with

unilateraland sham rTMS in a sufficiently
large sample of subject.
none of the studies were conducted for
longer than 10 days .
none used more than 300 LFR-rTMS pulses.

Metaanalyses of rTMS in
MDD

There have been at least 8 meta

-analyses evaluating the anti-depressant
effects of left DLPFC rTMS. All but one
have shown greater antidepressant
effects at 2 weeks of HFL-rTMS,
compared with sham.

Limitations of Current rTMS

Trials in MDD
Factors underlie the relative modest therapeutic
efficacy of rTMS studies conducted in MDD:
1- most of these studies involved left-sided
treatment alone to the DLPFC.
2- suboptimal methods were used to target the
DLPFC .
3-treatment durations were typically short (that
is, 2 to 4 weeks).
4- stimulation intensity might have been
insufficient by
not taking into consideration coil-to-cortex
distance

Anxiety Disorders

obsessive-compulsive disorder
posttraumatic stress disorder
panic disorder

Schizophrenia

reduced auditory hallucinations

reduced anxiety

Difference Between TMS

and ECT

TMS:

does not require general anaesthesia

easy to administer in alert and wake
subjects under medical supervision
no cognitive deficits reported at this point.
Does not involve induction of seizures

Adverse Effects of rTMS

Risk of inducing seizures (in patients with

a hx or family hx of seizures).current
safety protocols adjust the amount of
stimulation in relation to the motor
threshold of the individual.
Muscle tension headache .
Short term changes in hearing threshold
related to the noise generated.
Cognitive changes only during stimulation

Thank You !