Non-invasive Brain Stimulation: Probing Intracortical Circuits and Improving Cognition in the Aging Brain

Age-related changes in responsiveness to non-invasive brain stimulation neuroplasticity paradigms: A systematic review with meta-analysis

OBJECTIVES

We aimed to summarise and critically appraise the available evidence for the effect of age on responsiveness to non-invasive brain stimulation (NBS) paradigms delivered to the primary motor cortex.

METHODS

Four databases (Medline, Embase, PsycINFO and Scopus) were searched from inception to February 7, 2023. Studies investigating age group comparisons and associations between age and neuroplasticity induction from NBS paradigms were included. Only studies delivering neuroplasticity paradigms to the primary motor cortex and responses measured via motor-evoked potentials (MEPs) in healthy adults were considered.

RESULTS

39 studies, encompassing 40 experiments and eight NBS paradigms were included: paired associative stimulation (PAS; n = 12), repetitive transcranial magnetic stimulation (rTMS; n = 2), intermittent theta burst stimulation (iTBS; n = 8), continuous theta burst stimulation (cTBS; n = 7), transcranial direct and alternating current stimulation ((tDCS; n = 7; tACS; n = 2)), quadripulse stimulation (QPS; n = 1) and i-wave periodic transcranial magnetic stimulation (iTMS; n = 1). Pooled findings from PAS paradigms suggested older adults have reduced post-paradigm responses, although there was considerable heterogeneity. Mixed results were observed across all other NBS paradigms and post-paradigm timepoints.

CONCLUSIONS/SIGNIFICANCE

Whilst age-dependent reduction in corticospinal excitability is possible, there is extensive inter- and intra-individual variability both within and between studies, making it difficult to draw meaningful conclusions from pooled analyses.

Facilitation of working memory capacity by transcranial direct current stimulation: a secondary analysis from the augmenting cognitive training in older adults (ACT) study

Aging is a public health concern with an ever-increasing magnitude worldwide. An array of neuroscience-based approaches like transcranial direct current stimulation (tDCS) and cognitive training have garnered attention in the last decades to ameliorate the effects of cognitive aging in older adults. This study evaluated the effects of 3 months of bilateral tDCS over the frontal cortices with multimodal cognitive training on working memory capacity. Two hundred ninety-two older adults without dementia were allocated to active or sham tDCS paired with cognitive training. These participants received repeated sessions of bilateral tDCS over the bilateral frontal cortices, combined with multimodal cognitive training. Working memory capacity was assessed with the digit span forward, backward, and sequencing tests. No baseline differences between active and sham groups were observed. Multiple linear regressions indicated more improvement of the longest digit span backward from baseline to post-intervention (p = 0.021) and a trend towards greater improvement (p = 0.056) of the longest digit span backward from baseline to 1 year in the active tDCS group. No significant between-group changes were observed for digit span forward or digit span sequencing. The present results provide evidence for the potential for tDCS paired with cognitive training to remediate age-related declines in working memory capacity. These findings are sourced from secondary outcomes in a large randomized clinical trial and thus deserve future targeted investigation in older adult populations.

Low-frequency rTMS modulated the excitability and high-frequency firing in hippocampal neurons of the Alzheimer's disease mouse model

Repetitive transcranial magnetic stimulation (rTMS), a non-invasive brain stimulation technique, holds potential for applications in the treatment of Alzheimer's disease (AD). This study aims to compare the therapeutic effects of rTMS at different frequencies on Alzheimer's disease and explore the alterations in neuronal electrophysiological properties throughout this process. APP/PS1 AD mice were subjected to two rTMS treatments at 0.5 Hz and 20 Hz, followed by assessments of therapeutic outcomes through the Novel Object Recognition (NOR) and Morris Water Maze (MWM) tests. Following this, whole-cell patch-clamp techniques were used to record action potential, voltage-gated sodium channel currents, and voltage-gated potassium channel currents in dentate gyrus granule neurons. The results show that AD mice exhibit significant cognitive decline compared to normal mice, along with a pronounced reduction in neuronal excitability and ion channel activity. Both frequencies of rTMS treatment partially reversed these changes, demonstrating similar therapeutic efficacy. Furthermore, the investigation indicates that low-frequency magnetic stimulation inhibited the concentrated firing of early action potentials in AD.

Transcranial direct current stimulation for global cognition in Alzheimer's disease: a systemic review and meta-analysis

This meta-analysis was to investigate the efficacy of transcranial direct current stimulation (tDCS) for general cognitive function in Alzheimer's disease (AD) and to investigate the potential influential factors. A systematic literature retrieval until August 2023 was performed by searching the PubMed, Embase, Web of Science, and Cochrane Library. Therapeutic effects of tDCS were evaluated using standardized mean difference (SMD) and 95% confidence interval (CI). Pooled effects of tDCS on AD patients were calculated immediately after treatment and at follow-up periods. Subgroup analyses were conducted to identify the potential prognostic factors. Eleven studies with 12 trials including 451 cases were included in our systemic review, in which 9 studies with 10 trials using Mini-Mental State Examination (MMSE) scales were included in the meta-analysis. tDCS significantly improved global cognition in AD immediately after the treatment (SMD, 0.46; 95% CI, 0.25-0.66; P<0.0001), but not at the shorter or longer follow-up period. Subgroup analyses suggested significant global cognitive improvement in patients receiving stimulation on temporal lobes instead of left dorsolateral prefrontal cortex, and in cases receiving tDCS with current density ≥ 0.08 mA/cm2 rather than <0.08 mA/cm2. Compared with tDCS plus cognitive training (CT), tDCS without CT produced obvious cognitive enhancement. In addition, patients with lower education were more likely to benefit from tDCS. tDCS was effective in improving general cognition in AD after treatment. However, further randomized trials are warranted to validate its longer-term effects as well as our subgroup analyses results.

Mechanisms of multi-omics and network pharmacology to explain traditional chinese medicine for vascular cognitive impairment: A narrative review

BACKGROUND

The term "vascular cognitive impairment" (VCI) describes various cognitive conditions that include vascular elements. It increases the risk of morbidity and mortality in the elderly population and is the most common cognitive impairment associated with cerebrovascular disease. Understanding the etiology of VCI may aid in identifying approaches to target its possible therapy for the condition. Treatment of VCI has focused on vascular risk factors. There are no authorized conventional therapies available right now. The medications used to treat VCI are solely approved for symptomatic relief and are not intended to prevent or slow the development of VCI.

PURPOSE

The function of Chinese medicine in treating VCI has not yet been thoroughly examined. This review evaluates the preclinical and limited clinical evidence to comprehend the "multi-component, multi-target, multi-pathway" mechanism of Traditional Chinese medicine (TCM). It investigates the various multi-omics approaches in the search for the pathological mechanisms of VCI, as well as the new research strategies, in the hopes of supplying supportive evidence for the clinical treatment of VCI.

METHODS

This review used the Preferred Reporting Items for Preferred reporting items for systematic reviews and meta-analyses (PRISMA) statements. Using integrated bioinformatics and network pharmacology approaches, a thorough evaluation and analysis of 25 preclinical studies published up to July 1, 2023, were conducted to shed light on the mechanisms of TCM for vascular cognitive impairment. The studies for the systematic review were located using the following databases: PubMed, Web of Science, Scopus, Cochrane, and ScienceDirect.

RESULTS

We discovered that the multi-omics analysis approach would hasten the discovery of the role of TCM in the treatment of VCI. It will explore components, compounds, targets, and pathways, slowing the progression of VCI from the perspective of inhibiting oxidative stress, stifling neuroinflammation, increasing cerebral blood flow, and inhibiting iron deposition by a variety of molecular mechanisms, which have significant implications for the treatment of VCI.

CONCLUSION

TCM is a valuable tool for developing dementia therapies, and further research is needed to determine how TCM components may affect the operation of the neurovascular unit. There are still some limitations, although several research have offered invaluable resources for searching for possible anti-dementia medicines and treatments. To gain new insights into the molecular mechanisms that precisely modulate the key molecules at different levels during pharmacological interventions-a prerequisite for comprehending the mechanism of action and determining the potential therapeutic value of the drugs-further research should employ more standardized experimental methods as well as more sophisticated science and technology. Given the results of this review, we advocate integrating chemical and biological component analysis approaches in future research on VCI to provide a more full and objective assessment of the standard of TCM. With the help of bioinformatics, a multi-omics analysis approach will hasten the discovery of the role of TCM in the treatment of VCI, which has significant implications for the treatment of VCI.

Classification of cognitive impairment in older adults based on brain functional state measurement data via hierarchical clustering analysis

Introduction

Cognitive impairment (CI) is a common degenerative condition in the older population. However, the current methods for assessing CI are not based on brain functional state, which leads to delayed diagnosis, limiting the initiatives towards achieving early interventions.

Methods

A total of one hundred and forty-nine community-dwelling older adults were recruited. Montreal Cognitive Assessment (MoCA) and Mini-Mental State Exam (MMSE) were used to screen for CI, while brain functional was assessed by brain functional state measurement (BFSM) based on electroencephalogram. Bain functional state indicators associated with CI were selected by lasso and logistic regression models (LRM). We then classified the CI participants based on the selected variables using hierarchical clustering analysis.

Results

Eighty-one participants with CI detected by MoCA were divided into five groups. Cluster 1 had relatively lower brain functional states. Cluster 2 had highest mental task-switching index (MTSi, 13.7 ± 3.4), Cluster 3 had the highest sensory threshold index (STi, 29.9 ± 7.7), Cluster 4 had high mental fatigue index (MFi) and cluster 5 had the highest mental refractory period index (MRPi), and external apprehension index (EAi) (21.6 ± 4.4, 35.4 ± 17.7, respectively). Thirty-three participants with CI detected by MMSE were divided into 3 categories. Cluster 1 had the highest introspective intensity index (IIi, 63.4 ± 20.0), anxiety tendency index (ATi, 67.2 ± 13.6), emotional resistance index (ERi, 50.2 ± 11.9), and hypoxia index (Hi, 41.8 ± 8.3). Cluster 2 had the highest implicit cognitive threshold index (ICTi, 87.2 ± 12.7), and cognitive efficiency index (CEi, 213.8 ± 72.0). Cluster 3 had higher STi. The classifications both showed well intra-group consistency and inter-group variability.

Conclusion

In our study, BFSM-based classification can be used to identify clinically and brain-functionally relevant CI subtypes, by which clinicians can perform personalized early rehabilitation.

Transcranial direct current stimulation over dorsolateral prefrontal cortex improves postural stability in non-specific chronic low back pain patients with high fear of pain: A randomized sham-controlled trial

Deficits in postural stability in response to environmental challenges are seen in chronic low back pain (CLBP) patients with high fear of pain (HFP). Hence, it is essential to follow effective approaches to treat postural stability deficits and improve the health status of these patients. The current study aimed to compare the effects of cathodal and anodal transcranial direct current stimulation (c-tDCS and a-tDCS) over the left dorsolateral prefrontal cortex (DLPFC) on postural stability in non-specific CLBP patients with HFP. In this randomized clinical trial study, 75 patients were randomly assigned to left DLPFC a-tDCS, left DLPFC c-tDCS and sham stimulation groups (n = 25 in each group). All groups received a single-session 2 mA tDCS for 20 min, but the stimulation was slowly turned off after 30 s in the sham group. Before, immediately, 24 h and 1 week after the interventions, postural stability indices were assessed using a Biodex Balance System. A significant reduction in most indices was shown in both a-tDCS and c-tDCS groups after interventions (immediately, 24 h and 1 week follow-up) during static and dynamic postural tasks compared with the sham tDCS group (p < .01). In addition, some tests showed a significant difference between a-tDCS and c-tDCS (p < .05). The findings indicated positive effects of both a-tDCS and c-tDCS on the left DLPFC, with more efficacy of a-tDCS on postural stability in LBP patients with HFP.

Tackling seizures in patients with Alzheimer's disease

INTRODUCTION

In past years, a possible bidirectional link between epilepsy and Alzheimer's disease (AD) has been proposed: if AD patients are more likely to develop epilepsy, people with late-onset epilepsy evidence an increased risk of dementia. Furthermore, current research suggested that subclinical epileptiform discharges may be more frequent in patients with AD and network hyperexcitability may hasten cognitive impairment.

AREAS COVERED

In this narrative review, the authors discuss the recent evidence linking AD and epilepsy as well as seizures semeiology and epileptiform activity observed in patients with AD. Finally, anti-seizure medications (ASMs) and therapeutic trials to tackle seizures and network hyperexcitability in this clinical scenario have been summarized.

EXPERT OPINION

There is growing experimental evidence demonstrating a strong connection between seizures, neuronal hyperexcitability, and AD. Epilepsy in AD has shown a good response to ASMs both at the late and prodromal stages. The new generation ASMs with fewer cognitive adverse effects seem to be a preferable option. Data on the possible effects of network hyperexcitability and ASMs on AD progression are still inconclusive. Further clinical trials are mandatory to identify clear guidelines about treatment of subclinical epileptiform discharges in patients with AD without seizures.

Effects of excitatory transcranial magnetic stimulation over the different cerebral hemispheres dorsolateral prefrontal cortex for post-stroke cognitive impairment: a systematic review and meta-analysis

Background

Post-stroke cognitive impairment (PSCI) is a significant health concern. Transcranial magnetic stimulation (TMS) is considered a promising rehabilitation therapy for improving cognition, and the effects of excitatory TMS on PSCI have received much attention in recent years. However, the effects of different cerebral hemispheres on excitatory TMS treatment of cognitive impairment have not been studied. This review aimed to study the effects of excitatory TMS over the dorsolateral prefrontal cortex (DLPFC) of different cerebral hemispheres on the cognitive function of patients with PSCI.

Methods

Literature published in PubMed, Web of Science, Embase, Cochrane Library, Scopus, and Wiley from inception to September 30, 2022, were searched. Two researchers independently performed literature screening, data extraction, and quality assessment. Furthermore, we conducted a meta-analysis using RevMan software (version 5.4) and rated the strength of evidence using GRADEpro.

Results

A total of 19 studies were included in this meta-analysis. The results showed that excitatory TMS over the left hemisphere DLPFC was significantly better in improving global cognition (SMD = 2.26, 95% CI 1.67-2.86, P < 0.00001; vs. SMD = 2.53, 95% CI 1.86-3.20, P < 0.00001), memory (SMD = 1.29, 95% CI 0.72-1.87, P < 0.0001), attention (SMD = 2.32, 95% CI 1.64-3.01, P < 0.00001), executive (SMD = 0.64, 95% CI 0.21-1.07, P = 0.004), P300 latency (SMD = 2.69, 95% CI 2.13-3.25, P < 0.00001), and depression (SMD = 0.95, 95% CI 0.26-1.63, P = 0.007) than that of the control group, but the effect on improving activities of daily living (ADL) was unclear (P = 0.03 vs. P = 0.17). Subgroup analysis further showed that excitatory TMS over the right hemisphere DLPFC was effective in improving the global cognition of PSCI patients (P < 0.00001), but the stimulation effect over the ipsilateral hemisphere DLPFC was unclear (P = 0.11 vs. P = 0.003). Additionally, excitatory TMS over the ipsilateral hemisphere DLPFC showed no statistical difference in improving ADL between the two groups (P = 0.25).

Conclusions

Compared to other hemispheric sides, excitatory TMS over the left hemisphere DLPFC was a more effective stimulation area, which can significantly improved the global cognitive function, memory, attention, executive, P300 latency, and depression in patients with PSCI. There was no apparent therapeutic effect on improving activities of daily living (ADL). In the future, more randomized controlled trials with large-sample, high quality, and follow-up are necessary to explore a usable protocol further.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022369096.

Machine-learning defined precision tDCS for improving cognitive function

BACKGROUND

Transcranial direct current stimulation (tDCS) paired with cognitive training (CT) is widely investigated as a therapeutic tool to enhance cognitive function in older adults with and without neurodegenerative disease. Prior research demonstrates that the level of benefit from tDCS paired with CT varies from person to person, likely due to individual differences in neuroanatomical structure.

OBJECTIVE

The current study aims to develop a method to objectively optimize and personalize current dosage to maximize the functional gains of non-invasive brain stimulation.

METHODS

A support vector machine (SVM) model was trained to predict treatment response based on computational models of current density in a sample dataset (n = 14). Feature weights of the deployed SVM were used in a weighted Gaussian Mixture Model (GMM) to maximize the likelihood of converting tDCS non-responders to responders by finding the most optimum electrode montage and applied current intensity (optimized models).

RESULTS

Current distributions optimized by the proposed SVM-GMM model demonstrated 93% voxel-wise coherence within target brain regions between the originally non-responders and responders. The optimized current distribution in original non-responders was 3.38 standard deviations closer to the current dose of responders compared to the pre-optimized models. Optimized models also achieved an average treatment response likelihood and normalized mutual information of 99.993% and 91.21%, respectively. Following tDCS dose optimization, the SVM model successfully predicted all tDCS non-responders with optimized doses as responders.

CONCLUSIONS

The results of this study serve as a foundation for a custom dose optimization strategy towards precision medicine in tDCS to improve outcomes in cognitive decline remediation for older adults.

Working memory ımprovement after transcranial direct current stimulation paired with working memory training ın diabetic peripheral neuropathy

Association of cognitive deficits and diabetic peripheral neuropathy (DPN) is frequent. Working memory (WM) deficits result in impairment of daily activities, diminished functionality, and treatment compliance. Mounting evidence suggests that transcranial Direct Current Stimulation (tDCS) with concurrent working memory training (WMT) ameliorates cognitive deficits. Emboldening results of tDCS were shown in DPN. The study aimed to evaluate the efficacy of anodal tDCS over the left dorsolateral prefrontal cortex (DLPFC) coupled with cathodal right DLPFC with concurrent WMT in DPN for the first time. The present randomized triple-blind parallel-group sham-controlled study evaluated the efficacy of 5 sessions of tDCS over the DLPFC concurrent with WMT in 28 individuals with painful DPN on cognitive (primary) and pain-related, psychiatric outcome measures before, immediately after, and 1-month after treatment protocol. tDCS enhanced the efficacy of WMT on working memory and yielded lower anxiety levels than sham tDCS but efficacy was not superior to sham on other cognitive domains, pain severity, quality of life, and depression. tDCS with concurrent WMT enhanced WM and ameliorated anxiety in DPN without affecting other cognitive and pain-related outcomes. Further research scrutinizing the short/long-term efficacy with larger samples is accredited.

A comprehensive review of transcranial magnetic stimulation in secondary dementia

Although primary degenerative diseases are the main cause of dementia, a non-negligible proportion of patients is affected by a secondary and potentially treatable cognitive disorder. Therefore, diagnostic tools able to early identify and monitor them and to predict the response to treatment are needed. Transcranial magnetic stimulation (TMS) is a non-invasive neurophysiological technique capable of evaluating in vivo and in “real time” the motor areas, the cortico-spinal tract, and the neurotransmission pathways in several neurological and neuropsychiatric disorders, including cognitive impairment and dementia. While consistent evidence has been accumulated for Alzheimer’s disease, other degenerative cognitive disorders, and vascular dementia, to date a comprehensive review of TMS studies available in other secondary dementias is lacking. These conditions include, among others, normal-pressure hydrocephalus, multiple sclerosis, celiac disease and other immunologically mediated diseases, as well as a number of inflammatory, infective, metabolic, toxic, nutritional, endocrine, sleep-related, and rare genetic disorders. Overall, we observed that, while in degenerative dementia neurophysiological alterations might mirror specific, and possibly primary, neuropathological changes (and hence be used as early biomarkers), this pathogenic link appears to be weaker for most secondary forms of dementia, in which neurotransmitter dysfunction is more likely related to a systemic or diffuse neural damage. In these cases, therefore, an effort toward the understanding of pathological mechanisms of cognitive impairment should be made, also by investigating the relationship between functional alterations of brain circuits and the specific mechanisms of neuronal damage triggered by the causative disease. Neurophysiologically, although no distinctive TMS pattern can be identified that might be used to predict the occurrence or progression of cognitive decline in a specific condition, some TMS-associated measures of cortical function and plasticity (such as the short-latency afferent inhibition, the short-interval intracortical inhibition, and the cortical silent period) might add useful information in most of secondary dementia, especially in combination with suggestive clinical features and other diagnostic tests. The possibility to detect dysfunctional cortical circuits, to monitor the disease course, to probe the response to treatment, and to design novel neuromodulatory interventions in secondary dementia still represents a gap in the literature that needs to be explored.

Does transcranial direct current stimulation enhance cognitive performance in Parkinson's disease mild cognitive impairment? An event-related potentials and neuropsychological assessment study

BACKGROUND

Parkinson's disease-mild cognitive impairment (PD-MCI) is garnering attention as a key interventional period for cognitive impairment. Currently, there are no approved treatments for PD-MCI and encouraging results of transcranial direct current stimulation (tDCS) combined with other interventions have been proposed, though the efficacy and neural mechanisms of tDCS alone have not been studied in PD-MCI yet.

OBJECTIVES

The present double-blind, randomized, sham-controlled study assessed the effects of tDCS over the dorsolateral prefrontal cortex on cognitive functions via neuropsychological and electrophysiological evaluations in individuals with PD-MCI for the first time.

METHOD

Twenty-six individuals with PD-MCI were administered 10 sessions of active (n = 13) or sham (n = 13) prefrontal tDCS twice a day, for 5 days. Changes were tested through a comprehensive neuropsychological battery and event-related potential recordings, which were performed before, immediately, and 1 month after the administrations.

RESULTS

Neuropsychological assessment showed an improvement in delayed recall and executive functions in the active group. N1 amplitudes in response to targets in the oddball test-likely indexing attention and discriminability and NoGo N2 amplitudes in the continuous performance test-likely indexing cognitive control and conflict monitoring increased in the active group. Active stimulation elicited higher benefits 1 month after the administrations.

CONCLUSION

The present findings substantiate the efficacy of tDCS on cognitive control and episodic memory, along with the neural underpinnings of cognitive control, highlighting its potential for therapeutic utility in PD-MCI.

TRIAL REGISTRATION

NCT 04,171,804. Date of registration: 21/11/2019.

Improvement of poststroke cognitive impairment by intermittent theta bursts: A double-blind randomized controlled trial

BACKGROUND

Intermittent theta burst stimulation (iTBS) is known to improve cognitive impairment caused by Alzheimer's disease and Parkinson's disease, but studies are lacking with respect to the efficacy of iTBS on poststroke cognitive impairment (PSCI).

OBJECTIVE

This study was conducted to investigate the effect of left dorsolateral prefrontal cortex (DLPFC) iTBS on improving cognitive function in stroke patients.

METHODS

Fifty-eight patients with PSCI are randomly divided into iTBS (n = 28) and sham stimulation groups (n = 30). Both groups receive routine cognitive-related rehabilitation. The iTBS group is treated with iTBS intervention of the left DLPFC, and the sham stimulation group is treated with the same parameters at the same site for 2 weeks. Outcome measures are assessed at baseline (T0) and immediately after the last intervention (T1) by mini-mental state examination (MMSE), Oxford cognitive screen, and event-related potential P300.

RESULTS

There are no differences in baseline clinical characteristics between the two groups. After intervention, the MMSE scores and P300 amplitude increase significantly for both groups, and the P300 incubation period reduces significantly. The change value of the iTBS group is significantly higher than that of sham stimulation group (p < .05). Compared with the sham stimulation group, the iTBS group has more significant changes in semantic comprehension and executive function (p < .05).

CONCLUSION

iTBS can effectively and safely improve overall cognitive impairment in stroke patients, including semantic understanding and executive function, and it also has a positive impact on memory function. Future randomized controlled studies with large samples and long-term follow-up should be conducted to further validate the results of the present study.

A Neuroscience Primer for Integrating Geroscience With the Neurobiology of Aging

Neuroscience has a rich history of studies focusing on neurobiology of aging. However, much of the aging studies in neuroscience occur outside of the gerosciences. The goal of this primer is 2-fold: first, to briefly highlight some of the history of aging neurobiology and second, to introduce to geroscientists the broad spectrum of methodological approaches neuroscientists use to study the neurobiology of aging. This primer is accompanied by a corresponding geroscience primer, as well as a perspective on the current challenges and triumphs of the current divide across these 2 fields. This series of manuscripts is intended to foster enhanced collaborations between neuroscientists and geroscientists with the intent of strengthening the field of cognitive aging through inclusion of parameters from both areas of expertise.

Efficacy of non-invasive brain stimulation on global cognition and neuropsychiatric symptoms in Alzheimer's disease and mild cognitive impairment: A meta-analysis and systematic review

BACKGROUND

Non-invasive brain stimulation (NIBS) techniques have shown some promise in improving cognitive and neuropsychiatric symptoms (NPS) in people with Alzheimer's disease (AD) and its prodromal stage, mild cognitive impairment (MCI). However, data from clinical trials involving NIBS have shown inconsistent results. This meta-analysis investigated the efficacy of NIBS, specifically repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS) compared to sham stimulation on global cognition and NPS in people with AD and MCI.

METHOD

Multi-session randomized sham-controlled clinical trials were identified through MEDLINE, PsycINFO, and Embase until June 2021. Standardized mean difference (SMD) and 95% confidence interval (CI) between the active and sham treatments were calculated using random-effects meta-analyses. Included studies reported outcome measures for global cognition and/or NPS. Heterogeneity, from different NIBS techniques, disease populations, or tests used to assess global cognition or NPS, was measured using chi-square and I², and investigated using subgroup analyses. Possible effects of covariates were also investigated using meta-regressions.

RESULT

The pooled meta-analyses included 19 studies measuring global cognition (N_active=288, N_sham=264), and 9 studies investigating NPS (N_active=165, N_sham=140). NIBS significantly improved global cognition (SMD=1.14; 95% CI=0.49,1.78; p = 0.001; I² = 90.2%) and NPS (SMD=0.82; 95% CI=0.13, 1.50; p = 0.019; I² = 86.1%) relative to sham stimulation in patients with AD and MCI. Subgroup analyses found these effects were restricted to rTMS but not tDCS, and to patients with AD but not MCI. Meta-regression showed that age was significantly associated with global cognition response (N_studies=16, p = 0.020, I² = 89.51%, R² = 28.96%), with larger effects sizes in younger populations. All significant meta-analyses had large effect sizes (SMD ≥0.8), suggesting clinical utility of NIBS in the short term. There remained substantial heterogeneity across all subgroup analyses and meta-regressions (all I² > 50%). Egger's tests showed no evidence of publication biases.

CONCLUSION

rTMS improved global cognition and NPS in those with AD. Further studies in MCI and using tDCS will help to fully evaluate the specific NIBS techniques and populations most likely to benefit on global cognition and NPS measures. Additional research should investigate the long term clinical utility of NIBS in these populations.

Individualized tDCS modeling predicts functional connectivity changes within the working memory network in older adults

BACKGROUND

Working memory decline has been associated with normal aging. The frontal brain structure responsible for this decline is primarily located in the prefrontal cortex (PFC). Our previous neuroimaging study demonstrated a significant change in functional connectivity between the left dorsolateral PFC (DLPFC) and left ventrolateral PFC (VLPFC) when applying 2 mA tDCS in MRI scanner during an N-Back task. These regions were part of the working memory network. The present study is the first study that utilizes individualized finite element models derived from older adults' MRI to predict significant changes of functional connectivity observed from an acute tDCS application.

METHODS

Individualized head models from 15 healthy older adults (mean age = 71.3 years) were constructed to create current density maps. Each head model was segmented into 11 tissue types: white matter, gray matter, CSF, muscle, blood vessels, fat, eyes, air, skin, cancellous, and cortical bone. Electrodes were segmented from T1-weighted images and added to the models. Computed median and maximum current density values in the left DLPFC and left VLPFC regions of interest (ROIs) were correlated with beta values as functional connectivity metrics measured in different timepoint (baseline, during stimulation) and stimulation condition (active and sham).

MAIN RESULTS

Positive significant correlations (R2 = 0.523 for max J, R2 = 0.367 for median J, p < 0.05) were found between the beta values and computed current densities in the left DLPFC ROIs for active stimulation, but no significant correlation was found during sham stimulation. We found no significant correlation between connectivity and current densities computed in the left VLPFC for both active and sham stimulation.

CONCLUSIONS

The amount of current within the left DLPFC ROIs was found positively correlated with changes in functional connectivity between left DLPFC and left VLPFC during active 2 mA stimulation. Future work may include expansion of number of participants to further test the accuracy of tDCS models used to predict tDCS-induced functional connectivity changes within the working memory network.

Autonomic Modulation of Cardiac Arrhythmias: Methods to Assess Treatment and Outcomes

The autonomic nervous system plays a central role in the pathogenesis of multiple cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia. As such, autonomic modulation represents an attractive therapeutic approach in these conditions. Notably, autonomic modulation exploits the plasticity of the neural tissue to induce neural remodeling and thus obtain therapeutic benefit. Different forms of autonomic modulation include vagus nerve stimulation, tragus stimulation, renal denervation, baroreceptor activation therapy, and cardiac sympathetic denervation. This review seeks to highlight these autonomic modulation therapeutic modalities, which have shown promise in early preclinical and clinical trials and represent exciting alternatives to standard arrhythmia treatment. We also present an overview of the various methods used to assess autonomic tone, including heart rate variability, skin sympathetic nerve activity, and alternans, which can be used as surrogate markers and predictors of the treatment effect. Although the use of autonomic modulation to treat cardiac arrhythmias is supported by strong preclinical data and preliminary studies in humans, in light of the disappointing results of a number of recent randomized clinical trials of autonomic modulation therapies in heart failure, the need for optimization of the stimulation parameters and rigorous patient selection based on appropriate biomarkers cannot be overemphasized.

Repetitive Transcranial Magnetic Stimulation (rTMS) Reverses the Long-term Memory Impairment and the Decrease of Hippocampal Interleukin-10 Levels, both Induced by Neuropathic Pain in Rats

Neuropathic pain (NP) is characterized by the presence of spontaneous pain, allodynia and hyperalgesia. Repetitive transcranial magnetic stimulation (rTMS) is one of neuromodulatory techniques that induces satisfactory NP relief, including that from refractory pain patients. The objective of this study was to evaluate rTMS treatment over long term memory (LTM) and hippocampal BDNF and IL-10 levels in rats submitted to a NP model. A total of 81 adult (60-days old) male Wistar rats were randomly allocated to one of the following 9 experimental groups: control, control + sham rTMS, control + rTMS, sham neuropathic pain, sham neuropathic pain + sham rTMS, sham neuropathic pain + rTMS, neuropathic pain (NP), neuropathic pain + sham rTMS and neuropathic pain + rTMS. Fourteen days after the surgery for chronic constriction injury (CCI) of the sciatic nerve, NP establishment was accomplished. Then, rats were treated with daily 5-minute sessions of rTMS for eight consecutive days. LTM was assessed by the object recognition test (ORT) twenty-four hours after the end of rTMS treatment. Biochemical assays (BDNF and IL-10 levels) were performed in hippocampus tissue homogenates. rTMS treatment reversed the reduction of the discrimination index in the ORT and the hippocampal IL-10 levels in NP rats. This result shows that rTMS reverses the impairment LTM and the increase in the hippocampal IL-10 levels, both induced by NP. Moreover, it appears to be a safe non-pharmacological therapeutic tool since it did not alter LTM and neurochemical parameters in naive animals.

Age-related changes in motor cortex plasticity assessed with non-invasive brain stimulation: an update and new perspectives

It is commonly accepted that the brains capacity to change, known as plasticity, declines into old age. Recent studies have used a variety of non-invasive brain stimulation (NIBS) techniques to examine this age-related decline in plasticity in the primary motor cortex (M1), but the effects seem inconsistent and difficult to unravel. The purpose of this review is to provide an update on studies that have used different NIBS techniques to assess M1 plasticity with advancing age and offer some new perspective on NIBS strategies to boost plasticity in the ageing brain. We find that early studies show clear differences in M1 plasticity between young and older adults, but many recent studies with motor training show no decline in use-dependent M1 plasticity with age. For NIBS-induced plasticity in M1, some protocols show more convincing differences with advancing age than others. Therefore, our view from the NIBS literature is that it should not be automatically assumed that M1 plasticity declines with age. Instead, the effects of age are likely to depend on how M1 plasticity is measured, and the characteristics of the elderly population tested. We also suggest that NIBS performed concurrently with motor training is likely to be most effective at producing improvements in M1 plasticity and motor skill learning in older adults. Proposed NIBS techniques for future studies include combining multiple NIBS protocols in a co-stimulation approach, or NIBS strategies to modulate intracortical inhibitory mechanisms, in an effort to more effectively boost M1 plasticity and improve motor skill learning in older adults.

Examining and Modulating Neural Circuits in Psychiatric Disorders With Transcranial Magnetic Stimulation and Electroencephalography: Present Practices and Future Developments

Transcranial magnetic stimulation (TMS) is a noninvasive brain stimulation technique uniquely equipped to both examine and modulate neural systems and related cognitive and behavioral functions in humans. As an examination tool, TMS can be used in combination with EEG (TMS-EEG) to elucidate directly, objectively, and noninvasively the intrinsic properties of a specific cortical region, including excitation, inhibition, reactivity, and oscillatory activity, irrespective of the individual's conscious effort. Additionally, when applied in repetitive patterns, TMS has been shown to modulate brain networks in healthy individuals, as well as ameliorate symptoms in individuals with psychiatric disorders. The key role of TMS in assessing and modulating neural dysfunctions and associated clinical and cognitive deficits in psychiatric populations is therefore becoming increasingly evident. In this article, the authors review TMS-EEG studies in schizophrenia and mood disorders, as most TMS-EEG studies to date have focused on individuals with these disorders. The authors present the evidence on the efficacy of repetitive TMS (rTMS) and theta burst stimulation (TBS), when targeting specific cortical areas, in modulating neural circuits and ameliorating symptoms and abnormal behaviors in individuals with psychiatric disorders, especially when informed by resting-state and task-related neuroimaging measures. Examples of how the combination of TMS-EEG assessments and rTMS and TBS paradigms can be utilized to both characterize and modulate neural circuit alterations in individuals with psychiatric disorders are also provided. This approach, along with the evaluation of the behavioral effects of TMS-related neuromodulation, has the potential to lead to the development of more effective and personalized interventions for individuals with psychiatric disorders.

Contribution of TMS and TMS-EEG to the Understanding of Mechanisms Underlying Physiological Brain Aging

In the human brain, aging is characterized by progressive neuronal loss, leading to disruption of synapses and to a degree of failure in neurotransmission. However, there is increasing evidence to support the notion that the aged brain has a remarkable ability to reorganize itself, with the aim of preserving its physiological activity. It is important to develop objective markers able to characterize the biological processes underlying brain aging in the intact human, and to distinguish them from brain degeneration associated with many neurological diseases. Transcranial magnetic stimulation (TMS), coupled with electromyography or electroencephalography (EEG), is particularly suited to this aim, due to the functional nature of the information provided, and thanks to the ease with which it can be integrated with behavioral manipulation. In this review, we aimed to provide up to date information about the role of TMS and TMS-EEG in the investigation of brain aging. In particular, we focused on data about cortical excitability, connectivity and plasticity, obtained by using readouts such as motor evoked potentials and transcranial evoked potentials. Overall, findings in the literature support an important potential contribution of TMS to the understanding of the mechanisms underlying normal brain aging. Further studies are needed to expand the current body of information and to assess the applicability of TMS findings in the clinical setting.

The Effect of Transcranial Random Noise Stimulation on Cognitive Training Outcome in Healthy Aging

Background and Objective: Aging is associated with a decline in attentional and executive abilities, which are linked to physiological, structural, and functional brain changes. A variety of novel non-invasive brain stimulation methods have been probed in terms of their neuroenhancement efficacy in the last decade; one that holds significant promise is transcranial random noise stimulation (tRNS) that delivers an alternate current at random amplitude and frequency. The aim of this study was to investigate whether repeated sessions of tRNS applied as an add-on to cognitive training (CT) may induce long-term near and far transfer cognitive improvements. Methods: In this sham-controlled, randomized, double-blinded study forty-two older adults (age range 60-86 years) were randomly assigned to one of three intervention groups that received 20 min of 0.705 mA tRNS (N = 14), 1 mA tRNS (N = 14), or sham tRNS (N = 19) combined with 30 min of CT of executive functions (cognitive flexibility, inhibitory control, working memory). tRNS was applied bilaterally over the dorsolateral prefrontal cortices for five sessions. The primary outcome (non-verbal logical reasoning) and other cognitive functions (attention, memory, executive functions) were assessed before and after the intervention and at a 1-month follow-up. Results: Non-verbal logical reasoning, inhibitory control and reaction time improved significantly over time, but stimulation did not differentially affect this improvement. These changes occurred during CT, while no further improvement was observed during follow-up. Performance change in logical reasoning was significantly correlated with age in the group receiving 1 mA tRNS, indicating that older participants profited more from tRNS than younger participants. Performance change in non-verbal working memory was significantly correlated with age in the group receiving sham tRNS, indicating that in contrast to active tRNS, older participants in the sham group declined more than younger participants. Interpretation: CT induced cognitive improvements in all treatment groups, but tRNS did not modulate most of these cognitive improvements. However, the effect of tRNS depended on age in some cognitive functions. We discuss possible explanations leading to this result that can help to improve the design of future neuroenhancement studies in older populations.

High-Frequency rTMS Improves Cognitive Function by Regulating Synaptic Plasticity in Cerebral Ischemic Rats

Poststroke cognitive impairment (PSCI) is one of the most severe sequelae of stroke and lacks effective treatment. Previous studies have shown that high-frequency repetitive transcranial magnetic stimulation (rTMS) may be a promising PSCI therapeutic approach, but the underlying mechanism is unclear. To uncover the effect of rTMS on PSCI, a transient middle cerebral artery occlusion (tMCAO) model was established. Modified Neurological Severity Score (mNSS) test and Morris Water Maze (MWM) test were performed to assess the neurological and cognitive function of rats. Furthermore, to explore the underlying mechanism, differentially expressed genes (DEGs) in the hippocampus of rats in the rTMS group and tMCAO group were compared using RNA sequencing. Then, bioinformatics analysis, including gene ontology (GO) analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis and protein-protein interaction (PPI) network analysis, was conducted to elaborate these DEGs. Our results indicated that high-frequency rTMS could significantly improve neurological and cognitive function, according to mNSS and MWM tests. We found 85 DEGs, including 71 upregulated genes and 14 downregulated genes, between the rTMS group and tMCAO group. The major functional category was related to chemical synaptic transmission modulation and several DEGs were significantly upregulated in processes related to synaptic plasticity, such as glutamatergic synapses. Calb2, Zic1, Kcnk9, and Grin3a were notable in PPI analysis. These results demonstrate that rTMS has a beneficial effect on PSCI, and its mechanism may be related to the regulation of synaptic plasticity and functional genes such as Calb2, Zic1, Kcnk9, and Grin3a in the hippocampus.

A Systematic Review and Meta-Analysis of Transcranial Direct Current Stimulation to Remediate Age-Related Cognitive Decline in Healthy Older Adults

BACKGROUND

Transcranial direct current stimulation (tDCS) has been proposed as a possible method for remediating age-associated cognitive decline in the older adult population. While tDCS has shown potential for improving cognitive functions in healthy older adults, stimulation outcomes on various cognitive domains have been mixed.

METHODS

A systematic search was performed in four databases: PubMed, EMBASE, Web of Science, and PsychInfo. Search results were then screened for eligibility based on inclusion/exclusion criteria to only include studies where tDCS was applied to improve cognition in healthy older adults 65 years and above. Eligible studies were reviewed and demographic characteristics, tDCS dose parameters, study procedures, and cognitive outcomes were extracted. Reported effect sizes for active compared to sham group in representative cognitive domain were converted to Hedges' g.

MAIN RESULTS

A total of thirteen studies involving healthy older adults (n=532, mean age=71.2+5.3 years) were included in the meta-analysis. The majority of included studies (94%) targeted the prefrontal cortex with stimulation intensity 1-2 mA using various electrode placements with anodes near the frontal region. Across all studies, we found Hedges' g values ranged from -0.31 to 1.85 as reported group effect sizes of active stimulation compared to sham.

CONCLUSION

While observed outcomes varied, overall findings indicated promising effects of tDCS to remediate cognitive aging and thus deserves further exploration. Future characterization of inter-individual variability in tDCS dose response and applications in larger cohorts are warranted to further validate benefits of tDCS for cognition in healthy older adults.

Evaluation and Treatment of Vascular Cognitive Impairment by Transcranial Magnetic Stimulation

The exact relationship between cognitive functioning, cortical excitability, and synaptic plasticity in dementia is not completely understood. Vascular cognitive impairment (VCI) is deemed to be the most common cognitive disorder in the elderly since it encompasses any degree of vascular-based cognitive decline. In different cognitive disorders, including VCI, transcranial magnetic stimulation (TMS) can be exploited as a noninvasive tool able to evaluate in vivo the cortical excitability, the propension to undergo neural plastic phenomena, and the underlying transmission pathways. Overall, TMS in VCI revealed enhanced cortical excitability and synaptic plasticity that seem to correlate with the disease process and progression. In some patients, such plasticity may be considered as an adaptive response to disease progression, thus allowing the preservation of motor programming and execution. Recent findings also point out the possibility to employ TMS to predict cognitive deterioration in the so-called "brains at risk" for dementia, which may be those patients who benefit more of disease-modifying drugs and rehabilitative or neuromodulatory approaches, such as those based on repetitive TMS (rTMS). Finally, TMS can be exploited to select the responders to specific drugs in the attempt to maximize the response and to restore maladaptive plasticity. While no single TMS index owns enough specificity, a panel of TMS-derived measures can support VCI diagnosis and identify early markers of progression into dementia. This work reviews all TMS and rTMS studies on VCI. The aim is to evaluate how cortical excitability, plasticity, and connectivity interact in the pathophysiology of the impairment and to provide a translational perspective towards novel treatments of these patients. Current pitfalls and limitations of both studies and techniques are also discussed, together with possible solutions and future research agenda.

White matter hyperintensities affect transcranial electrical stimulation in the aging brain

BACKGROUND

White matter hyperintensities (WMH) are estimated to occur in greater than 63% of older adults over the age of 60 years. WMH identified in the T2-weighted FLAIR images can be combined with T1-weighted images to enhance individualized current flow models of older adults by accounting for the presence of WMH and its effects on delivered tES current in the aging brain.

METHODS

Individualized head models were derived from T1-weighted images of 130 healthy older adults (mean = 71 years). Lesions segmented from FLAIR acquisition were added to individualized models. Current densities were computed in the brain and compared between models with and without lesions.

MAIN RESULTS

Integrating WMH into the models resulted in an overall decrease (up to 7%) in median current densities in the brain outside lesion regions. Changes in current density and total lesion volume was positively correlated (R² = 0.31, p < 0.0001).

CONCLUSIONS

Incorporating WMH into individualized models may increase the accuracy of predicted tES current flow in the aging brain.

Effects of transcranial electrical stimulation on episodic memory in physiological and pathological ageing

Memory for personally-relevant past events (episodic memory) is critical for activities of daily living. Decline in this type of declarative long-term memory is a common characteristic of healthy ageing, a process accelerated in patients with mild cognitive impairment (MCI) and Alzheimer's disease (AD). Transcranial electrical stimulation (tES) has been used as a strategy to ameliorate episodic memory. Here, we critically review studies investigating whether tES may improve episodic memory in physiological and pathological ageing. Most of the studies suggest that tES over the prefrontal or temporoparietal cortices can have a positive effect on episodic memory, but the transfer to improvement of execution of daily living activities is still unknown. Further work is needed to better understand the mechanisms underlying the effects of stimulation, combine tES with neuroimaging and optimizing the dosing of stimulation. Future studies should also investigate the optimal timing of stimulation and the combination with medications to induce long-lasting beneficial effects in pathological ageing. More open science efforts should be done to improve rigor and reliability of tES in ageing research.

High-frequency versus theta burst transcranial magnetic stimulation for the treatment of poststroke cognitive impairment in humans

Background

Because the reliability of repetitive transcranial magnetic stimulation (rTMS) in treating poststroke cognitive impairment has not been convincingly demonstrated, we systematically examined the effectiveness of this regimen with 2 protocols.

Methods

We randomly allocated 41 patients with poststroke cognitive impairment to receive 5 Hz rTMS (n = 11), intermittent theta burst stimulation (iTBS; n = 15) or sham stimulation (n = 15). Each group received 10 stimulation sessions over the left dorsolateral prefrontal cortex. We performed the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the Beck Depression Inventory at baseline and after the intervention.

Results

The 5 Hz rTMS group showed significantly greater improvement than the sham group in RBANS total score (p = 0.006), attention (p = 0.001) and delayed memory (p < 0.001). The iTBS group showed significantly greater improvement than the sham group in RBANS total score (p = 0.005) and delayed memory (p = 0.007). The 5 Hz rTMS group exhibited a superior modulating effect in attention compared to the iTBS group (p = 0.016). Patients without comorbid hypertension (p = 0.008) were predisposed to favourable therapeutic outcomes.

Limitations

Although we included only patients with left hemispheric stroke, heterogeneity associated with cortical and subcortical implications existed. We did not investigate the remote effects of rTMS.

Conclusion

Our results demonstrated that both 5 Hz rTMS and iTBS were effective for poststroke cognitive impairment in terms of global cognition, attention and memory function; the domain of attention was susceptible to 5 Hz modulation. Treatment with 5 Hz rTMS may slow cognitive decline, representing both a pivotal process in poststroke cognitive impairment and an aspect of neuroplasticity that contributes to disease-modifying strategies.

Clinical trial registration

NCT02006615; clinicaltrials.gov/ct2/show/NCT02006615.

[Repetitive transcranial magnetic stimulation significantly improves cognitive impairment and neuronal excitability during aging in mice]

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive brain stimulation technique that has been paid attention to with increasing interests as a therapeutic neural rehabilitative tool. Studies confirmed that high-frequency rTMS could improve the cognitive performance in behavioral test as well as the excitability of the neuron in animals. This study aimes to investigate the effects of rTMS on the cognition and neuronal excitability of Kunming mice during the natural aging. Twelve young mice, 12 adult mice, and 12 aged mice were used, and each age group were randomly divided into rTMS group and control group. rTMS-treated groups were subjected to high-frequency rTMS treatment for 15 days, and control groups were treated with sham stimulation for 15 days. Then, novel object recognition and step-down tests were performed to examine cognition of learning and memory. Whole-cell patch clamp technique was used to record and analyze resting membrane potential, action potential (AP), and related electrical properties of AP of hippocampal dentate gyrus (DG) granule neurons. Data analysis showed that cognition of mice and neuronal excitability of DG granule neurons were degenerated significantly as the age increased. Cognitive damage and degeneration of some electrical properties were alleviated under the condition of high-frequency rTMS. It may be one of the mechanisms of rTMS to alleviate cognitive damage and improve cognitive ability by changing the electrophysiological properties of DG granule neurons and increasing neuronal excitability.

Modeling transcranial electrical stimulation in the aging brain

BACKGROUND

Varying treatment outcomes in transcranial electrical stimulation (tES) recipients may depend on the amount of current reaching the brain. Brain atrophy associated with normal aging may affect tES current delivery to the brain. Computational models have been employed to compute predicted tES current inside the brain. This study is the largest study that uses computational models to investigate tES field distribution in healthy older adults.

METHODS

Individualized head models from 587 healthy older adults (mean = 73.9years, 51-95 years) were constructed to create field maps. Two electrode montages (F3-F4, M1-SO) with 2 mA input current were modeled using ROAST with modified codes. A customized template of healthy older adults, the UFAB-587, was created from the same dataset and used to warp individual brains into the same space. Warped models were analyzed to determine the relationship between computed field measures, brain atrophy and age.

MAIN RESULTS

Computed field measures were inversely correlated with brain atrophy (R² = 0.0829, p = 1.14e-12). Field pattern showed negative correlation with age in brain sub-regions including part of DLPFC and precentral gyrus. Mediation analysis revealed that the negative correlation between age and current density is partially mediated by brain-to-CSF ratio.

CONCLUSIONS

Computed field measures showed decreasing amount of tES current reaching the brain with increasing atrophy. Therefore, adjusting current dose by modifying tES stimulation parameters in older adults based on degree of atrophy may be necessary to achieve desired stimulation benefits. Results from this study may inform future tES application in healthy older adults.

TREAT AF (Transcutaneous Electrical Vagus Nerve Stimulation to Suppress Atrial Fibrillation): A Randomized Clinical Trial

OBJECTIVES

This study was a sham-controlled, double-blind, randomized clinical trial to examine the effect of chronic low level tragus stimulation (LLTS) in patients with paroxysmal AF.

BACKGROUND

Low-level transcutaneous electrical stimulation of the auricular branch of the vagus nerve at the tragus (LLTS) acutely suppresses atrial fibrillation (AF) in humans, but the chronic effect remains unknown.

METHODS

LLTS (20 Hz, 1 mA below the discomfort threshold) was delivered using an ear clip attached to the tragus (active arm) (n = 26) or the ear lobe (sham control arm) (n = 27) for 1 h daily over 6 months. AF burden over 2-week periods was assessed by noninvasive continuous electrocardiogram monitoring at baseline, 3 months, and 6 months. Five-minute electrocardiography and serum were obtained at each visit to measure heart rate variability and inflammatory cytokines, respectively.

RESULTS

Baseline characteristics were balanced between the 2 groups. Adherence to the stimulation protocol (≤4 sessions lost per month) was 75% in the active arm and 83% in the control arm (p > 0.05). At 6 months, the median AF burden was 85% lower in the active arm compared with the control arm (ratio of medians: 0.15; 95% confidence interval: 0.03 to 0.65; p = 0.011). Tumor necrosis factor-alpha was significantly decreased by 23% in the active group relative to the control group (ratio of medians: 0.77; 95% confidence interval: 0.63 to 0.94; p = 0.0093). Frequency domain indices of heart rate variability were significantly altered with active versus control stimulation (p < 0.01). No device-related side effects were observed.

CONCLUSIONS

Chronic, intermittent LLTS resulted in lower AF burden than did sham control stimulation, supporting its use to treat paroxysmal AF in selected patients. (Transcutaneous Electrical Vagus Nerve Stimulation to Suppress Atrial Fibrillation [TREAT-AF]; NCT02548754).

Evaluation and Treatment of Vascular Cognitive Impairment by Transcranial Magnetic Stimulation

The exact relationship between cognitive functioning, cortical excitability, and synaptic plasticity in dementia is not completely understood. Vascular cognitive impairment (VCI) is deemed to be the most common cognitive disorder in the elderly since it encompasses any degree of vascular-based cognitive decline. In different cognitive disorders, including VCI, transcranial magnetic stimulation (TMS) can be exploited as a noninvasive tool able to evaluate in vivo the cortical excitability, the propension to undergo neural plastic phenomena, and the underlying transmission pathways. Overall, TMS in VCI revealed enhanced cortical excitability and synaptic plasticity that seem to correlate with the disease process and progression. In some patients, such plasticity may be considered as an adaptive response to disease progression, thus allowing the preservation of motor programming and execution. Recent findings also point out the possibility to employ TMS to predict cognitive deterioration in the so-called "brains at risk" for dementia, which may be those patients who benefit more of disease-modifying drugs and rehabilitative or neuromodulatory approaches, such as those based on repetitive TMS (rTMS). Finally, TMS can be exploited to select the responders to specific drugs in the attempt to maximize the response and to restore maladaptive plasticity. While no single TMS index owns enough specificity, a panel of TMS-derived measures can support VCI diagnosis and identify early markers of progression into dementia. This work reviews all TMS and rTMS studies on VCI. The aim is to evaluate how cortical excitability, plasticity, and connectivity interact in the pathophysiology of the impairment and to provide a translational perspective towards novel treatments of these patients. Current pitfalls and limitations of both studies and techniques are also discussed, together with possible solutions and future research agenda.

Large-scale network dysfunction in vascular cognitive disorder supports connectional diaschisis in advanced arteriosclerosis

BACKGROUND AND PURPOSE

The interrelation of cognitive performance, cerebrovascular damage and brain functional connectivity (FC) in advanced arteriosclerosis remains unclear. Our aim was to investigate the associations between FC, white matter damage and cognitive impairment in carotid artery disease.

METHODS

Seventy-one participants with a recent cerebrovascular event and with written informed consent underwent resting-state functional magnetic resonance imaging and the Addenbrooke's Cognitive Examination - Revised (ACE-R). Network and inter-hemispheric FC metrics were compared between cognitively normal and impaired subjects, and interrelated with cognition. In order to explore the nature of FC changes, their associations with microstructural damage of related white matter tracts and cognitive performance were investigated, followed by mediation analysis.

RESULTS

Participants with global cognitive impairment showed reduced FC compared to the cognitively intact subjects within the central executive network (CEN), and between hemispheres. Patients with executive dysfunction had decreased CEN FC whilst patients with memory loss demonstrated low FC in both the CEN and the default mode network (DMN). Global performance correlated with connectivity metrics of the CEN hub with DMN nodes, and between hemispheres. Cingulum mean diffusivity (MD) was negatively correlated with ACE-R and CEN-DMN FC. The cingulum MD-cognition association was partially mediated by CEN-DMN FC.

CONCLUSIONS

Long-range functional disconnection of the CEN with DMN nodes is the main feature of cognitive impairment in elderly subjects with symptomatic carotid artery disease. Our findings provide further support for the connectional diaschisis concept of vascular cognitive disorder, and highlight a mediation role of functional disconnection to explain associations between microstructural white matter tract damage and cognitive impairment.

Cortical network dynamics are coupled with cognitive aging in rats

Changes in neuronal network activity and increased interindividual variability in memory are among the most consistent features of growing older. Here, we examined the relationship between these hallmarks of aging. Young and aged rats were trained on a water maze task where aged individuals reliably display an increased range of spatial memory capacities relative to young. Two weeks later, neuronal activity was induced pharmacologically with a low dose of pilocarpine and control animals received vehicle. Activity levels were proxied by quantifying the immediate early gene products Arc and c-Fos. While no relationship was observed between basal, resting activity, and individual differences in spatial memory in any brain region, pilocarpine-induced marker expression was tightly coupled with memory in all areas of the prefrontal cortex (PFC) and hippocampus examined. The nature of this association, however, differed across regions and in relation to age-related cognitive outcome. Specifically, in the medial PFC, induced activity was greatest in aged rats with cognitive impairment and correlated with water maze performance across all subjects. In the hippocampus, the range of induced marker expression was comparable between groups and similarly coupled with memory in both impaired and unimpaired aged rats. Together the findings highlight that the dynamic range of neural network activity across multiple brain regions is a critical component of neurocognitive aging.

Effects of in-Scanner Bilateral Frontal tDCS on Functional Connectivity of the Working Memory Network in Older Adults

Working memory is an executive memory process essential for everyday decision-making and problem solving that declines with advanced age. Transcranial direct current stimulation (tDCS) is a non-invasive form of brain stimulation that has demonstrated potential for improving working memory performance in older adults. However, the neural mechanisms underlying effects of tDCS on working memory are not well understood. This mechanistic study investigated the acute and after-effects of bilateral frontal (F3/F4) tDCS at 2 mA for 12-min on functional connectivity of the working memory network in older adults. We hypothesized active tDCS over sham would increase frontal connectivity during working memory performance. The study used a double-blind within-subject 2 session crossover design. Participants performed an functional magnetic resonance imaging (fMRI) N-Back working memory task before, during, and after active or sham stimulation. Functional connectivity of the working memory network was assessed within and between stimulation conditions (FDR < 0.05). Active tDCS produced a significant increase in functional connectivity between left ventrolateral prefrontal cortex (VLPFC) and left dorsolateral PFC (DLPFC) during stimulation, but not after stimulation. Connectivity did not significantly increase with sham stimulation. In addition, our data demonstrated both state-dependent and time-dependent effects of tDCS working memory network connectivity in older adults. tDCS during working memory performance produces a selective change in functional connectivity of the working memory network in older adults. These data provide important mechanistic insight into the effects of tDCS on brain connectivity in older adults, as well as key methodological considerations for tDCS-working memory studies.

Methods to monitor accurate and consistent electrode placements in conventional transcranial electrical stimulation

BACKGROUND

Inaccurate electrode placement and electrode drift during a transcranial electrical stimulation (tES) session have been shown to alter predicted field distributions in the brain and thus may contribute to a large variation in tES study outcomes. Currently, there is no objective and independent measure to quantify electrode placement accuracy/drift in tES clinical studies.

OBJECTIVE/HYPOTHESIS

We proposed and tested novel methods to quantify accurate and consistent electrode placements in tES using models generated from a 3D scanner.

METHODS

Accurate electrode placements were quantified as Discrepancy in eight tES participants by comparing landmark distances of physical electrode locations F3/F4 to their model counterparts. Distances in models were computed using curve and linear based methods. Variability of landmark locations in a single subject was computed for multiple stimulation sessions to determine consistent electrode placements across four experimenters.

MAIN RESULTS

We obtained an average of 0.4 cm in Discrepancy, which was within the placement accuracy/drift threshold (1 cm) for conventional tES electrodes (∼35 cm2) to achieve reliable tES sessions suggested in the literature. Averaged Variability was 5.2%, with F4 electrode location as the least consistent placement.

CONCLUSIONS

These methods provide objective feedback for experimenters on their performance in placing tES electrodes. Applications of these methods can be used to monitor electrode locations in tES studies of a larger cohort using F3/F4 montage and other conventional electrode arrangements. Future studies may include co-registering the landmark locations with imaging-derived head models to quantify the effects of electrode accuracy/drift on predicted field distributions in the brain.