Transcranial Magnetic Brain Stimulation

Transcranial Magnetic Stimulation or TMS is a non-invasive method of treating numerous psychiatric and several neurologic disorders by means of repetitive magnetic impulses. It can ben also called as rTMS.

NPISTANBUL Brain Hospital was the first private hospital in Turkey that performed this kind of treatment. A patient may need one session of TMS or several sessions depending on his/her complaints and anamnesis.

The breakthrough and discoveries in science and technology of the last 15 years allowed to design a gadget that is able to evaluate the nerve impulses’ speed. Apart from treating abilities, TMS possesses this function.     

What is TMS?

TMS creates strong magnetic field alongside a patient’s head. This field directly stimulates nerve cells in the brain, which allows to improve or ease, for example, the symptoms of depression. In other words, electromagnetic induction occurs and delivers repetitive magnetic pulses to the cortex. Therefore, this method enables us to intervene in the brain function without any surgical procedures. TMS is an important method of not only treatment, but also as a part of diagnostics. TMS or rTMS is usually used in treating patients with depression, generalized anxiety syndrome, etc. Besides, TMS is being an effective and absolutely less traumatic method of treatment in comparison with Electroconvulsive Therapy (ECT).

When is TMS recommended?

According to FDA (U.S. Food and Drug Administration) guidelines TMS can be used in patients with severe depression or in patients, who were recommended to undergo ECT. There are numerous patients with medication treatment-resistant depression. For such patient TMS is probably the only possible way of treatment left. All in all, there is a list of psychiatric disorders that require transcranial magnetic stimulation or TMS, they are as follows: psychiatric disorders with no regression or positive effect despite conservative treatment has been taken, progression of schizophrenia, hallucinations, substance abuse, and obsessive-compulsive syndrome. One of the most pivotal things is to come up with a right and individual treatment plan for each patient. This responsibility rests on the shoulders of a psychiatrist.

Deep TMS

Deep Transcranial Magnetic Stimulation or dTMS uses deep magnetic waves to activate targeted brain regions to decrease activity in depression or another disorder. This techniques also allows to stimulate brain cortex of the patient via repetitive magnetic impulses.  

When to apply dTMS?

Deep TMS is used in the treatment of substance abuse, especially drug addiction, schizophrenia, obsessive-convulsive disorder, attention deficit and hyperactivity disorder in adults and several other psychiatric disorders. TMS and deep TMS treatments are approved by FDA and are applied all around the world. This kind of treatment is commonly used in the USA, Canada, Austria, Germany, Belgium, Italy and numerous European and South American countries.

TMS indications:

• substance abuse,
• Alzheimer’s disease,
• cocaine abuse,
• multiple sclerosis,
• neuropathic pain,
• obsessive-convulsive disorder,
• autism,
• Parkinson’s disease,
• tobacco abuse and dependence,
• severe schizophrenia with no signs of regression,
• treatment-resistant psychiatric disorders.

TMS under neuronavigation system

Using TMS with neuronavigation system allows the doctor to precisely detect an accurate location for magnetic stimulation. First, brain MRI is done, then those MR images is transmitted to the computed neuronavigation system. That area of the brain is determined by the doctor. Thus, neuronavigation in combination with TMS enables to choose an area for magnetic brain stimulation accurately to a millimetre.      

When will I feel a positive effect after TMS?

1. The first positive effect after TMS session patients usually experience during the first or the second week.
2. Our patients typically feel better and notice symptoms’ cessation on the second week after the first TMS session.  
3. In difficult cases of severe symptoms’ manifestation positive effects after TMS may be delayed and patients may feel better only on the third week. This can be an indication for an additional TMS session.  
4. Sometimes a patient might need additional session 8-12 months later.
5. The second and additional sessions of TMS are usually shorter.  
6. We strongly recommend our patients to seek for a medical assistance and consult their doctors if they start feeling relapse condition or worsening of the symptoms.

TMS effects on a human body

• Seizures

Seizures are one of the most common adverse events after TMS. However, some chronic conditions can increase the risk of seizures manifestation. Such conditions as ischemic cerebral stroke, paralysis, different brain tumours and lesions, contusions in anamnesis will need a close look of your doctor. Therefore, an individual and accurate plan of treatment is of great importance. It makes medical examination and overall health assessment before TMS crucial to avoid possible unexpected side effects (Wasserman, 1998).

• Cardio-vascular system

Serious adverse events concerning high-blood pressure were not seen in patient after TMS (Foerster, 1997).

• Hearing

A clinical trial has been held on a possible risk of hearing impairment or hearing loss after TMS. 12 patients took part in it. No serious adverse events concerning heralding loss were found (Loo, 2001).

• Headache

Transcranial magnetic stimulation directly affects head area. That is why patient can feel slight discomfort or a headache, because magnetic impulses go through hair follicles and nerve cells (George, 1999). Overall discomfort depends on the depth of magnetic impulses and the area they cover: the deeper the waves go through, the more there is a risk of a headache after the session. According to the latest clinical trials, 20% of all patient who underwent TMS experience a headache (George, 1999). 

TMS’s adverse events

In comparison with other methods of brain stimulation TMS is a non-invasive one. It means that there is no surgical interference into the brain or a cortex. However, TMS also has its own risks and possible adverse events as headaches, painful scalp or tender spots on your head, a sudden change of hearing and even temporary decrease of cognitive functions.

All adverse events mentioned above are of short-term and non-permanent character. Clinical trials on animals have shown that there were no harm caused to nerve cells or brain tissue by TMS. Also, in regard to recent clinical trials TMS doesn’t cause any changes or abnormalities on EEG test (Graf и др. 2001).

Можно ли применять ТМС в лечении пациентов старшей возрастной группы?

Patients in an advanced age are at a higher risk of treatment-resistant depression or other psychiatric disorders. Increasing the dosage of medication or using several pills in a combination are not always possible due to the poor general health condition of those patients. A single clinical trial concerning older adult patients presenting treatment-resistant depression was held in Turkey. The average age of the participants were about 66,6 years old. The patients received 18 sessions of TMS in combination with antidepressants intake. 38 patients out of 65 noticed partial recovery, while 19 of them experienced complete recovery. No serious adverse events were found out (Hızlı Sayar, 2013)..

ТМС milestones

• TMS is performed in case of severe depression, if there are direct indications.
• TMS module is fixed on the head of a patient, therefore the doctor can control the area that would be stimulated.
• The aim of TMS is to stimulate the functions of brain, especially by improving the functions of different brain areas.
• TMS is a device, which produces inducing magnetic field in a shape of repetative pulses that activate the functions of a human brain.
• TMS device contains eight focal coils that produce magnetic field. It is covered with safe plastic material, i.e. it can be placed against patients’ head and hair with no risk. Mgentic impulses directly affect the cortex.
• TMS induces inhibitory neurones of the cortex.
• Depth, duration and localization of the magnetic waves can be adjusted in an individual way. Settings and parameters are changeable. This is the biggest advantage of this treatment.
• Clinical trials and medical test held have confirmed the possibility to recommend TMS for different psychiatric and neurological disorders. For example, Canada started using TMS in 2002.  
• Numerous research articles were published in reputable medical magazines stating the indications for TMS. Among those indications there were such diseases as Parkinson’s disease, hearing hallucinations, tinnitus, schizophrenia, obsessive-compulsive disorder, eating disorders, migraine-like headaches, chronic pain, and other mental disorders.  

 

TMS results in Mind Care Centers in Canada:

• TMS were performed to more than 300 patients.
• 2/3 of all patients stated the decrease of symptoms after TMS.
• The majority of patients noticed the decrease of depression symptoms for about 75%.
• TMS statistics of Mind Care Centers:
  • 34.6% of the patients did not notice any positive effect after TMS.
  • 62.4% of the patients confirmed obvious stable positive effect after TMS.
  • 5.1% of the patients were not sure about the answer.
• Apart from subjective opinion of the patients, this research contains the outcomes of Beck’s Depression Inventory, Hamilton 7 Index, Hamilton Anxiety Rating Scale (HAR-S) tests. 

 

  How long does the effect after TMS last?

• Patients typically experience positive after-treatment effect on the first or on the second weeks after the first session of transcranial magnetic stimulation.
• On the second week the majority of the patients presents improvements of the symptoms. Those patients who started feeling symptoms cessation on the third week, we strongly recommend to consult your doctor and undoubtedly let him/her know.
• An additional session of TMS might be needed 8-12 months after the first session.
• In regard to duration of the procedure additional sessions are usually shorter.   
• Patients who feel relapse approaching after TMS should consult their doctors immediately.

NPISTANBUL Brain Hospital performs Transcranial Magnetic Stimulation as a second-line therapy of psychiatric disorders. Unlike Canada, Turkish psychiatrists apply TMS to patients with treatment-resistant psychiatric disorders only after receiving a special officially approved permit.