Excitability of the motor cortex during ovulatory and anovulatory cycles: a transcranial magnetic stimulation study

The influence of menstrual phase on synaptic plasticity induced via intermittent theta-burst stimulation

BACKGROUND

Ovarian hormones influence the propensity for short-term plasticity induced by repetitive transcranial magnetic stimulation (rTMS). Estradiol appears to enhance the propensity for neural plasticity. It is currently unknown how progesterone influences short-term plasticity induced by rTMS.

OBJECTIVE

The present research investigates whether the luteal versus follicular phase of the menstrual cycle influence short-term plasticity induced by intermittent theta-burst stimulation (iTBS). We tested the hypothesis that iTBS would increase motor evoked potentials (MEPs) during the follicular phase. Further, we explored the effects of the luteal phase on iTBS-induced neural plasticity.

METHOD

Twenty-nine adult females participated in a placebo-controlled study that delivered real and sham iTBS to the left primary motor cortex in separate sessions corresponding to the follicular phase (real iTBS), luteal phase (real iTBS), and a randomly selected day (sham iTBS). Outcomes included corticospinal excitability as measured by the amplitude of MEPs and short-interval intracortical inhibition (SICI) recorded from the right first dorsal interosseous muscle before and following iTBS (612 pulses).

RESULTS

MEP amplitude was increased following real iTBS during the follicular condition. No significant changes in MEP amplitude were observed during the luteal or sham visits. SICI was unchanged by iTBS irrespective of menstrual phase.

CONCLUSION

These findings suggest women experience a variable propensity for iTBS-induced short-term plasticity across the menstrual cycle. This information is important for designing studies aiming to induce plasticity via rTMS in women.

Non-Invasive Brain Stimulation and Sex/Polypeptide Hormones in Reciprocal Interactions: A Systematic Review

A better understanding of interindividual differences and the development of targeted therapies is one of the major challenges of modern medicine. The sex of a person plays a crucial role in this regard. This systematic review aimed to summarise and analyse available evidence on the mutual interactions between non-invasive brain stimulation and sex/polypeptide hormones. The PubMed database was searched from its inception to 31 March 2023, for (i) studies that investigated the impact of sex and/or polypeptide hormones on the effects induced by non-invasive brain stimulation, or (ii) studies that investigated non-invasive brain stimulation in the modulation of sex and/or polypeptide hormones. Eighteen studies (319 healthy and 96 disabled participants) were included. Most studies focused on female sex hormone levels during the menstrual cycle. The later follicular phase is associated with a weak between hemispheric and intracortical inhibition, strong intracortical facilitation, and high stimulation-induced neural and behavioural changes. The opposite effects are observed during the luteal phase. In addition, the participant's sex, presence and/or absence of real ovulation and increase in oestradiol level by chorionic gonadotropin injection influence the stimulation-induced neurophysiological and behavioural effects. In Parkinson's disease and consciousness disorders, the repetitive application of non-invasive brain stimulation increases oestradiol and dehydroepiandrosterone levels and reduces disability. To date, male hormones have not been sufficiently included in these studies. Here, we show that the sex and/or polypeptide hormones and non-invasive brain stimulation methods are in reciprocal interactions. This may be used to create a more effective and individualised approach for healthy individuals and individuals with disabilities.

The Impact of Sex Hormones on Transcranial Magnetic Stimulation Measures of Cortical Excitability: A Systematic Review and Considerations for Clinical Practice

ABSTRACT

Repetitive transcranial magnetic stimulation (rTMS) has emerged as a promising alternative for the treatment of major depressive disorder (MDD), although its clinical effectiveness varies substantially. The effects of sex hormone fluctuations on cortical excitability have been identified as potential factors that can explain this variability. However, data on how sex hormone changes affect clinical response to rTMS is limited. To address this gap, we reviewed the literature examining the effects of sex hormones and hormonal treatments on transcranial magnetic stimulation (TMS) measures of cortical excitability. Results show that variations of endogenous estrogen, testosterone, and progesterone have modulatory effects on TMS-derived measures of cortical excitability. Specifically, higher levels of estrogen and testosterone were associated with greater cortical excitability, while higher progesterone was associated with lower cortical excitability. This highlights the importance of additional investigation into the effects of hormonal changes on rTMS outcomes and circuit-specific physiological variables. These results call for TMS clinicians to consider performing more frequent motor threshold (MT) assessments in patients receiving high doses of estrogen, testosterone, and progesterone in cases such as in vitro fertilization, hormone replacement therapy, and gender-affirming hormonal treatments. It may also be important to consider physiological hormonal fluctuations and their impact on depressive symptoms and the MT when treating female patients with rTMS.

The effects of estradiol levels on crossmodal perception: a study on the sound induced flash illusion in healthy and menstrually related migraine individuals

OBJECTIVE

The sound-induced flash illusion (SIFI) is a valid paradigm to study multisensorial perception. In the "fission" SIFI, multiple flashes are perceived when observing a single flash paired with two or more beeps. SIFI is largely dependent on visual and acoustic cortex excitability; in migraine, dysfunctional cortical excitability affects SIFI perception. Since estrogen peak occurring during ovulation can increase neuronal excitability, the present study aims to verify whether cortical excitability shifts linked to the menstrual cycle could influence SIFI.

METHODS

In a comparative prospective study, we tested the effect of estrogens on crossmodal perception using the SIFI. We recruited 27 females in reproductive age, including 16 healthy and 11 menstrually related migraine females, testing their proneness to SIFI on day 14 (high estradiol) and day 27 (low estradiol) of menstrual cycle.

RESULTS

Women on day 14 reported less flashes than on day 27 (p = 0.02) in the fission illusion, suggesting a pro-excitatory effect of estradiol on visual cortex excitability during ovulation. Moreover, we confirmed that migraine women perceived less flashes (p = 0.001) than controls, independently from cycle phase. Non-migraineurs women significantly reported more flashes on day 27 than on day 14 (p = 0.04).

CONCLUSIONS

This study suggests that estradiol may influence the multisensory perception due to changes of visual cortex excitability, with high estradiol peak leading to increased visual cortical sensitivity during ovulation in non-migraineurs. Visual cortex hyperresponsiveness, here reflected by reduced SIFI, is not influenced by estradiol fluctuations in migraine women, as shown by reduced fission effects on day 14 and 27.

Hierarchical Bayesian modeling of the relationship between task-related hemodynamic responses and cortical excitability

Investigating the relationship between task-related hemodynamic responses and cortical excitability is challenging because it requires simultaneous measurement of hemodynamic responses while applying noninvasive brain stimulation. Moreover, cortical excitability and task-related hemodynamic responses are both associated with inter-/intra-subject variability. To reliably assess such a relationship, we applied hierarchical Bayesian modeling. This study involved 16 healthy subjects who underwent simultaneous Paired Associative Stimulation (PAS10, PAS25, Sham) while monitoring brain activity using functional Near-Infrared Spectroscopy (fNIRS), targeting the primary motor cortex (M1). Cortical excitability was measured by Motor Evoked Potentials (MEPs), and the motor task-related hemodynamic responses were measured using fNIRS 3D reconstructions. We constructed three models to investigate: (1) PAS effects on the M1 excitability, (2) PAS effects on fNIRS hemodynamic responses to a finger tapping task, and (3) the correlation between PAS effects on M1 excitability and PAS effects on task-related hemodynamic responses. Significant increase in cortical excitability was found following PAS25, whereas a small reduction of the cortical excitability was shown after PAS10 and a subtle increase occurred after sham. Both HbO and HbR absolute amplitudes increased after PAS25 and decreased after PAS10. The probability of the positive correlation between modulation of cortical excitability and hemodynamic activity was 0.77 for HbO and 0.79 for HbR. We demonstrated that PAS stimulation modulates task-related cortical hemodynamic responses in addition to M1 excitability. Moreover, the positive correlation between PAS modulations of excitability and hemodynamics brought insight into understanding the fundamental properties of cortical function and cortical excitability.

Inter-Individual Variability in tDCS Effects: A Narrative Review on the Contribution of Stable, Variable, and Contextual Factors

Due to its safety, portability, and cheapness, transcranial direct current stimulation (tDCS) use largely increased in research and clinical settings. Despite tDCS's wide application, previous works pointed out inconsistent and low replicable results, sometimes leading to extreme conclusions about tDCS's ineffectiveness in modulating behavioral performance across cognitive domains. Traditionally, this variability has been linked to significant differences in the stimulation protocols across studies, including stimulation parameters, target regions, and electrodes montage. Here, we reviewed and discussed evidence of heterogeneity emerging at the intra-study level, namely inter-individual differences that may influence the response to tDCS within each study. This source of variability has been largely neglected by literature, being results mainly analyzed at the group level. Previous research, however, highlighted that only a half-or less-of studies' participants could be classified as responders, being affected by tDCS in the expected direction. Stable and variable inter-individual differences, such as morphological and genetic features vs. hormonal/exogenous substance consumption, partially account for this heterogeneity. Moreover, variability comes from experiments' contextual elements, such as participants' engagement/baseline capacity and individual task difficulty. We concluded that increasing knowledge on inter-dividual differences rather than undermining tDCS effectiveness could enhance protocols' efficiency and reproducibility.

Biomarkers Obtained by Transcranial Magnetic Stimulation in Neurodevelopmental Disorders

SUMMARY

Transcranial magnetic stimulation (TMS) is a method for focal brain stimulation that is based on the principle of electromagnetic induction where small intracranial electric currents are generated by a powerful fluctuating magnetic field. Over the past three decades, TMS has shown promise in the diagnosis, monitoring, and treatment of neurological and psychiatric disorders in adults. However, the use of TMS in children has been more limited. We provide a brief introduction to the TMS technique; common TMS protocols including single-pulse TMS, paired-pulse TMS, paired associative stimulation, and repetitive TMS; and relevant TMS-derived neurophysiological measurements including resting and active motor threshold, cortical silent period, paired-pulse TMS measures of intracortical inhibition and facilitation, and plasticity metrics after repetitive TMS. We then discuss the biomarker applications of TMS in a few representative neurodevelopmental disorders including autism spectrum disorder, fragile X syndrome, attention-deficit hyperactivity disorder, Tourette syndrome, and developmental stuttering.

The effects of monophasic anodal transcranial pulsed current stimulation on corticospinal excitability and motor performance in healthy young adults: A randomized double-blind sham-controlled study

INTRODUCTION

Transcranial pulsed current stimulation (tPCS) could be used to deliver electrical pulses at different frequencies to entrain the cortical neurons of the brain. Frequency dependence of these pulses in the induction of changes in corticospinal excitability (CSE) has not been reported.

OBJECTIVE

We aimed to assess the effect of anodal tPCS (a-tPCS) at theta (4 Hz), and gamma (75 Hz) frequencies on CSE as assessed by the peak-to-peak amplitude of transcranial magnetic stimulation (TMS) induced motor evoked potentials (MEPs) and motor performance.

METHOD

In a randomized double-blinded sham-controlled cross over design study, seventeen healthy participants attended three experimental sessions and received either a-tPCS at 4 Hz, 75 Hz, or sham a-tPCS with 1.5 mA for 15 min. The amplitude of TMS induced resting MEPs and time for completion of the grooved pegboard test were recorded at baseline, immediately after, and 30-min after a-tPCS.

RESULTS

Both a-tPCS at 75 Hz and 4 Hz showed significantly increased CSE compared to sham. The a-tPCS at 75 Hz induced significantly higher CSE changes compared to 4 Hz. There was a significant increase in intracortical facilitation and a significant reduction in short-interval intra-cortical inhibition with both 4 and 75 Hz stimulation. However, the inhibition and facilitation did not correlate with CSE. Motor performance was unaffected by the interventions.

CONCLUSION

The high CSE changes in M1 in a-tPCS at 75 Hz provides an initial understanding of the frequency-specific effect of a-tPCS. More research is needed to establish this concept and to assess its behavioural relevance.

Gray Matter Volume Variability in Young Healthy Adults: Influence of Gender Difference and Brain-Derived Neurotrophic Factor Genotype

Although brain gray matter (GM) plastically changes during short-term training, it is still unclear whether brain structures are stable for short periods (several months). Therefore, this study aimed to re-test the short-term variability of GM volumes and to clarify the effect of factors (gender and BDNF-genotype) expected to contribute to such variability. The subjects comprised 41 young healthy adults. T1-weighted images were acquired twice with an interval of approximately 4 months using a 3 T-MRI scanner. Voxel-based morphometry (VBM) was used to calculate GM volumes in 47 regions. The intraclass correlation coefficient (ICC) and Test–retest variability (%TRV) were used as indices of variability. As a result, the ICCs in 43 regions were excellent (ICC > 0.90) and those in 3 regions were good (ICC > 0.80), whereas the ICC in the thalamus was moderate (ICC = 0.694). Women had a higher %TRV than men in 5 regions, and %TRV of the Val66Val group was higher than that of the Met carrier group in 2 regions. Moreover, the Female-Val66Val group had a higher %TRV than the Male-Met carrier group in 3 regions. These results indicate that although the short-term variability of GM volumes is small, it is affected by within-subject factors.

Test Re-test Reliability of Dual-site TMS Measures of SMA-M1 Connectivity Differs Across Inter-stimulus Intervals in Younger and Older Adults

Dual-site transcranial magnetic stimulation (TMS) is a promising tool to measure supplementary motor area and primary motor cortex (SMA-M1) connectivity in younger and older adults, and could be used to understand the pathophysiology of movement disorders. However, test re-test reliability of dual-site TMS measures of SMA-M1 connectivity has not been established. We examined the reliability of SMA-M1 connectivity using dual-site TMS in two sessions in 30 younger and 30 older adults. For dual-site TMS, a conditioning pulse delivered to SMA (140% of active motor threshold) preceded a test pulse delivered to M1 (intensity that elicited MEPs of ~1 mV) by inter-stimulus intervals (ISI) of 6 ms, 7 ms, and 8 ms. Moderate intraclass correlation coefficients (ICC) were found for SMA-M1 connectivity at an ISI of 7 ms in younger (ICC: 0.69) and older adults (ICC: 0.68). Poor ICCs were found for SMA-M1 connectivity at ISIs of 6 ms and 8 ms in both age groups (ICC range: 0.01-0.40). We report evidence for stable measures of SMA-M1 connectivity at an ISI of 7 ms in both age groups. These findings are foundational for future research developing evidence-based interventions to strengthen SMA-M1 connectivity to improve bilateral motor control in older adults and populations with movement disorders.

Large-scale analysis of interindividual variability in single and paired-pulse TMS data

OBJECTIVE

This study brought together over 60 transcranial magnetic stimulation (TMS) researchers to create the largest known sample of individual participant single and paired-pulse TMS data to date, enabling a more comprehensive evaluation of factors driving response variability.

METHODS

Authors of previously published studies were contacted and asked to share deidentified individual TMS data. Mixed-effects regression investigated a range of individual and study level variables for their contribution to variability in response to single and paired-pulse TMS data.

RESULTS

687 healthy participant's data were pooled across 35 studies. Target muscle, pulse waveform, neuronavigation use, and TMS machine significantly predicted an individual's single-pulse TMS amplitude. Baseline motor evoked potential amplitude, motor cortex hemisphere, and motor threshold (MT) significantly predicted short-interval intracortical inhibition response. Baseline motor evoked potential amplitude, test stimulus intensity, interstimulus interval, and MT significantly predicted intracortical facilitation response. Age, hemisphere, and TMS machine significantly predicted MT.

CONCLUSIONS

This large-scale analysis has identified a number of factors influencing participants' responses to single and paired-pulse TMS. We provide specific recommendations to minimise interindividual variability in single and paired-pulse TMS data.

SIGNIFICANCE

This study has used large-scale analyses to give clarity to factors driving variance in TMS data. We hope that this ongoing collaborative approach will increase standardisation of methods and thus the utility of single and paired-pulse TMS.

Reduced Cerebellar Brain Inhibition Measured Using Dual-Site TMS in Older Than in Younger Adults

Dual-site transcranial magnetic stimulation (TMS) can be used to measure the cerebellar inhibitory influence on the primary motor cortex, known as cerebellar brain inhibition (CBI), which is thought to be important for motor control. The aim of this study was to determine whether age-related differences in CBI (measured at rest) were associated with an age-related decline in bilateral motor control measured using the Purdue Pegboard task, the Four Square Step Test, and a 10-m walk. In addition, we examined test re-test reliability of CBI measured using dual-site TMS with a figure-of-eight coil in two sessions. There were three novel findings. First, CBI was less in older than in younger adults, which is likely underpinned by an age-related loss of Purkinje cells. Second, greater CBI was associated with faster 10-m walking performance in older adults, but slower 10-m walking performance in younger adults. Third, moderate intraclass correlation coefficients (ICCs: 0.53) were found for CBI in younger adults; poor ICCs were found for CBI (ICC: 0.40) in older adults. Together, these results have important implications for the use of dual-site TMS to increase our understanding of age- and disease-related changes in cortical motor networks, and the role of functional connectivity in motor control.

Pinging the brain with transcranial magnetic stimulation reveals cortical reactivity in time and space

BACKGROUND

Single-pulse transcranial magnetic stimulation (TMS) elicits an evoked electroencephalography (EEG) potential (TMS-evoked potential, TEP), which is interpreted as direct evidence of cortical reactivity to TMS. Thus, combining TMS with EEG can be used to investigate the mechanism underlying brain network engagement in TMS treatment paradigms. However, controversy remains regarding whether TEP is a genuine marker of TMS-induced cortical reactivity or if it is confounded by responses to peripheral somatosensory and auditory inputs. Resolving this controversy is of great significance for the field and will validate TMS as a tool to probe networks of interest in cognitive and clinical neuroscience.

OBJECTIVE

Here, we delineated the cortical origin of TEP by spatially and temporally localizing successive TEP components, and modulating them with transcranial direct current stimulation (tDCS) to investigate cortical reactivity elicited by single-pulse TMS and its causal relationship with cortical excitability.

METHODS

We recruited 18 healthy participants in a double-blind, cross-over, sham-controlled design. We collected motor-evoked potentials (MEPs) and TEPs elicited by suprathreshold single-pulse TMS targeting the left primary motor cortex (M1). To causally test cortical and corticospinal excitability, we applied tDCS to the left M1.

RESULTS

We found that the earliest TEP component (P25) was localized to the left M1. The following TEP components (N45 and P60) were largely localized to the primary somatosensory cortex, which may reflect afferent input by hand-muscle twitches. The later TEP components (N100, P180, and N280) were largely localized to the auditory cortex. As hypothesized, tDCS selectively modulated cortical and corticospinal excitability by modulating the pre-stimulus mu-rhythm oscillatory power.

CONCLUSION

Together, our findings provide causal evidence that the early TEP components reflect cortical reactivity to TMS.

Genetic Polymorphisms Do Not Predict Interindividual Variability to Cathodal Transcranial Direct Current Stimulation of the Primary Motor Cortex

Introduction: High variability between individuals (i.e., interindividual variability) in response to transcranial direct current stimulation (tDCS) has become a commonly reported issue in the tDCS literature in recent years. Inherent genetic differences between individuals have been proposed as a contributing factor to observed response variability. This study investigated whether tDCS interindividual variability was genetically mediated. Methods: A large sample size of 61 healthy males received cathodal tDCS (c-tDCS) and sham-tDCS of the primary motor cortex at 1 mA and 10 min via 6 × 4 cm active and 7 × 5 cm return electrodes. Corticospinal excitability (CSE) was assessed via 25 single-pulse transcranial magnetic stimulation motor-evoked potentials (MEPs). Intracortical inhibition was assessed via twenty-five 3 msec interstimulus interval (ISI) paired-pulse MEPs, known as short-interval intracortical inhibition (SICI). Intracortical facilitation (ICF) was assessed via twenty-five 10 msec ISI paired-pulse MEPs. Gene variants encoding for excitatory and inhibitory neuroreceptors were determined via saliva samples. Predetermined thresholds and statistical cluster analyses were used to subgroup individuals. Results: Two distinct subgroups were identified, "responders" reducing CSE following c-tDCS and "nonresponders" showing no reduction or even increase in CSE. Differences in CSE between responders and nonresponders following c-tDCS were not explained by changes in SICI or ICF. Conclusions: No significant relationships were reported between gene variants and interindividual variability to c-tDCS, suggesting that the chosen gene variants did not influence the activity of the neuroreceptors involved in eliciting changes in CSE in responders following c-tDCS. In this largest c-tDCS study of its kind, novel insights were reported into the contribution genetic factors may play in observed interindividual variability to c-tDCS. Impact statement This study adds insight into the issue of interindividual variability to c-tDCS. It highlights not all individuals respond to c-tDCS similarly when exposed to the same stimulus parameters. This disparity in response to c-tDCS between individuals does not appear to be genetically mediated. For c-tDCS to progress to large-scale clinical application, reliability, predictability and reproducibility are essential. Systematically investigating factors contributing to interindividual variability take steps towards this progress the c-tDCS field towards the potential development of screening tools to determine clinical suitability to c-tDCS to ensure its application in those who may benefit the most.

Menstrual Cycle Variations in Gray Matter Volume, White Matter Volume and Functional Connectivity: Critical Impact on Parietal Lobe

The role of gonadal hormones in neural plasticity remains unclear. This study aimed to examine the effects of naturally fluctuating hormone levels over the menstrual cycle in healthy females. Gray matter, functional connectivity (FC) and white matter changes over the cycle were assessed by using functional magnetic resonance imaging (fMRI), resting state fMRI, and structural MRIs, respectively, and associated with serum gonadal hormone levels. Moreover, electrocutaneous sensitivity was evaluated in 14 women in four phases of their menstrual cycle (menstrual, follicular, ovulatory, and luteal). Electrocutaneous sensitivity was greater during follicular compared to menstrual phase. Additionally, pain unpleasantness was lower in follicular phase than other phases while pain intensity ratings did not change over the cycle. Significant variations in cycle phase effects on gray matter volume were found in the left inferior parietal lobule (IPL) using voxel-based morphometry. Subsequent Freesurfer analysis revealed greater thickness of left IPL during the menstrual phase when compared to other phases. Also, white matter volume fluctuated across phases in left IPL. Blood estradiol was positively correlated with white matter volume both in left parietal cortex and whole cortex. Seed-driven FC between left IPL and right secondary visual cortex was enhanced during ovulatory phase. A seed placed in right IPL revealed enhanced FC between left and right IPL during the ovulatory phase. Additionally, we found that somatosensory cortical gray matter was thinner during follicular compared to menstrual phase. We discuss these results in the context of likely evolutionary pressures selecting for enhanced perceptual sensitivity across modalities specifically during ovulation.

Parallel modulation of intracortical excitability of somatosensory and visual cortex by the gonadal hormones estradiol and progesterone

The levels of the gonadal hormones estradiol and progesterone vary throughout the menstrual cycle thereby affecting cognition, emotion, mood, and social behaviour. However, how these hormones modulate the balance of neural excitation and inhibition, which crucially regulate processing and plasticity, is not fully understood. We here used paired-pulse stimulation to investigate in healthy humans the action of low and high estradiol and progesterone on intracortical inhibition in somatosensory (SI) and visual cortex (V1). We found that paired-pulse suppression in both SI and VI depended on estradiol. During high estradiol levels, paired-pulse suppression was significantly reduced. No comparable effects were found for progesterone, presumably due to a confounding effect of estradiol. Also, no hormone level-depending effects were observed for single-pulse evoked SEPs (somatosensory evoked potentials) and VEPs (visual evoked potentials) indicating a specific hormonal action on intracortical processing. The results demonstrate that estradiol globally modulates the balance of excitation and inhibition of SI and VI cortex.

The effects of a single-session cathodal transcranial pulsed current stimulation on corticospinal excitability: A randomized sham-controlled double-blinded study

Transcranial pulsed current stimulation (tPCS) of the human motor cortex has received much attention in recent years. Although the effect of anodal tPCS with different frequencies has been investigated, the effect of cathodal tPCS (c-tPCS) has not been explored yet. Therefore, the aim of the present study was to investigate the effect of c-tPCS at 4 and 75 Hz frequencies on corticospinal excitability (CSE) and motor performance. In a randomized sham-controlled crossover design, fifteen healthy participants attended three experimental sessions and received either c-tPCS at 75 Hz, 4 Hz or sham with 1.5 mA for 15 min. Transcranial magnetic stimulation and grooved pegboard test were performed before, immediately after and 30 min after the completion of stimulation at rest. The findings indicate that c-tPCS at both 4 and 75 Hz significantly increased CSE compared to sham. Both c-tPCS at 75 and 4 Hz showed a significant increase in intracortical facilitation compared to sham, whereas the effect on short-interval intracortical inhibition was not significant. The c-tPCS at 4 Hz but not 75 Hz induced modulation of intracortical facilitation correlated with the CSE. Motor performance did not show any significant changes. These results suggest that, compared with sham stimulation, c-tPCS at both 4 and 75 Hz induces an increase in CSE.

Cortical Excitability by Transcranial Magnetic Stimulation as Biomarkers for Seizure Controllability in Temporal Lobe Epilepsy

OBJECTIVE

To investigate whether indicators of cortical excitability are good biomarkers of seizure controllability in temporal lobe epilepsy (TLE).

MATERIALS AND METHODS

Three groups of subjects were recruited: those with poorly controlled (PC) TLE (N = 41), well-controlled (WC) TLE (N = 71), and healthy controls (N = 44). Short- and long-latency recovery curves were obtained by paired-pulse transcranial magnetic stimulation. Linear mixed effect models were used to study the effects of group, interstimulus interval (ISI), and antiepileptic drugs on long-interval intracortical inhibition (LICI) and short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF).

RESULTS

The mixed effect model that did not incorporate antiepileptic drugs showed that group and ISI were significant factors for LICI and SICI/ICF. LICI in the healthy control group was greater than in the two epilepsy groups, and the difference was significant at ISIs of 50, 150, and 200 msec. In contrast, SICI/ICF in the PC group was greater than in the healthy control and WC groups, and the difference was significant at an ISI of 15 msec. However, due to large variance, it was difficult to identify a cutoff value with both good sensitivity and good specificity. Incorporating the information of antiepileptic drugs to the mixed effect model did not change the overall results.

CONCLUSIONS

Although LICI and SICI/ICF parameters were significantly different at the group level, they may not be suitable biomarkers for the controllability of TLE at the subject level.

Learning to Expect: Predicting Sounds During Movement Is Related to Sensorimotor Association During Listening

Sensory experiences, such as sound, often result from our motor actions. Over time, repeated sound-producing performance can generate sensorimotor associations. However, it is not clear how sensory and motor information are associated. Here, we explore if sensory prediction is associated with the formation of sensorimotor associations during a learning task. We recorded event-related potentials (ERPs) while participants produced index and little finger-swipes on a bespoke device, generating novel sounds. ERPs were also obtained as participants heard those sounds played back. Peak suppression was compared to assess sensory prediction. Additionally, transcranial magnetic stimulation (TMS) was used during listening to generate finger-motor evoked potentials (MEPs). MEPs were recorded before and after training upon hearing these sounds, and then compared to reveal sensorimotor associations. Finally, we explored the relationship between these components. Results demonstrated that an increased positive-going peak (e.g., P2) and a suppressed negative-going peak (e.g., N2) were recorded during action, revealing some sensory prediction outcomes (P2: p = 0.050, ηp2 = 0.208; N2: p = 0.001, ηp2 = 0.474). Increased MEPs were also observed upon hearing congruent sounds compared with incongruent sounds (i.e., associated to a finger), demonstrating precise sensorimotor associations that were not present before learning (Index finger: p < 0.001, ηp2 = 0.614; Little finger: p < 0.001, ηp2 = 0.529). Consistent with our broad hypotheses, a negative association between the MEPs in one finger during listening and ERPs during performance of the other was observed (Index finger MEPs and Fz N1 action ERPs; r = −0.655, p = 0.003). Overall, data suggest that predictive mechanisms are associated with the fine-tuning of sensorimotor associations.

Test-Retest Reliability of the Effects of Continuous Theta-Burst Stimulation

OBJECTIVES

The utility of continuous theta-burst stimulation (cTBS) as index of cortical plasticity is limited by inadequate characterization of its test-retest reliability. We thus evaluated the reliability of cTBS aftereffects, and explored the roles of age and common single-nucleotide polymorphisms in the brain-derived neurotrophic factor (BDNF) and apolipoprotein E (APOE) genes.

METHODS

Twenty-eight healthy adults (age range 21-65) underwent two identical cTBS sessions (median interval = 9.5 days) targeting the motor cortex. Intraclass correlation coefficients (ICCs) of the log-transformed, baseline-corrected amplitude of motor evoked potentials (ΔMEP) at 5-60 min post-cTBS (T5-T60) were calculated. Adjusted effect sizes for cTBS aftereffects were then calculated by taking into account the reliability of each cTBS measure.

RESULTS

ΔMEP at T50 was the most-reliable cTBS measure in the whole sample (ICC = 0.53). Area under-the-curve (AUC) of ΔMEPs was most reliable when calculated over the full 60 min post-cTBS (ICC = 0.40). cTBS measures were substantially more reliable in younger participants (< 35 years) and in those with BDNF Val66Val and APOE ε4- genotypes.

CONCLUSION

cTBS aftereffects are most reliable when assessed 50 min post-cTBS, or when cumulative ΔMEP measures are calculated over 30-60 min post-cTBS. Reliability of cTBS aftereffects is influenced by age, and BDNF and APOE polymorphisms. Reliability coefficients are used to adjust effect-size calculations for interpretation and planning of cTBS studies.

Neurophysics Assessment of the Muscle Bioenergy Generated by Transcranial Magnetic Stimulation

The content of the rectified motor evoked potential (MEP) induced by transcranial magnetic stimulation (TMS) has ambiguously been assessed without the precision that energy calculation deserves. This fact has misled data interpretation and misguided biomedical interventions. To definitively fill the gap that exits in the neurophysics processing of these signals, we computed, in Walls (W^), the bioenergy within the rectified MEP recorded from the human first digitorum index (FDI) muscle at rest and under isometric contraction. We also gauged the biowork exerted by this muscle. Here we show that bioenergy and biowork can accurately and successfully be assessed, validated, and determined in W^ from MEP signals induced by TMS, regardless of knowing the mathematical expression of the function of the signal. Our novel neurophysics approach represents a dramatic paradigm shift in analysis and interpretation of the content of the MEP and will give a true meaning to the content of rectified signals. Importantly, this innovative approach allowed unveiling that women exerted more bioenergy than men at the magnetic stimulations used in this study. Revisitation of conclusions drawn from studies published elsewhere assessing rectified EMG signals that have used ambiguous units is strongly recommended.

Neurophysics Assessment of the Muscle Bioenergy Generated by Transcranial Magnetic Stimulation

The content of the rectified motor evoked potential (MEP) induced by transcranial magnetic stimulation (TMS) has ambiguously been assessed without the precision that energy calculation deserves. This fact has misled data interpretation and misguided biomedical interventions. To definitively fill the gap that exits in the neurophysics processing of these signals, we computed, in Walls (W ^ ), the bioenergy within the rectified MEP recorded from the human first digitorum index (FDI) muscle at rest and under isometric contraction. We also gauged the biowork exerted by this muscle. Here we show that bioenergy and biowork can accurately and successfully be assessed, validated, and determined inW ^ from MEP signals induced by TMS, regardless of knowing the mathematical expression of the function of the signal. Our novel neurophysics approach represents a dramatic paradigm shift in analysis and interpretation of the content of the MEP and will give a true meaning to the content of rectified signals. Importantly, this innovative approach allowed unveiling that women exerted more bioenergy than men at the magnetic stimulations used in this study. Revisitation of conclusions drawn from studies published elsewhere assessing rectified EMG signals that have used ambiguous units is strongly recommended.

Biological and anatomical factors influencing interindividual variability to noninvasive brain stimulation of the primary motor cortex: a systematic review and meta-analysis

Noninvasive brain stimulation (NIBS) modifies corticospinal excitability (CSE) historically in a predictable manner dependent on stimulation parameters. Researchers, however, discuss high degrees of variability between individuals, either responding as expected or not responding as expected. The explanation for this interindividual variability remains unknown with suggested interplay between stimulation parameters and variations in biological, anatomical, and physiological factors. This systematic review and meta-analysis aimed to investigate the effect of variation in inherent factors within an individual (biological and anatomical factors) on CSE in response to NIBS of the primary motor cortex. Twenty-two studies were included investigating genetic variation (n=7), age variation (n=4), gender variation (n=7), and anatomical variation (n=5). The results indicate that variation in brain-derived neurotrophic factor genotypes may have an effect on CSE after NIBS. Variation between younger and older adults also affects CSE after NIBS. Variation between age-matched males and females does not affect CSE after NIBS, but variation across the menstrual cycle does. Variation between skull thickness and brain tissue morphology influences the electric field magnitude that ultimately reaches the primary motor cortex. These findings indicate that biological and anatomical variations may in part account for interindividual variability in CSE in response to NIBS of the primary motor cortex, categorizing individuals as responding as expected (responders) or not responding as expected (nonresponders).

Peak visual gamma frequency is modified across the healthy menstrual cycle

Fluctuations in gonadal hormones over the course of the menstrual cycle are known to cause functional brain changes and are thought to modulate changes in the balance of cortical excitation and inhibition. Animal research has shown this occurs primarily via the major metabolite of progesterone, allopregnanolone, and its action as a positive allosteric modulator of the GABAA receptor. Our study used EEG to record gamma oscillations induced in the visual cortex using stationary and moving gratings. Recordings took place during twenty females' mid-luteal phase when progesterone and estradiol are highest, and early follicular phase when progesterone and estradiol are lowest. Significantly higher (∼5 Hz) gamma frequency was recorded during the luteal compared to the follicular phase for both stimuli types. Using dynamic causal modeling, these changes were linked to stronger self-inhibition of superficial pyramidal cells in the luteal compared to the follicular phase. In addition, the connection from inhibitory interneurons to deep pyramidal cells was found to be stronger in the follicular compared to the luteal phase. These findings show that complex functional changes in synaptic microcircuitry occur across the menstrual cycle and that menstrual cycle phase should be taken into consideration when including female participants in research into gamma-band oscillations.

Long-interval intracortical inhibition as biomarker for epilepsy: a transcranial magnetic stimulation study

Cortical excitability, as measured by transcranial magnetic stimulation combined with electromyography, is a potential biomarker for the diagnosis and follow-up of epilepsy. We report on long-interval intracortical inhibition data measured in four different centres in healthy controls (n = 95), subjects with refractory genetic generalized epilepsy (n = 40) and with refractory focal epilepsy (n = 69). Long-interval intracortical inhibition was measured by applying two supra-threshold stimuli with an interstimulus interval of 50, 100, 150, 200 and 250 ms and calculating the ratio between the response to the second (test stimulus) and to the first (conditioning stimulus). In all subjects, the median response ratio showed inhibition at all interstimulus intervals. Using a mixed linear-effects model, we compared the long-interval intracortical inhibition response ratios between the different subject types. We conducted two analyses; one including data from the four centres and one excluding data from Centre 2, as the methods in this centre differed from the others. In the first analysis, we found no differences in long-interval intracortical inhibition between the different subject types. In all subjects, the response ratios at interstimulus intervals 100 and 150 ms showed significantly more inhibition than the response ratios at 50, 200 and 250 ms. Our second analysis showed a significant interaction between interstimulus interval and subject type (P = 0.0003). Post hoc testing showed significant differences between controls and refractory focal epilepsy at interstimulus intervals of 100 ms (P = 0.02) and 200 ms (P = 0.04). There were no significant differences between controls and refractory generalized epilepsy groups or between the refractory generalized and focal epilepsy groups. Our results do not support the body of previous work that suggests that long-interval intracortical inhibition is significantly reduced in refractory focal and genetic generalized epilepsy. Results from the second analysis are even in sharper contrast with previous work, showing inhibition in refractory focal epilepsy at 200 ms instead of facilitation previously reported. Methodological differences, especially shorter intervals between the pulse pairs, may have contributed to our inability to reproduce previous findings. Based on our results, we suggest that long-interval intracortical inhibition as measured by transcranial magnetic stimulation and electromyography is unlikely to have clinical use as a biomarker of epilepsy.

Transcallosal conduction in paroxysmal kinesigenic dyskinesia

OBJECTIVES

Detecting whether a possible disequilibrium between the excitatory and inhibitory interhemispheric interactions in paroxysmal kinesigenic dyskinesia (PKD) exists.

METHODS

This study assessed measures of motor threshold, motor evoked potential latency, the cortical silent period, the ipsilateral silent period and the transcallosal conduction time (TCT) in PKD patients. Data were compared between the clinically affected hemisphere (aH) and the fellow hemisphere (fH).

RESULTS

The transcallosal conduction time from the aH to the fH was 11.8 ms (range = 2.3-20.7) and 13.6 ms (range = 2.8-67.7) from the fH to the aH. The difference in TCT in the affected side was significant (p = .019).

CONCLUSION

The findings demonstrated that, although inhibitory interneurons act normally and symmetrically between the motor cortices and transcallosal inhibition was normal and symmetrical between both sides, the onset of transcallosal inhibition was asymmetrical. The affected hemisphere's inhibition toward the unaffected hemisphere is faster compared to the inhibition provided by the fellow hemisphere. These results are consistent with an inhibitory deficit in the level of interhemispheric interactions.

SIGNIFICANCE

This study revealed a defect in inhibition of the motor axis could be responsible in the pathological mechanisms of kinesigenic dyskinesia.

The duration of the cortical silent period is not abnormal in Restless Legs Syndrome/Willis-Ekbom Disease

OBJECTIVE

To compare the duration of the cortical silent period (CSP) measured in a hand muscle in subjects with primary Restless Legs Syndrome (RLS/WED) and controls, using four different methods of analysis.

METHODS

The CSP to transcranial magnetic stimulation of the dominant motor cortex was assessed in the abductor digiti minimi of 33 subjects with RLS/WED and 24 controls. CSP duration was measured by an automated and three visually-guided methods.

RESULTS

There were significant differences between absolute values of CSP duration according to the method of analysis. However, irrespectively of the method used for CSP assessment, no differences were found between measurements performed in subjects with RLS/WED and subjects from the control group.

CONCLUSIONS

Absolute values of CSP durations analyzed by different methods should not be directly compared, because significantly different results can be obtained from the same data set.

SIGNIFICANCE

The CSP assessed from a hand muscle is unlikely to be a biomarker of primary RLS/WED. Our results highlight the importance of standardizing the definition of CSP onset and offset, as well as of describing in detail the methodology chosen to record and measure CSP duration, in order to enable comparisons between studies.

Repeatability of long intracortical inhibition in healthy subjects

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LICI repeatability showed a large variation at the subject level and ISI level.

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Good repeatability at group level decreased when including inter-subject variation.

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Added value of robot-guided coil positioning seems limited for paired pulse TMS.

Objectives

Transcranial magnetic stimulation (TMS) is widely used to assess cortical excitability. To detect changes in excitability with longitudinal studies, it is important to validate the repeatability of excitability measures within a subject between different sessions. Repeatability studies on long intracortical inhibition (LICI) are limited and reported agreement ranges from poor to good. This study aims to evaluate the repeatability of LICI in healthy subjects using paired pulse TMS. In addition, it investigates whether LICI repeatability differs for manual and robot-guided coil positioning.

Methods

Thirty healthy subjects (10 males, mean age 28.4 ± 8.2 years) were studied twice, approximately one week apart. Both motor cortices were stimulated with 50 paired pulses (intensity 120% of resting motor threshold) at interstimulus intervals (ISIs): 50, 100, 150, 200, 250 and 300 ms. In twenty subjects a figure-of-eight coil was positioned and held in place manually during both sessions, while in ten subjects a robot-navigated arm was used. LICI repeatability was assessed using the intraclass correlation coefficient (ICC).

Results

For manual and robot-guided coil positioning we found a large variation in repeatability at the subject level and ISI level, ranging from poor to good agreement. On a group level, we found good repeatability for averaged LICI curves (manual: ICC = 0.91, robot-guided: ICC = 0.95), which decreased when individual curves were correlated between sessions (manual: ICC = 0.76, robot-guided: ICC = 0.84).

Conclusion

For a correct interpretation of longitudinal study outcomes it is important to know the subject specific LICI repeatability and to analyze each ISI individually. Furthermore, the added value of robot-guided coil positioning for paired pulse TMS seems limited.

Significance

The large variation in LICI repeatability at the subject level and ISI level should be taken into account in longitudinal studies, while robot-guided coil positioning seems unnecessary.

GABA+ levels in postmenopausal women with mild-to-moderate depression: A preliminary study

BACKGROUND

It is increasingly being recognized that alterations of the GABAergic system are implicated in the pathophysiology of depression. This study aimed to explore in vivo gamma-aminobutyric acid (GABA) levels in the anterior cingulate cortex/medial prefrontal cortex (ACC/mPFC) and posterior-cingulate cortex (PCC) of postmenopausal women with depression using magnetic resonance spectroscopy (H-MRS).

METHODS

Nineteen postmenopausal women with depression and thirteen healthy controls were enrolled in the study. All subjects underwent H-MRS of the ACC/mPFC and PCC using the "MEGA Point Resolved Spectroscopy Sequence" (MEGA-PRESS) technique. The severity of depression was assessed by 17-item Hamilton Depression Scale (HAMD). Quantification of MRS data was performed using Gannet program. Differences of GABA+ levels from patients and controls were tested using one-way analysis of variance. Spearman correlation coefficients were used to evaluate the linear associations between GABA+ levels and HAMD scores, as well as estrogen levels.

RESULTS

Significantly lower GABA+ levels were detected in the ACC/mPFC of postmenopausal women with depression compared to healthy controls (P = 0.002). No significant correlations were found between 17-HAMD/14-HAMA and GABA+ levels, either in ACC/mPFC (P = 0.486; r = 0.170/P = 0.814; r = -0.058) or PCC (P = 0.887; r = 0.035/ P = 0.987; r = -0.004) in the patients; there is also no significant correlation between GABA+ levels and estrogen levels in patients group (ACC/mPFC: P = 0.629, r = -0.018; PCC: P = 0.861, r = 0.043).

CONCLUSION

Significantly lower GABA+ levels were found in the ACC/mPFC of postmenopausal women with depression, suggesting that the dysfunction of the GABAergic system may also be involved in the pathogenesis of depression in postmenopausal women.

The Effects of Sex Hormonal Fluctuations during Menstrual Cycle on Cortical Excitability and Manual Dexterity (a Pilot Study)

AIM

To investigate whether hormonal fluctuations during the menstrual cycle affect corticospinal excitability, intracortical inhibition (ICI) or facilitation (ICF) in primary motor cortex, and also whether the hormonal fluctuations have any effect on manual dexterity in neurologically intact women.

MATERIALS AND METHODS

Twenty volunteers (10 Female, 10 Male) were included in this study. The levels of progesterone and estradiol were measured from saliva during the women's menstrual follicular, ovulation and mid-luteal phases. Motor evoked potentials were recorded from the right first dorsal interosseous muscle. Single and paired-pulse Transcranial Magnetic Stimulation (TMS) were delivered in a block of 20 stimuli. With paired-pulse technique, 3ms and 10ms inter-stimulus intervals were used to assess ICI and ICF, respectively. The Grooved Pegboard Test (GPT) was completed in each session before the TMS assessments. Male participants were tested at similar time intervals as female participants.

RESULTS

Mixed design ANOVA revealed that GPT score in female participants was significantly lower at the mid-luteal phase compared to the ovulation phase (p = 0.017). However, it was not correlated with progesterone or estrogen fluctuations during the menstrual cycle. The results also showed that the effect of phase, sex and the interaction of phase by sex for resting motor threshold, ICI or ICF were not significant (p > 0.05).

CONCLUSION

Manual dexterity performance fluctuates during the menstrual cycle in neurologically intact women, which might be due to the balance of the neuromodulatory effects of P4 and E2 in the motor cortex during different phases.

Mental imagery-induced attention modulates pain perception and cortical excitability

Background

Mental imagery is a powerful method of altering brain activity and behavioral outcomes, such as performance of cognition and motor skills. Further, attention and distraction can modulate pain-related neuronal networks and the perception of pain. This exploratory study examined the effects of mental imagery-induced attention on pressure pain threshold and cortical plasticity using transcranial magnetic stimulation (TMS). This blinded, randomized, and parallel-design trial comprised 30 healthy right-handed male subjects. Exploratory statistical analyses were performed using ANOVA and t-tests for pain and TMS assessments. Pearson’s correlation was used to analyze the association between changes in pain threshold and cortical excitability.

Results

In the analysis of pain outcomes, there was no significant interaction effect on pain between group versus time. In an exploratory analysis, we only observed a significant effect of group for the targeted left hand (ANOVA with pain threshold as the dependent variable and time and group as independent variables). Although there was only a within-group effect of mental imagery on pain, further analyses showed a significant positive correlation of changes in pain threshold and cortical excitability (motor-evoked potentials via TMS).

Conclusions

Mental imagery has a minor effect on pain modulation in healthy subjects. Its effects appear to differ compared with chronic pain, leading to a small decrease in pain threshold. Assessments of cortical excitability confirmed that these effects are related to the modulation of pain-related cortical circuits. These exploratory findings suggest that neuronal plasticity is influenced by pain and that the mental imagery effects on pain depend on the state of central sensitization.

Systematic review of gamma-aminobutyric-acid inhibitory deficits across the reproductive life cycle

Deficiencies in the inhibitory functioning of gamma-aminobutyric acid (GABA) have been implicated in the pathophysiology of depressive disorders. Reproductive life cycle events, including menstruation, pregnancy, and menopause, are consistently associated with increased psychopathology, in particular mood disorders. Given that GABA-inhibitory activity may be modulated directly or indirectly by estrogen, progesterone, and their metabolites receptors, it has been hypothesized that GABA deficits may be evident during these reproductive periods. We aimed to compare GABA function among women during these "high-risk" reproductive periods to GABA function among women at other time periods. We conducted a systematic review of studies comparing women during reproductive life stages associated with depressive disorder risk (luteal phase of the menstrual cycle, perinatal period, and menopausal transition) to women at other time periods. The study outcome was GABA function. The review included 11 studies, 9 focused on the menstrual cycle, and 2 focused on the perinatal period. GABA-inhibitory function fluctuated across the menstrual cycle, with differing patterns in women with and without depressive disorders. GABA-inhibitory function was reduced in pregnancy and early postpartum compared to the nonpregnant state. Key limitations were the absence of studies evaluating the menopausal transition, and the heterogeneity of GABA outcome measures. GABA-inhibitory function fluctuates across the menstrual cycle and is reduced perinatally. This has potential implications for a role of GABAergically mediated interventions in the prevention and treatment of menstrual cycle-related and perinatal depressive disorders.

CORTICAL EXCITABILITY AS A POTENTIAL CLINICAL MARKER OF EPILEPSY: A REVIEW OF THE CLINICAL APPLICATION OF TRANSCRANIAL MAGNETIC STIMULATION

Transcranial magnetic stimulation (TMS) can be used for safe, noninvasive probing of cortical excitability (CE). We review 50 studies that measured CE in people with epilepsy. Most showed cortical hyperexcitability, which can be corrected with anti-epileptic drug treatment. Several studies showed that decrease of CE after epilepsy surgery is predictive of good seizure outcome. CE is a potential biomarker for epilepsy. Clinical application may include outcome prediction of drug treatment and epilepsy surgery.

Are patterns of cortical hyperexcitability altered in catamenial epilepsy?

OBJECTIVE

We used transcranial magnetic stimulation to determine menstrual cycle-related changes in cortical excitability in women with and without catamenial epilepsy and investigated whether these changes differed between ovulatory and anovulatory cohorts.

METHODS

Healthy nonepilepsy women and women with generalized and focal epilepsy were investigated during ovulatory (n=11, 46, and 43, respectively) and anovulatory (n=9, 42, and 41) cycles. Patients were divided based on seizure pattern into catamenial (C1=perimenstrual, C2=periovulatory, C3=luteal seizure exacerbation), noncatamenial, and seizure free. Cortical excitability was assessed using motor threshold (MT) and paired pulse stimulation at short (2-15 milliseconds) and long (100-300 milliseconds) interstimulus intervals twice, at the (1) late follicular and (2) mid luteal phases of the menstrual cycle.

RESULTS

In controls, cortical excitability was greatest in the follicular study, where intracortical facilitation was increased (p<0.05). The opposite was seen in women with epilepsy, where intracortical facilitation was greatest and intracortical inhibition was least in the luteal studies (p<0.05). There were no differences between the ovulatory and anovulatory groups in any of the cohorts. No changes were observed in MT.

INTERPRETATION

Nonhormonal factors are involved in the cyclicity of cortical excitability across the menstrual cycle. Normal menstrual cycle variations in cortical excitability are altered in a similar pattern in ovulatory and anovulatory women with epilepsy regardless of seizure patterns. The underlying neural changes associated with epilepsy may alter responses to sex hormones. This may be an important underlying mechanism for catamenial seizure clustering.

Inter- and intraobserver variability in motor mapping of the hotspot for the abductor policis brevis muscle

Background

For accuracy in navigated transcranial magnetic stimulation (nTMS), determination of the hotspot location of small hand muscles is crucial because it is the basis for the resting motor threshold (RMT) and, therefore, its spatial resolution. We investigated intra- and interobserver differences of hotspot mapping to provide evidence for the reproducibility of this method.

Ten subjects underwent nTMS motor mapping of the hotspot for the abductor pollicis brevis muscle (APB) three times. The first two sessions were performed by the same examiner; the third mapping was performed by a different examiner. Distances between the first and second mappings (intraobserver variability) and between the second and third mappings (interobserver variability) were measured.

Results

Intraobserver variability had a mean of 8.1 ± 3.3 mm (limits of agreement (LOA) 1.7 to 14.6 mm), whereas mean interobserver variability was 10.3 ± 3.3 mm (LOA 3.8 to 16.7 mm). Concerning RMT, CCC was 0.725 (95% CI: 0.276; 0.914). The mean variability in the same cortical depth was measured as 5.7 ± 3.3 mm (LOA −0.7 to 12.2 mm) for intraobserver and 9.2 ± 3.3 mm (LOA 2.7 to 15.8 mm) for interobserver examinations. When evaluating the RMT, CCC was 0.709 (95% CI: 0.244; 0.909).

Conclusions

Overall, intraobserver variability showed higher reliability than interobserver variability. Our findings show that we can achieve good reliability in hotspot determination, ranging within the calculated precision of the system.

Diagnosis and management of catamenial seizures: a review

Catamenial epilepsy is defined as a pattern of seizures that changes in severity during particular phases of the menstrual cycle, wherein estrogens are proconvulsant, increasing the neuronal excitability; and progesterone is anticonvulsant, enhancing GABA-mediated inhibition. Thus, changes in serum estradiol/progesterone ratio throughout a normal reproductive cycle bring about an increased or decreased risk of seizure occurrence. To date, there are no specific drug treatments for catamenial epilepsy however, non-hormonal and hormonal therapies have been proposed. The aim of this review is to report preclinical and clinical evidences about the relationship between female reproductive steroids and epileptic seizures, and to describe treatment approaches for catamenial epilepsy.

Analgesic effects of noninvasive brain stimulation in rodent animal models: a systematic review of translational findings

OBJECTIVES

Noninvasive brain stimulation (NIBS) interventions have demonstrated promising results in the clinical treatment of pain, according to several preliminary trials, although the results have been mixed. The limitations of clinical research on NIBS are the insufficient understanding of its mechanisms of action, a lack of adequate safety data, and several disparities with regard to stimulation parameters, which have hindered the generalizability of such studies. Thus, experimental animal research that allows the use of more invasive interventions and creates additional control of independent variables and confounders is desirable. To this end, we systematically reviewed animal studies investigating the analgesic effects of NIBS. In addition, we also explored the investigation of NIBS in animal models of stroke as to compare these findings with NIBS animal pain research.

METHODS

Of 1916 articles that were found initially, we identified 15 studies (stroke and pain studies) per our eligibility criteria that used NIBS methods, such as transcranial direct current stimulation, paired associative stimulation, transcranial magnetic stimulation, and transcranial electrostimulation. We extracted the main outcomes on stroke and pain, as well as the methods and electrical parameters of each technique.

RESULTS

NIBS techniques are effective in alleviating pain. Similar beneficial clinical effects are observed in stroke. The main insights from these animal studies are the following: 1) combination of NIBS with analgesic drugs has a synergistic effect; 2) effects are dependent on the parameters of stimulation, and in fact, not necessarily the strongest stimulation parameter (i.e., the largest intensity of stimulation) is associated with the largest benefit; 3) pain studies show an overall good quality as indexed by Animals in Research: Reporting In Vivo Experiments guidelines of the reporting of animal experiments, but insufficient with regard to the reporting of safety data for brain stimulation; 4) these studies suggest that NIBS techniques have a primary effect on synaptic plasticity, but they also suggest other mechanisms of action such as via neurovascular modulation.

CONCLUSIONS

We found a limited number of animal studies for both pain and stroke NIBS experimental research. There is a lack of safety data in animal studies in these two topics and results from these studies have not been yet fully tested and translated to human research. We discuss the challenges and limitations of translating experimental animal research on NIBS into clinical studies.

Dissociation of motor task-induced cortical excitability and pain perception changes in healthy volunteers

BACKGROUND

There is evidence that interventions aiming at modulation of the motor cortex activity lead to pain reduction. In order to understand further the role of the motor cortex on pain modulation, we aimed to compare the behavioral (pressure pain threshold) and neurophysiological effects (transcranial magnetic stimulation (TMS) induced cortical excitability) across three different motor tasks.

METHODOLOGY/PRINCIPAL FINDINGS

Fifteen healthy male subjects were enrolled in this randomized, controlled, blinded, cross-over designed study. Three different tasks were tested including motor learning with and without visual feedback, and simple hand movements. Cortical excitability was assessed using single and paired-pulse TMS measures such as resting motor threshold (RMT), motor-evoked potential (MEP), intracortical facilitation (ICF), short intracortical inhibition (SICI), and cortical silent period (CSP). All tasks showed significant reduction in pain perception represented by an increase in pressure pain threshold compared to the control condition (untrained hand). ANOVA indicated a difference among the three tasks regarding motor cortex excitability change. There was a significant increase in motor cortex excitability (as indexed by MEP increase and CSP shortening) for the simple hand movements.

CONCLUSIONS/SIGNIFICANCE

Although different motor tasks involving motor learning with and without visual feedback and simple hand movements appear to change pain perception similarly, it is likely that the neural mechanisms might not be the same as evidenced by differential effects in motor cortex excitability induced by these tasks. In addition, TMS-indexed motor excitability measures are not likely good markers to index the effects of motor-based tasks on pain perception in healthy subjects as other neural networks besides primary motor cortex might be involved with pain modulation during motor training.

Abnormal motor cortex excitability is associated with reduced cortical thickness in X monosomy

Turner syndrome (TS) is a noninherited genetic disorder caused by the absence of one or part of one X chromosome. It is characterized by physical and cognitive phenotypes that include motor deficits that may be related to neuroanatomical abnormalities of sensorimotor pathways. Here, we used transcranial magnetic stimulation (TMS) and cortical thickness analysis to assess motor cortex excitability and cortical morphology in 17 individuals with TS (45, X) and 17 healthy controls. Exploratory analysis was performed to detect the effect of parental origin of the X chromosome (X(mat), X(pat)) on both measures. Results showed that long-interval intracortical inhibition was reduced and motor threshold (MT) was increased in TS relative to controls. Areas of reduced thickness were observed in the precentral gyrus of individuals with TS that correlated with MT. A significant difference between X(mat) (n = 11) and X(pat) (n = 6) individuals was found on the measure of long-interval intracortical inhibition. These findings demonstrate the presence of converging anatomical and neurophysiological abnormalities of the motor system in X monosomy.

The effect of daily prefrontal repetitive transcranial magnetic stimulation over several weeks on resting motor threshold

BACKGROUND

The resting motor threshold (rMT) is an important factor in the selection of treatment intensity for patients receiving repetitive transcranial magnetic stimulation (rTMS). In many clinical studies to date, due to concerns about potential drift, the rMT has been routinely re-measured weekly or every fifth session.

OBJECTIVE

Our aim is to investigate whether ongoing treatment with rTMS affects the rMT, the degree of change, and whether frequent remeasurement is needed.

METHODS

Clinical data were drawn from 50 medication free patients receiving treatment for major depression with rTMS in a large U.S. NIH-sponsored multisite study. Four measurements of rMT were obtained including before and after the double blind phase, followed by weekly measurements during the open phase. Active treatment consisted of 75 four second trains of 10Hz stimulation applied over 37.5 minutes with the coil over the left DLPFC at 120% rMT.

RESULTS

For the group as a whole, there was no significant change in the rMT during a minimum of 2 weeks of treatment with prefrontal rTMS (p=0.911, one way ANOVA). The average within-subject coefficient of variation was 6.58%. On average the last rMT was 2.45% less than the baseline rMT (range 32.3% increase, 40.6% decrease).

CONCLUSION

Daily left prefrontal rTMS over several weeks as delivered in this trial does not cause systematic changes in rMT. While most subjects had <10% variance in rMT over time, 5 subjects had changes of approximately 20% from baseline, raising dosing and safety issues if undetected. We recommend that clinical trials of rTMS have periodic retesting of rMT, especially if the dose is at or near the edge of the TMS safety tables.

The role of neurosteroids in the pathophysiology and treatment of catamenial epilepsy

Catamenial epilepsy is a multifaceted neuroendocrine condition in which seizures are clustered around specific points in the menstrual cycle, most often around perimenstrual or periovulatory period. Generally, a twofold or greater increase in seizure frequency during a particular phase of the menstrual cycle could be considered as catamenial epilepsy. Based on this criteria, recent clinical studies indicate that catamenial epilepsy affects 31-60% of the women with epilepsy. Three types of catamenial seizures (perimenstrual, periovulatory and inadequate luteal) have been identified. However, there is no specific drug available today for catamenial epilepsy, which has not been successfully treated with conventional antiepileptic drugs. Elucidation of the pathophysiology of catamenial epilepsy is a prerequisite to develop specific targeted approaches for treatment or prevention of the disorder. Cyclical changes in the circulating levels of estrogens and progesterone play a central role in the development of catamenial epilepsy. There is emerging evidence that endogenous neurosteroids with anticonvulsant or proconvulsant effects could play a critical role in catamenial epilepsy. It is thought that perimenstrual catamenial epilepsy is associated with the withdrawal of anticonvulsant neurosteroids. Progesterone and other hormonal agents have been shown in limited trials to be moderately effective in catamenial epilepsy, but may cause endocrine side effects. Synthetic neurosteroids, which enhance the tonic GABA-A receptor function, might provide an effective approach for the catamenial epilepsy therapy without producing hormonal side effects.