Here we outline the procedure for MRI-guided repetitive transcranial magnetic stimulation to the dorsomedial prefrontal cortex as an experimental treatment for major depressive disorder.
Here we outline the protocol for magnetic resonance imaging (MRI) guided repetitive transcranial magnetic stimulation (rTMS) to the dorsal medial prefrontal cortex (dmPFC) in patients with major depressive disorder (MDD). Technicians used a neuronavigation system to process patient MRIs to generate a 3-dimensional head model. The head model was subsequently used to identify patient-specific stimulatory targets. The dmPFC was stimulated daily for 20 sessions. Stimulation intensity was titrated to address scalp pain associated with rTMS. Weekly assessments were conducted on the patients using the Hamilton Rating Scale for Depression (HamD17) and Beck Depression Index II (BDI-II). Treatment-resistant MDD patients achieved significant improvements on both HAMD and BDI-II. Of note, angled, double-cone coil rTMS at 120% resting motor threshold allows for optimal stimulation of deeper midline prefrontal regions, which results in a possible therapeutic application for MDD. One major limitation of the rTMS field is the heterogeneity of treatment parameters across studies, including duty cycle, number of pulses per session and intensity. Further work should be done to clarify the effect of stimulation parameters on outcome. Future dmPFC-rTMS work should include sham-controlled studies to confirm its clinical efficacy in MDD.
重复经颅磁刺激(rTMS治疗)是间接的局灶性皮质刺激的一种形式。颅磁刺激员工短暂,焦电磁场脉冲穿透颅骨刺激目标的大脑区域。磁刺激被认为是啮合的突触长期增强,长期抑郁的机制,从而增加或减少区域的皮层的兴奋性刺激的1。一般地,磁刺激脉冲的频率决定其效应:较高频率刺激趋向于兴奋性,而较低的频率是抑制性的。非侵入性的刺激程序也被广泛使用作为因果探针以诱导临时“皮质性病变”,并且通过暂时禁用期望皮层区2的功能建立神经行为关系或功能区域– 4。
颅磁刺激治疗涉及多个刺激会话,通常施一次ðaily在几个星期,治疗各种疾病,包括重度抑郁症(MDD)5,进食障碍6,和强迫症7。磁刺激MDD的是难治的患者潜在的选择,并且允许临床医生能够无创靶向并改变直接参与与抑郁病因或病理生理学皮质区的兴奋性。对于MDD-rTMS治疗常规皮质目标是背外侧前额叶皮层(DLPFC)8。然而,从神经影像学,病变组织,刺激研究的证据,确定背内侧前额皮层(dmPFC)作为MDD 9潜在的重要治疗靶标和各种在自我调节的思想,行为特征在于赤字其它精神障碍和情感规定10。该dmPFC是一致的活化在情绪调节11,行为监管12,13的区域。该dmPFC也与神经化学相关的14,15的结构和功能异常16在MDD
此处所描述的程序是用于磁共振成像(MRI)引导的磁刺激的dmPFC双边的20届(4周),作为用于抑郁症的治疗。除了 施加在30分钟的常规10赫兹协议,间歇THETA突发刺激方案(TBS)进行了讨论,其在6分钟会话17施加50赫兹三峰脉冲串在5赫兹。这两个协议都被认为是兴奋性的,与具有实现使用短得多的会话18可比效 应的可能性的TBS协议。在这两个协议,解剖核磁共振成像以及临床评估之前将磁刺激获得的。神经导航使用解剖扫描占dmPFC的解剖变化和优化磁刺激的位置。一个相对较新的120°-angled流体冷却磁刺激线圈也是我们ED为了刺激更深中线皮质结构。最后,磁刺激强度滴定,使用过的rTMS会话的第一个星期,以确保病人能,观察者与dmPFC刺激相关的更高的疼痛水平相对于传统DLPFC刺激。
这里,MRI引导dmPFC-磁刺激涂敷了用于治疗难治性抑郁症。在一般情况下,的rTMS在这个网站的耐受性良好,轻度头皮不适和疼痛刺激时的网站使用自适应滴定充分的管理。在开放性试验和图审查,既10赫兹和theta爆裂刺激导致抑郁症的严重程度显著的改善为由HAMD 17和BDI-II测量。
有两个值得注意的rTMS治疗过程中进行优化dmPFC刺激的关键步骤。首先,有角度的,双锥形…
The authors have nothing to disclose.
The authors wish to thank Aisha Dar, Vanathy Niranjan, and Dr. Umar Dar for technical assistance with rTMS delivery and data collection. The authors also wish to acknowledge the generous support of the Toronto General and Western Hospital Foundation, the Buchan Family Foundation, and the Ontario Brain Institute in funding this work.
3T GE Signa HDx Scanner | GE | n/a | |
Visor 2.0 Neuronavigation System | ANT Neuro | n/a | |
MagPro R30 Stimulator | MagVenture | n/a | |
Cool-DB80 Coil | MagVenture | n/a |