BRAIN STIMULATION METHODS

BACUD, BALDADO, BARREDO, BI, CAMPUSPOS, KUPUA, KHAN

BRAIN STIMULATION

In psychiatric practice and research uses

electrical currents or magnetic fields to alter
neuronal firing
Either apply electrical or magnetic fields
transcranially or involve the surgical implantation
of electrodes to deliver electrical currents to a
cranial nerve to the brain directly.
Therapeutic Neuromodulation

Mechanism of Action
Electrical Stimulation Common pathway
Different brain stimulation modalities (electrical or
magnetic pulses) share one common final pathway ----
they affect neurons electrically.
DIRECT transcranial delivery / intracerebral delivery
INDIRECT - TMS and MST- induce electrical fields in the
brain through application of alternating magnetic fields
 A single pulse delivered at sufficient intensity
can:
Induce depolarization
Trigger an action potential
Release neurotransmitters at the synapse
Result in transsynaptic propagation with
subsequent activation of a functional circuit
Transcranial Magnetic Stimulation

It uses a hand-held magnet to allow focused

electrical stimulation across the scalp and
cranium without the pain associated with
percutaneous electrical stimulation. If TMS pulses
are delivered repetitively and rhythmically, the
technique is called rTMS.
Repeated transcranial magnetic stimulation
(rTMS)

Noninvasive technique for stimulating cells of the cerebral cortex

Creates a time-varying magnetic field in which a localized pulse
magnetic field over the surface of the head depolarizes the
superficial neurons.
Used to map cortical motor control and hemisphere dominance
Stimulating the motor cortex with rTMS results in a contralateral
motor response. Likewise, stimulating Broca's area with rTMS has
resulted in speech blockage.
 TMS

The subject is awake and alert and sitting in a

reclined chair. The headholder maintains the
TMS coil in the correct position next to the
prefrontal cortex. In antidepressant trials,
patients receive TMS in this manner for about
30 minutes every weekday for several weeks.
Note: The patient is wearing noise-cancelling
earphones. She also has the active sham system being
used in the NIMH optimization of TMS for the
treatment of depression clinical trial, with EEG being
recorded and an active sham system.
rTMS

Powerful electrical current is passed through a small coil

applied to the scalp. This current generates a focused
magnetic field of 1.5 to 2.0 T that passes through the
scalp and is largely unimpeded by bone or tissue. The
magnetic field, in turn, depolarizes brain cells to a
depth of 2 cm from the coil. Cortical interneurons are
more likely to be stimulated than are cortical output
cells, because the interneurons tend to lie parallel to
the brain surface
rTMS

Uses magnetic stimulators with multiple capacitors

capable of generating rapid pulses as great as 60 Hz
Low-frequency pulses in the range of 1 Hz may have an
inhibitory effect on cortical cells, whereas higher frequencies
have an excitatory effect.
Higher intensities of stimulation might be needed to reach the
prefrontal cortex, especially in elderly patients with prefrontal
atrophy
Side Effects

Common side effects which are generally mild to moderate

and improve shortly after an individual session:
headache
scalp discomfort at the site of stimulation
tingling, spasms or twitching of facial muscles
lightheadedness
Uncommon side effects which may be serious:
seizures
mania, particularly in people with bipolar disorder
hearing loss if there is inadequate ear protection during treatment
Patient Selection

Patients with major depression

Obsessive compulsive disorder (OCD)
Posttraumatic stress disorder (PTSD)
Parkinsons disease, symptoms such as bradykinesia may be
diminished
Future Directions

Therapeutic effects of TMS take several weeks to

consolidate, and, thus, the initial trials of TMS in
acute depression, which have lasted 2 weeks or
less, may be too short to assess efficacy.
Video
 Transcranial Direct Current Stimulation

Noninvasive, uses very weak (1 to 3 mA),

constant direct electrical current applied
to the scalp which modulates neuronal
activity
Uses two electrodes place over the head
Usually operated using portable, DC
batteries operated equipment
Mostly uses saline solution-soaked
electrodes
 Transcranial Direct Current Stimulation

Side Effects
No known side effects
Mostly minimal tingling at the site of stimulation
Few reports of skin irritation
Mechanism of Action

Due to early stages of exploration, little is known about actual

mechanism
DC polarizes current
Alteration of neuronal membrane polarization
Affect of polarization to firing and conductance by:
Lowering or raising the threshold activation
Due to low currents using cathodal and anodal electrodes
polarization can either inhibit or facilitate function
Anodal stimulation excites neuronal activity
Cathodal stimulation inhibits or reduces neuronal activity
Transcranial Direct Current Stimulation

Advantages
Cheap
Non-invasive
Painless
Safe
Portable
Transcranial Direct Current Stimulation

Current Studies
- may enhance certain brain functions independent of mood
- current research focus on effectiveness in recovery from
stroke and certain forms of dementia
- may be a valuable tool for treatment of :
- depression
- anxiety
- Parkinsons disease
- chronic pain
- currently not an US FDA-approved treatment
Video
Cranial electrotherapy
stimulation (CES)
What we will do?

Cranial electrotherapy stimulation (CES) is a

noninvasive procedure that has been used mainly
to treat anxiety, depression, and insomnia in the
general population.
CES in ADHD children, moderate hypertension and
chronic diseases as well as in adolescents with
general anxiety and depression.
 Cranial electrotherapy stimulation (CES) uses
medical devices about the size of a cell phone
that send a pulsed, weak electrical current to the
brain via electrodes placed on the ear lobes,
maxilla-occipital junction, mastoid processes, or
temples. It produces current of microamperes
(A), preset to 0.5Hz, emitted in cycles for 20
minute countdown to auto-off.
Procedure

Dgn DSM-VPsychometric tests ( Beck Depression

Inventory, MMPI, Anxiety scales, etc)
QEEG, ERPsInfluence on alpha brain waves (20,
40, 60 min. duration)
Evaluation of results
Video
Magnetic Seizure Therapy
What is Magnetic Seizure Therapy??

Novel form of a convulsive treatment

Under development in several research institutions in the U.S and
Europe
First therapeutic induction in a psychiatric patient was May 2000 in
Switzerland.
Uses an alternating magnetic field that crosses the scalp and the
calvarium bone unaffected by their high electrical impedance, to
in turn induce a more localized electrical current in the targeted
regions of the cerebral cortex
Aim = produce a seizure whose focus and patterns of spread
may be controlled
 MST is a convulsive treatment, similar to ECT.
clinical research reported to date concludes that it seems that
MST offers the same clinical efficacy as ECT but without side effects.
Preformed under GA with a muscle relaxant
It requires approximately the same preparation and
infrastructure as ECT
However, it is given using a modified TMS device
Stage of clinical trials and is not FDA approved
MST VS ECT
Mechanism of Action

Induction of a seizure is hypothesized to be the

underlying event responsible for the likely
multiple specific mechanisms of action of MST
treatment
FOCALITY
MST appears to represent a tool better suited
than ECT to the study the mechanisms of action
of convulsive therapy.
Potential of inducing seizures initiated in different regions in
the brain.
Method

Treatment procedure is very similar to a regular ECT

treatment.
Treatments are delivered with a magnetic stimulator
(MagVenture MagPro MST) using the highly efficient Twin
Coil.
Stimulation repetition rate 100 pps. Number of pulses: 100-
600 (duration 1-6s)
Two MST sessions per week.
The procedure and protocol used so far can probably be
further optimized.
MagVenture MagPro MST
What are the side effects?

headache, nausea, dizziness or cognitive disorder have not

been observed.
Furthermore, a faster recovery of orientation compared to
ECT patient has been reported.
MST magnetic coils produces a clicking noise that may
potentially affect hearing
Earplugs both patient and treating team
Studies suggest: Less retrograde and anterograde amnesia
than ECT
Replicated in larger trial
Can we use or recommend this treatment at
present time??

No clinical algorithms exist for MST, given that it

is still an investigational protocol and treatments
outside of research are not FDA approved.
Important role prior to referral for ECT
VAGUS NERVE STIMULATION
Vagus Nerve Stimulation

First FDA approved device for epilepsy and treatment refractory

depression (1997)
The most prevalent neurostimulation method (60,000 patients in
US)
Programmed to have constant modulation, and a magnet rescue
setting
Trials demonstrate between 25-50% of patients had a reduction of
>50% of seizure frequency; few become seizure free.*
VAGUS NERVE PROJECTION IN BRAIN
INDICATION

VNS Therapy is indicated for the adjunctive long-term

treatment of chronic or recurrent depression for patients
18 years of age or older who are experiencing a major
depressive episode and have not had an adequate response
to four or more adequate antidepressant treatments. (FDA
Criterion)
Vagal nerve stimulation is an alternative treatment for
patients with refractory epilepsy who cannot tolerate
surgery for the epileptic seizures.
Vagus Nerve Stimulation

Leads are wrapped around the vagus nerve in the neck. Through an unknown
Mechanism, can decrease the frequency of seizures in partial onset epilepsy.

Fridley Neurosurg Focus 2012

What is VNS Therapy?

VNS Therapy stands for Vagus Nerve

Stimulation
The vagus nerve:
Is one of the primary communication
pathways from the major organs of
the body to the brain
Appears to communicate with areas
of the brain involved in regulating
mood
Does not contain pain fibers
How VNS Therapy works

VNS Therapy is delivered by a pulse

generatora device like a pacemaker
The pulse generator sends mild,
intermittent pulses through a thin, flexible
wire leading to electrodes attached to the
left vagus nerve
Because the vagus nerve does not contain
pain fibers, VNS Therapy is typically painless
VNS Therapy is regular, automatic, and
generally unnoticeable
VNS Therapy is added to your current
antidepressant medications
What is the pulse generator?

The device delivers very mild intermittent brief

pulses to the left vagus nerve. 30s/5m
The pulses that are delivered to the left vagus
nerve are transmitted to the central nervous
system, and they appear to go to specific areas
in the central nervous system that control
mood, motivation, sleep, appetite, and other
symptoms that are relevant to depression.
VNS Therapy targets specific areas of the brain
that affect the production or activity of
neurotransmitters, such as serotonin and
norepinephrine.
What does the pulse generator look like?
Side effects

Side effects typically occur only during stimulation and may

include:
Temporary hoarseness or changes in voice tone, cough,
tickling in the throat, or a feeling of shortness of breath
during exertion
Some may complain of no side effects
The incidence of sleep disturbance and weight gain (also
commonly reported side effects of other antidepressant
treatments) is less than 2%
 END. Thank you.
BACUD, BALDADO, BARREDO, BI, CAMPUSPOS, KUPUA, KHAN