Transcranial Magnetic Stimulation in Psychiatry

Prof. Nahla Nagy(MD) Prof. Psychiatry Ain Shams Faculty of Medicine Cairo,Egypt

Transcranial magnetic stimulation (TMS) was introduced in 1985 as a non invasive and safe stimulation of the cerebral cortex (Baker et al, 1985). The development of stimulators capable of discharging at high frequencies (up to 100 Hz) has expanded the application of TMS into the areas of cognitive and behavioral functions (Pascaut-Leone et al, 1995). Depending on Stimulation Parameters (frequency, rate and duration) repetitive stimuli to specific cortical regions can either decrease or enhance the excitability of the affected brain structures (Pascaut-Leone, 1994).

ECT vs TMS
Electroconvulsive therapy (ECT) requires application of intense electrical stimulation because the skull isolates electric current and intracerebral structures shunt current directly from one electrode to the other (Zyss,1994). The intensity of stimulation usually used in patients induces a self-sustained after-discharge of cortical neurons, which produces convulsive seizure. Therefore, ECT requires general anesthesia, induces massive autonomic stimulation, and can produce transient memory loss(Khan et al,1993)

ECT induces activation throughout the brain and, particularly, in hippocampus and neocortex, (Cole et al,1990) . By contrast, a single application of rTMS produces a much more discrete stimulation more in the dorsal midthalamus, specifically the paraventricular nucleus , in the frontal and medial cerebral cortex, including cingulate, primary, and secondary motor cortex The effects of rTMS in the cingulate cortex are more evident in anterior brain sections . However, rTMS does not induce activation in lateral cortical regions such as forelimb and parietal cortex as well as midbrain, pons, medulla, and cerebellum(Rong et al,1998)(activation of the brain assessed by mRNA expression).

Most effort have focused on stimulating localized brain areas and limiting the hazards posed by TMS .However ,the actual effect and distribution of resulting electric currents is still a complicated task

Technique of TMS
rTMS was administrated to head model by using a modelled figure of eight coil and the Magstim Rapid Rate Stimulator at a rate of 8 Hz with 100% power that generates a field of approximately 2 tesla. The coil was held above the right dorsolateral prefrontal cortex oriented laterally and ventrally.

Comparing magnitude of induced electric current after TMS in different brain regions ipsilateral and opposite to the site of stimulation Brain regions Frontal lobe Parietal lobe Tempora l lobe Occipital lobe Thalamu s Caudate nucleus Right side (Side of stimulation) a/m2 10.5 13 9 2 1.6 3.8 Left side a/m2 3 5.5 1 2 0.85 3.4

Single TMS in Tobacco Smokers

TMS over the frontal cortex was used to examine CNS effects of chronic nicotine use in 20 subjects Results showed shorter cortical motor evoked potentials in smokers compared with nonsmoker controls,indicating increased neuronal activity in the frontal lobe.

HFS 30 25 20 15 10 5 0
Before Just after
15.7 12.6 24 27

LFS

17.4 12.6

16.9 14.1

2 weeks after

1 month after

Rt sided P-value Lt sided Time of group assessme group nt Before 28.2+1.3 27.1+2.5 TMS After 5sessions After 10session s 23.4+1.5 21.0+0.9 24.0+1.0 23.2+1.2 0.031

TMS in Parkinsonism
Bilateral prefrontal simulation with HF produces decrease bradykinesia which is short limited (few days)

Repetitive Transcranial Magnetic Stimulation treatment in Post stroke Depression

Clinical response no Percentage

Responders

12

60%

Nonresponders

40%

Timing of the study

HDRS M+SD

Differences

Just before 24.4+5.093 TMS Just after 14.30+5.469 10.1(41.39) TMS % Two weeks 15.00+7.004 9.4(38.52) % after One month 14.6+6.573 9.8(40.16)% after

Cognitive test Visual associate learning Tapping forward Taping backward

Before After TMS TMS 7.30+2.84 9.60+3. 99 6.00+1.50 6.20+1. 95 4.80+1.95 5.03+1. 47

P-value 0.006

0.48 0.46

No side effects

Headache

Others

40%

15% 45%

Thank you