Optimizing functional accuracy of TMS in cognitive studies: a comparison of methods

Cognitive enhancement

Cognitive enhancement refers to the improvement of cognitive ability in normal healthy individuals. In this article, we focus on the use of pharmaceutical agents and brain stimulation for cognitive enhancement, reviewing the most common methods of pharmacologic and electronic cognitive enhancement, and the mechanisms by which they are believed to work, the effectiveness of these methods and their prevalence. We note the many gaps in our knowledge of these matters, including open questions about the size, reliability and nature of the enhancing effects, and we conclude with recommendations for further research. WIREs Cogn Sci 2014, 5:95-103. doi: 10.1002/wcs.1250 CONFLICT OF INTEREST: The authors have declared no conflicts of interest for this article. For further resources related to this article, please visit the WIREs website.

Single pulse TMS differentially modulates reward behavior

Greater knowledge of cortical brain regions in reward processing may set the stage for using transcranial magnetic stimulation (TMS) as a treatment in patients with avolition, apathy or other drive-related symptoms. This study examined the effects of single pulse (sp) TMS to two reward circuit targets on drive in healthy subjects. Fifteen healthy subjects performed the monetary incentive delay task (MID) while receiving fMRI-guided spTMS to either inferior parietal lobe (IPL) or supplemental motor area (SMA). The study demonstrated decreasing reaction times (RT) for increasing reward. It also showed significant differences in RT modulation for TMS pulses to the IPL versus the SMA. TMS pulses during the delay period produced significantly more RT slowing when targeting the IPL than those to the SMA. This RT slowing carried over into subsequent trials without TMS stimulation, with significantly slower RTs in sessions that had targeted the IPL compared to those targeting SMA. The results of this study suggest that both SMA and IPL are involved in reward processing, with opposite effects on RT in response to TMS stimulation. TMS to these target cortical regions may be useful in modulating reward circuit deficits in psychiatric populations.

Comparison of spherical and realistically shaped boundary element head models for transcranial magnetic stimulation navigation

OBJECTIVE

MRI-guided real-time transcranial magnetic stimulation (TMS) navigators that apply electromagnetic modeling have improved the utility of TMS. However, their accuracy and speed depends on the assumed volume conductor geometry. Spherical models found in present navigators are computationally fast but may be inaccurate in some areas. Realistically shaped boundary-element models (BEMs) could increase accuracy at a moderate computational cost, but it is unknown which model features have the largest influence on accuracy. Thus, we compared different types of spherical models and BEMs.

METHODS

Globally and locally fitted spherical models and different BEMs with either one or three compartments and with different skull-to-brain conductivity ratios (1/1-1/80) were compared against a reference BEM.

RESULTS

The one-compartment BEM at inner skull surface was almost as accurate as the reference BEM. Skull/brain conductivity ratio in the range 1/10-1/80 had only a minor influence. BEMs were superior to spherical models especially in frontal and temporal areas (up to 20mm localization and 40% intensity improvement); in motor cortex all models provided similar results.

CONCLUSIONS

One-compartment BEMs offer a good balance between accuracy and computational cost.

SIGNIFICANCE

Realistically shaped BEMs may increase TMS navigation accuracy in several brain areas, such as in prefrontal regions often targeted in clinical applications.

Repeated measurements of cerebral blood flow in the left superior temporal gyrus reveal tonic hyperactivity in patients with auditory verbal hallucinations: a possible trait marker

Background: The left superior temporal gyrus (STG) has been suggested to play a key role in auditory verbal hallucinations (AVH) in patients with schizophrenia.

Methods: Eleven medicated subjects with schizophrenia and medication-resistant AVH and 19 healthy controls underwent perfusion magnetic resonance (MR) imaging with arterial spin labeling (ASL). Three additional repeated measurements were conducted in the patients. Patients underwent a treatment with transcranial magnetic stimulation (TMS) between the first 2 measurements. The main outcome measure was the pooled cerebral blood flow (CBF), which consisted of the regional CBF measurement in the left STG and the global CBF measurement in the whole brain.

Results: Regional CBF in the left STG in patients was significantly higher compared to controls (p < 0.0001) and to the global CBF in patients (p < 0.004) at baseline. Regional CBF in the left STG remained significantly increased compared to the global CBF in patients across time (p < 0.0007), and it remained increased in patients after TMS compared to the baseline CBF in controls (p < 0.0001). After TMS, PANSS (p = 0.003) and PSYRATS (p = 0.01) scores decreased significantly in patients.

Conclusions: This study demonstrated tonically increased regional CBF in the left STG in patients with schizophrenia and auditory hallucinations despite a decrease in symptoms after TMS. These findings were consistent with what has previously been termed a trait marker of AVH in schizophrenia.

Effects of cerebellar stimulation on processing semantic associations

Current research in cerebellar cognitive and linguistic functions makes plausible the idea that the cerebellum is involved in processing temporally contiguous linguistic input. In order to assess this hypothesis, a lexical decision task was constructed to study the effects of cerebellar transcranial magnetic stimulation on semantic noun-to-verb priming based on association (e.g. 'soap-cleaning') or similarity (e.g. 'robbery-stealing'). The results demonstrated a selective increase in associative priming size after stimulation of a lateral cerebellar site. The findings are discussed in the contexts of a cerebellar role in linguistic expectancy generation and the corticocerebellar 'prefrontal' reciprocal loop.

Enhancement of human cognitive performance using transcranial magnetic stimulation (TMS)

Here we review the usefulness of transcranial magnetic stimulation (TMS) in modulating cortical networks in ways that might produce performance enhancements in healthy human subjects. To date over sixty studies have reported significant improvements in speed and accuracy in a variety of tasks involving perceptual, motor, and executive processing. Two basic categories of enhancement mechanisms are suggested by this literature: direct modulation of a cortical region or network that leads to more efficient processing, and addition-by-subtraction, which is disruption of processing which competes or distracts from task performance. Potential applications of TMS cognitive enhancement, including research into cortical function, rehabilitation therapy in neurological and psychiatric illness, and accelerated skill acquisition in healthy individuals are discussed, as are methods of optimizing the magnitude and duration of TMS-induced performance enhancement, such as improvement of targeting through further integration of brain imaging with TMS. One technique, combining multiple sessions of TMS with concurrent TMS/task performance to induce Hebbian-like learning, appears to be promising for prolonging enhancement effects. While further refinements in the application of TMS to cognitive enhancement can still be made, and questions remain regarding the mechanisms underlying the observed effects, this appears to be a fruitful area of investigation that may shed light on the basic mechanisms of cognitive function and their therapeutic modulation.

Charting the functional relevance of Broca's area for visual word recognition and picture naming in Dutch using fMRI-guided TMS

Magnetoencephalography (MEG) has shown pseudohomophone priming effects at Broca's area (specifically pars opercularis of left inferior frontal gyrus and precentral gyrus; LIFGpo/PCG) within ∼100ms of viewing a word. This is consistent with Broca's area involvement in fast phonological access during visual word recognition. Here we used online transcranial magnetic stimulation (TMS) to investigate whether LIFGpo/PCG is necessary for (not just correlated with) visual word recognition by ∼100ms. Pulses were delivered to individually fMRI-defined LIFGpo/PCG in Dutch speakers 75-500ms after stimulus onset during reading and picture naming. Reading and picture naming reactions times were significantly slower following pulses at 225-300ms. Contrary to predictions, there was no disruption to reading for pulses before 225ms. This does not provide evidence in favour of a functional role for LIFGpo/PCG in reading before 225ms in this case, but does extend previous findings in picture stimuli to written Dutch words.

Physiological observations validate finite element models for estimating subject-specific electric field distributions induced by transcranial magnetic stimulation of the human motor cortex

Recent evidence indicates subject-specific gyral folding patterns and white matter anisotropy uniquely shape electric fields generated by TMS. Current methods for predicting the brain regions influenced by TMS involve projecting the TMS coil position or center of gravity onto realistic head models derived from structural and functional imaging data. Similarly, spherical models have been used to estimate electric field distributions generated by TMS pulses delivered from a particular coil location and position. In the present paper we inspect differences between electric field computations estimated using the finite element method (FEM) and projection-based approaches described above. We then more specifically examined an approach for estimating cortical excitation volumes based on individualistic FEM simulations of electric fields. We evaluated this approach by performing neurophysiological recordings during MR-navigated motormapping experiments. We recorded motor evoked potentials (MEPs) in response to single pulse TMS using two different coil orientations (45° and 90° to midline) at 25 different locations (5×5 grid, 1cm spacing) centered on the hotspot of the right first dorsal interosseous (FDI) muscle in left motor cortex. We observed that motor excitability maps varied within and between subjects as a function of TMS coil position and orientation. For each coil position and orientation tested, simulations of the TMS-induced electric field were computed using individualistic FEM models and compared to MEP amplitudes obtained during our motormapping experiments. We found FEM simulations of electric field strength, which take into account subject-specific gyral geometry and tissue conductivity anisotropy, significantly correlated with physiologically observed MEP amplitudes (rmax=0.91, p=1.8×10(-5) rmean=0.81, p=0.01). These observations validate the implementation of individualistic FEM models to account for variations in gyral folding patterns and tissue conductivity anisotropy, which should help improve the targeting accuracy of TMS in the mapping or modulation of human brain circuits.

Can transcranial electrical stimulation improve learning difficulties in atypical brain development? A future possibility for cognitive training

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Transcranial electrical stimulation (TES) can improve cognitive training effects in adults.

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TES can enhance neuroplasticity from the molecular level to the system level.

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We discuss the usage of TES with cognitive training in atypically developing children.

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We discuss the possible cognitive and physical side effects of TES.

Learning difficulties in atypical brain development represent serious obstacles to an individual's future achievements and can have broad societal consequences. Cognitive training can improve learning impairments only to a certain degree. Recent evidence from normal and clinical adult populations suggests that transcranial electrical stimulation (TES), a portable, painless, inexpensive, and relatively safe neuroenhancement tool, applied in conjunction with cognitive training can enhance cognitive intervention outcomes. This includes, for instance, numerical processing, language skills and response inhibition deficits commonly associated with profound learning difficulties and attention-deficit hyperactivity disorder (ADHD). The current review introduces the functional principles, current applications and promising results, and potential pitfalls of TES. Unfortunately, research in child populations is limited at present. We suggest that TES has considerable promise as a tool for increasing neuroplasticity in atypically developing children and may be an effective adjunct to cognitive training in clinical settings if it proves safe. The efficacy and both short- and long-term effects of TES on the developing brain need to be critically assessed before it can be recommended for clinical settings.

Hemispheric differences in the voluntary control of spatial attention: direct evidence for a right-hemispheric dominance within frontal cortex

Lesion studies in neglect patients have inspired two competing models of spatial attention control, namely, Heilman's "hemispatial" theory and Kinsbourne's "opponent processor" model. Both assume a functional asymmetry between the two hemispheres but propose very different mechanisms. Neuroimaging studies have identified a bilateral dorsal frontoparietal network underlying voluntary shifts of spatial attention. However, lateralization of attentional processes within this network has not been consistently reported. In the current study, we aimed to provide direct evidence concerning the functional asymmetry of the right and left FEF during voluntary shifts of spatial attention. To this end, we applied fMRI-guided neuronavigation to disrupt individual FEF activation foci with a longer-lasting inhibitory patterned TMS protocol followed by a spatial cueing task. Our results indicate that right FEF stimulation impaired the ability of shifting spatial attention toward both hemifields, whereas the effects of left FEF stimulation were limited to the contralateral hemifield. These results provide strong direct evidence for right-hemispheric dominance in spatial attention within frontal cortex supporting Heilman's "hemispatial" theory. This complements previous TMS studies that generally conform to Kinsbourne's "opponent processor" model after disruption of parietal cortex, and we therefore propose that both theories are not mutually exclusive.

Hierarchical organization of parietofrontal circuits during goal-directed action

Two parietofrontal networks share the control of goal-directed movements: a dorsomedial circuit that includes the superior parieto-occipital sulcus (sPOS) and a dorsolateral circuit comprising the anterior intraparietal sulcus (aIPS). These circuits are thought to independently control either reach and grip components (a functional dissociation), or planning and execution phases of grasping movements (a temporal dissociation). However, recent evidence of functional and temporal overlap between these circuits has undermined those models. Here, we test an alternative model that subsumes previous accounts: the dorsolateral and dorsomedial circuits operate at different hierarchical levels, resulting in functional and temporal dependencies between their computations. We asked human participants to grasp a visually presented object, manipulating movement complexity by varying object slant. We used concurrent single-pulse transcranial magnetic stimulation and electroencephalography (TMS-EEG) to probe and record neurophysiological activity in the two circuits. Changes in alpha-band oscillations (8-12 Hz) characterized the effects of task manipulations and TMS interferences over aIPS and sPOS. Increasing the complexity of the grasping movement was accompanied by alpha-suppression over dorsomedial parietofrontal regions, including sPOS, during both planning and execution stages. TMS interference over either aIPS or sPOS disrupted this index of dorsomedial computations; early when aIPS was perturbed, later when sPOS was perturbed, indicating that the dorsomedial circuit is temporally dependent on aIPS. TMS over sPOS enhanced alpha-suppression in inferior parietal cortex, indicating that the dorsolateral circuit can compensate for a transient sPOS perturbation. These findings suggest that both circuits specify the same grasping parameters, with dorsomedial computations depending on dorsolateral contributions.

Assessing brain plasticity across the lifespan with transcranial magnetic stimulation: why, how, and what is the ultimate goal?

Sustaining brain and cognitive function across the lifespan must be one of the main biomedical goals of the twenty-first century. We need to aim to prevent neuropsychiatric diseases and, thus, to identify and remediate brain and cognitive dysfunction before clinical symptoms manifest and disability develops. The brain undergoes a complex array of changes from developmental years into old age, putatively the underpinnings of changes in cognition and behavior throughout life. A functionally “normal” brain is a changing brain, a brain whose capacity and mechanisms of change are shifting appropriately from one time-point to another in a given individual's life. Therefore, assessing the mechanisms of brain plasticity across the lifespan is critical to gain insight into an individual's brain health. Indexing brain plasticity in humans is possible with transcranial magnetic stimulation (TMS), which, in combination with neuroimaging, provides a powerful tool for exploring local cortical and brain network plasticity. Here, we review investigations to date, summarize findings, and discuss some of the challenges that need to be solved to enhance the use of TMS measures of brain plasticity across all ages. Ultimately, TMS measures of plasticity can become the foundation for a brain health index (BHI) to enable objective correlates of an individual's brain health over time, assessment across diseases and disorders, and reliable evaluation of indicators of efficacy of future preventive and therapeutic interventions.

Repetitive transcranial magnetic stimulation elicits rate-dependent brain network responses in non-human primates

BACKGROUND

Transcranial magnetic stimulation (TMS) has the potential to treat brain disorders by tonically modulating firing patterns in disease-specific neural circuits. The selection of treatment parameters for clinical repetitive transcranial magnetic stimulation (rTMS) trials has not been rule based, likely contributing to the variability of observed outcomes.

OBJECTIVE

To utilize our newly developed baboon (Papio hamadryas anubis) model of rTMS during position-emission tomography (PET) to quantify the brain's rate-response functions in the motor system during rTMS.

METHODS

We delivered image-guided, suprathreshold rTMS at 3 Hz, 5 Hz, 10 Hz, 15 Hz and rest (in separate randomized sessions) to the primary motor cortex (M1) of the lightly anesthetized baboon during PET imaging; we also administered a (reversible) paralytic to eliminate any somatosensory feedback due to rTMS-induced muscle contractions. Each rTMS/PET session was analyzed using normalized cerebral blood flow (CBF) measurements; statistical parametric images and the resulting areas of significance underwent post-hoc analysis to determine any rate-specific rTMS effects throughout the motor network.

RESULTS

The motor system's rate-response curves were unimodal and system wide--with all nodes in the network showing highly similar rate response functions--and an optimal network stimulation frequency of 5 Hz.

CONCLUSION(S)

These findings suggest that non-invasive brain stimulation may be more efficiently delivered at (system-specific) optimal frequencies throughout the targeted network and that functional imaging in non-human primates is a promising strategy for identifying the optimal treatment parameters for TMS clinical trials in specific brain regions and/or networks.

Reduced neuronal activity in language-related regions after transcranial magnetic stimulation therapy for auditory verbal hallucinations

BACKGROUND

Transcranial magnetic stimulation (TMS) is a novel therapeutic approach, used in patients with pharmacoresistant auditory verbal hallucinations (AVH). To investigate the neurobiological effects of TMS on AVH, we measured cerebral blood flow with pseudo-continuous magnetic resonance-arterial spin labeling 20 ± 6 hours before and after TMS treatment.

METHODS

Thirty patients with schizophrenia or schizoaffective disorder were investigated. Fifteen patients received a 10-day TMS treatment to the left temporoparietal cortex, and 15 received the standard treatment. The stimulation location was chosen according to an individually determined language region determined by a functional magnetic resonance imaging language paradigm, which identified the sensorimotor language area, area Spt (sylvian parietotemporal), as the target region.

RESULTS

TMS-treated patients showed positive clinical effects, which were indicated by a reduction in AVH scores (p ≤ .001). Cerebral blood flow was significantly decreased in the primary auditory cortex (p ≤ .001), left Broca's area (p ≤ .001), and cingulate gyrus (p ≤ .001). In control subjects, neither positive clinical effects nor cerebral blood flow decreases were detected. The decrease in cerebral blood flow in the primary auditory cortex correlated with the decrease in AVH scores (p ≤ .001).

CONCLUSIONS

TMS reverses hyperactivity of language regions involved in the emergence of AVH. Area Spt acts as a gateway to the hallucination-generating cerebral network. Successful therapy corresponded to decreased cerebral blood flow in the primary auditory cortex, supporting its crucial role in triggering AVH and contributing to the physical quality of the false perceptions.

Proactive control of sequential saccades in the human supplementary eye field

Our ability to regulate behavior based on past experience has thus far been examined using single movements. However, natural behavior typically involves a sequence of movements. Here, we examined the effect of previous trial type on the concurrent planning of sequential saccades using a unique paradigm. The task consisted of two trial types: no-shift trials, which implicitly encouraged the concurrent preparation of the second saccade in a subsequent trial; and target-shift trials, which implicitly discouraged the same in the next trial. Using the intersaccadic interval as an index of concurrent planning, we found evidence for context-based preparation of sequential saccades. We also used functional MRI-guided, single-pulse, transcranial magnetic stimulation on human subjects to test the role of the supplementary eye field (SEF) in the proactive control of sequential eye movements. Results showed that (i) stimulating the SEF in the previous trial disrupted the previous trial type-based preparation of the second saccade in the nonstimulated current trial, (ii) stimulating the SEF in the current trial rectified the disruptive effect caused by stimulation in the previous trial, and (iii) stimulating the SEF facilitated the preparation of second saccades based on previous trial type even when the previous trial was not stimulated. Taken together, we show how the human SEF is causally involved in proactive preparation of sequential saccades.

Diminishing parochialism in intergroup conflict by disrupting the right temporo-parietal junction

Individuals react to violation of social norms by outgroup members differently than to transgressions of those same norms by ingroup members: namely outgroup perpetrators are punished much more harshly than ingroup perpetrators. This parochial punishment pattern has been observed and extensively studied in social psychology and behavioral economics. Despite progress in recent years, however, little is known about the neural underpinnings of this intergroup bias. Here, we demonstrate by means of transcranial magnetic stimulation (TMS) that the transient disruption of the right, but not the left temporo-parietal junction (TPJ), reduces parochial punishment in a third-party punishment paradigm with real social groups. Moreover, we show that this observed TMS effect on parochial punishment is mediated by a classical punishment motive, i.e. retaliation. Finally, our data suggests that a change in perspective-taking might be the underlying mechanism that explains the impact of right TPJ disruption on retaliation motivation and parochial punishment. These findings provide the first causal evidence that the right TPJ plays a pivotal role in the implementation of parochial behaviors.

The effect of head orientation on subarachnoid cerebrospinal fluid distribution and its implications for neurophysiological modulation and recording techniques

Gravitational forces may lead to local changes in subarachnoid cerebrospinal fluid (CSF) layer thickness, which has important implications for neurophysiological modulation and recording techniques. This study examines the effect of gravitational pull associated with different head positions on the distribution of subarachnoid CSF using structural magnetic resonance imaging. Images of seven subjects in three different positions (supine, left lateral and prone) were statistically compared. Results suggest that subarachnoid CSF volume decreases on the side of the head closest to the ground, due to downward brain movement with gravity. These findings warrant future research into currently unexplored gravitation-induced changes in regional subarachnoid CSF thickness.

Cortical modulation of short-latency TMS-evoked potentials

Transcranial magnetic stimulation–electroencephalogram (TMS–EEG) co-registration offers the opportunity to test reactivity of brain areas across distinct conditions through TMS-evoked potentials (TEPs). Several TEPs have been described, their functional meaning being largely unknown. In particular, short-latency potentials peaking at 5 (P5) and 8 (N8) ms after the TMS pulse have been recently described, but because of their large amplitude, the problem of whether their origin is cortical or not has been opened. To gain information about these components, we employed a protocol that modulates primary motor cortex excitability (MI): low frequency stimulation of premotor area (PMC). TMS was applied simultaneously with EEG recording from 70 electrodes. Amplitude of TEPs evoked by 200 single-pulses TMS delivered over MI at 110% of resting motor threshold (rMT) was measured before and after applying 900 TMS conditioning stimuli to left PMC with 1 Hz repetition rate. Single subject analyses showed reduction in TEPs amplitude after PMC conditioning in a sample of participants and increase in TEPs amplitude in two subjects. No effects were found on corticospinal excitability as recorded by motor-evoked potentials (MEPs). Furthermore, correlation analysis showed an inverse relation between the effects of the conditioning protocol on P5-N8 complex amplitude and MEPs amplitude. Because the effects of the used protocol have been ascribed to a cortical interaction between premotor area and MI, we suggest that despite the sign of P5-N8 amplitude modulation is not consistent across participant; this modulation could indicate, at least in part, their cortical origin. We conclude that with an accurate experimental procedure early latency components can be used to evaluate the reactivity of the stimulated cortex.

Hot Spot Hound: a novel robot-assisted platform for enhancing TMS performance

Transcranial Magnetic Stimulation (TMS) is a non-invasive technique that produces excitatory depolarization in the neurons located in the cerebral cortex. In order to proficiently stimulate a specific cerebral area it is of main importance the correct positioning and maintaining of the magnetic coil, while avoiding the mismatch due to subject head-coil relative movement. Hot Spot Hound is a novel robot-assisted experimental platform for enhancing TMS stimulation performance. It integrates a commercial optoelectronic neuronavigation system (E.M.S. srl, Italy) for gathering data on the relative pose (position and orientation) of subject's scalp and TMS coil, and a service robotic arm designed for human interaction (LWR system by KUKA, Germany). Besides integrating and synchronizing different platform sub-systems, we implement a control strategy to center the stimulation point and compensate for involuntary subject movements. Specifically, the proposed control maintains constant over time the homogeneous transformation matrix between the pose of the coil and of the head. The value of position stiffness has been chosen in order to assure the better compromise between coil position and orientation error, and the safety of the experimental subject. In this paper we show that Hot Spot Hound can provide coil position and orientation errors well beyond the ones achieved by manual experimenter, while assuring safety in the physical interaction with the stimulated subject.

Cerebral blood flow identifies responders to transcranial magnetic stimulation in auditory verbal hallucinations

Auditory hallucinations comprise a critical domain of psychopathology in schizophrenia. Repetitive transcranial magnetic stimulation (TMS) has shown promise as an intervention with both positive and negative reports. The aim of this study was to test resting-brain perfusion before treatment as a possible biological marker of response to repetitive TMS. Twenty-four medicated patients underwent resting-brain perfusion magnetic resonance imaging with arterial spin labeling (ASL) before 10 days of repetitive TMS treatment. Response was defined as a reduction in the hallucination change scale of at least 50%. Responders (n=9) were robustly differentiated from nonresponders (n=15) to repetitive TMS by the higher regional cerebral blood flow (CBF) in the left superior temporal gyrus (STG) (P<0.05, corrected) before treatment. Resting-brain perfusion in the left STG predicted the response to repetitive TMS in this study sample, suggesting this parameter as a possible bio-marker of response in patients with schizophrenia and auditory hallucinations. Being noninvasive and relatively easy to use, resting perfusion measurement before treatment might be a clinically relevant way to identify possible responders and nonresponders to repetitive TMS.

Biophysical determinants of transcranial magnetic stimulation: effects of excitability and depth of targeted area

Safe and effective transcranial magnetic stimulation (TMS) requires accurate intensity calibration. Output is typically calibrated to individual motor cortex excitability and applied to nonmotor brain areas, assuming that it captures a site nonspecific factor of excitability. We tested this assumption by correlating the effect of TMS at motor and visual cortex. In 30 participants, we measured motor threshold (MT) and phosphene threshold (PT) at the scalp surface and at coil-scalp distances of 3.17, 5.63, and 9.03 mm. We also modeled the effect of TMS in a simple head model to test the effect of distance. Four independent tests confirmed a significant correlation between PT and MT. We also found similar effects of distance in motor and visual areas, which did not correlate across participants. Computational modeling suggests that the relationship between the effect of distance and the induced electric field is effectively linear within the range of distances that have been explored empirically. We conclude that MT-guided calibration is valid for nonmotor brain areas if coil-cortex distance is taken into account. For standard figure-of-eight TMS coils connected to biphasic stimulators, the effect of cortical distance should be adjusted using a general correction factor of 2.7% stimulator output per millimeter.

Measuring and manipulating brain connectivity with resting state functional connectivity magnetic resonance imaging (fcMRI) and transcranial magnetic stimulation (TMS)

Both resting state functional magnetic resonance imaging (fcMRI) and transcranial magnetic stimulation (TMS) are increasingly popular techniques that can be used to non-invasively measure brain connectivity in human subjects. TMS shows additional promise as a method to manipulate brain connectivity. In this review we discuss how these two complimentary tools can be combined to optimally study brain connectivity and manipulate distributed brain networks. Important clinical applications include using resting state fcMRI to guide target selection for TMS and using TMS to modulate pathological network interactions identified with resting state fcMRI. The combination of TMS and resting state fcMRI has the potential to accelerate the translation of both techniques into the clinical realm and promises a new approach to the diagnosis and treatment of neurological and psychiatric diseases that demonstrate network pathology.

Effective connectivity hierarchically links temporoparietal and frontal areas of the auditory dorsal stream with the motor cortex lip area during speech perception

A left-hemispheric cortico-cortical network involving areas of the temporoparietal junction (Tpj) and the posterior inferior frontal gyrus (pIFG) is thought to support sensorimotor integration of speech perception into articulatory motor activation, but how this network links with the lip area of the primary motor cortex (M1) during speech perception is unclear. Using paired-coil focal transcranial magnetic stimulation (TMS) in healthy subjects, we demonstrate that Tpj→M1 and pIFG→M1 effective connectivity increased when listening to speech compared to white noise. A virtual lesion induced by continuous theta-burst TMS (cTBS) of the pIFG abolished the task-dependent increase in pIFG→M1 but not Tpj→M1 effective connectivity during speech perception, whereas cTBS of Tpj abolished the task-dependent increase of both effective connectivities. We conclude that speech perception enhances effective connectivity between areas of the auditory dorsal stream and M1. Tpj is situated at a hierarchically high level, integrating speech perception into motor activation through the pIFG.

Where does transcranial magnetic stimulation (TMS) stimulate? Modelling of induced field maps for some common cortical and cerebellar targets

Computational models have been be used to estimate the electric and magnetic fields induced by transcranial magnetic stimulation (TMS) and can provide valuable insights into the location and spatial distribution of TMS stimulation. However, there has been little translation of these findings into practical TMS research. This study uses the International 10-20 EEG electrode placement system to position a standard figure-of-eight TMS coil over 13 commonly adopted targets. Using a finite element method and an anatomically detailed and realistic head model, this study provides the first pictorial and numerical atlas of TMS-induced electric fields for a range of coil positions. The results highlight the importance of subject-specific gyral folding patterns and of local thickness of subarachnoid cerebrospinal fluid (CSF). Our modelling shows that high electric fields occur primarily on the peaks of those gyri which have only a thin layer of CSF above them. These findings have important implications for inter-individual generalizability of the TMS-induced electric field. We propose that, in order to determine with accuracy the site of stimulation for an individual subject, it is necessary to solve the electric field distribution using subject-specific anatomy obtained from a high-resolution imaging modality such as MRI.

Parieto-motor functional connectivity is impaired in Parkinson's disease

BACKGROUND

Bradykinesia in Parkinson's disease is associated with a difficulty in selecting and executing motor actions, likely due to alterations in the functional connectivity of cortico-cortical circuits.

OBJECTIVE/HYPOTHESIS

Our aims were to analyse the functional interplay between the posterior parietal cortex and the ipsilateral primary motor area in Parkinson's disease using bifocal transcranial magnetic stimulation, to evaluate its modulation by dopaminergic treatment and its relationship to a simple choice reaction task.

METHODS

We studied 12 Parkinson's disease patients with and without dopaminergic treatment and 12 healthy controls. A paired-pulse transcranial magnetic stimulation protocol was applied over the right posterior parietal cortex and the right primary motor area using different conditioning stimulus intensities and interstimulus intervals. Reaction and movement times were studied by a simple choice reaction task.

RESULTS

In controls, we observed a significant facilitation of motor evoked potential amplitudes at 4 ms interstimulus interval when conditioning stimulus intensity was set to 90% of resting motor threshold. This functional interaction was not observed in Parkinson's disease patients without dopaminergic treatment and was not restored with treatment. Moreover, correlation analyses revealed that Parkinson's disease patients with less impaired parieto-motor interaction were faster in executing reaching movements in a choice reaction time task, suggesting that the functional parieto-motor impairment described here could be related to bradykinesia observed in Parkinson's disease patients.

CONCLUSIONS

Parieto-motor functional connectivity is impaired in Parkinson's disease. The reduced efficacy of this connection could be related to presence of bradykinesia previously observed in Parkinson's disease.

Posttraining transcranial magnetic stimulation of striate cortex disrupts consolidation early in visual skill learning

Practice-induced improvements in skilled performance reflect "offline " consolidation processes extending beyond daily training sessions. According to visual learning theories, an early, fast learning phase driven by high-level areas is followed by a late, asymptotic learning phase driven by low-level, retinotopic areas when higher resolution is required. Thus, low-level areas would not contribute to learning and offline consolidation until late learning. Recent studies have challenged this notion, demonstrating modified responses to trained stimuli in primary visual cortex (V1) and offline activity after very limited training. However, the behavioral relevance of modified V1 activity for offline consolidation of visual skill memory in V1 after early training sessions remains unclear. Here, we used neuronavigated transcranial magnetic stimulation (TMS) directed to a trained retinotopic V1 location to test for behaviorally relevant consolidation in human low-level visual cortex. Applying TMS to the trained V1 location within 45 min of the first or second training session strongly interfered with learning, as measured by impaired performance the next day. The interference was conditional on task context and occurred only when training in the location targeted by TMS was followed by training in a second location before TMS. In this condition, high-level areas may become coupled to the second location and uncoupled from the previously trained low-level representation, thereby rendering consolidation vulnerable to interference. Our data show that, during the earliest phases of skill learning in the lowest-level visual areas, a behaviorally relevant form of consolidation exists of which the robustness is controlled by high-level, contextual factors.

Frontal and parietal theta burst TMS impairs working memory for visual-spatial conjunctions

In tasks that selectively probe visual or spatial working memory (WM) frontal and posterior cortical areas show a segregation, with dorsal areas preferentially involved in spatial (e.g. location) WM and ventral areas in visual (e.g. object identity) WM. In a previous fMRI study [1], we showed that right parietal cortex (PC) was more active during WM for orientation, whereas left inferior frontal gyrus (IFG) was more active during colour WM. During WM for colour-orientation conjunctions, activity in these areas was intermediate to the level of activity for the single task preferred and non-preferred information. To examine whether these specialised areas play a critical role in coordinating visual and spatial WM to perform a conjunction task, we used theta burst transcranial magnetic stimulation (TMS) to induce a functional deficit. Compared to sham stimulation, TMS to right PC or left IFG selectively impaired WM for conjunctions but not single features. This is consistent with findings from visual search paradigms, in which frontal and parietal TMS selectively affects search for conjunctions compared to single features, and with combined TMS and functional imaging work suggesting that parietal and frontal regions are functionally coupled in tasks requiring integration of visual and spatial information. Our results thus elucidate mechanisms by which the brain coordinates spatially segregated processing streams and have implications beyond the field of working memory.

Safety and efficacy of repetitive transcranial magnetic stimulation in the treatment of obsessive-compulsive disorder: a review

OBJECTIVES

Obsessive-compulsive disorder (OCD) is a chronic, often severe, neuropsychiatric disorder leading to a dramatic impairment in interpersonal and occupational functions. rTMS has been tried out in several studies in patients with OCD with different characteristics. In this paper, we review the safety and efficacy of rTMS in the treatment of mostly severe resistant OCD.

METHODS

A review of the English literature from 1966 to 2010 pertaining to rTMS in the treatment of OCD was conducted using MEDLINE by selectively entering the search terms "transcranial magnetic stimulation", "repetitive transcranial magnetic stimulation", "obsessive-compulsive disorder" and "OCD". Twelve studies including open and randomized, sham-controlled trials were included in this review.

RESULTS

Although available data about the use of rTMS in OCD treatment are quite heterogeneous in terms of sample size, study design, stimulus parameters used and stimulation areas targeted, promising findings regarding rTMS efficacy appeared for two structures based on recent controlled studies: the supplementary motor area and the orbitofrontal cortex. On the other hand, rTMS of the dorsolateral prefrontal cortex is not significantly effective when compared to sham rTMS.

CONCLUSIONS

Three target areas have already been selected of which the supplementary motor area in particular and the orbitofrontal cortex seem to be the most promising in terms of potential efficacy and could more accurately be targeted with the help of neuronavigational techniques. Larger randomized controlled trials should be conducted in order to better clarify the therapeutic role of rTMS in OCD.

Topographic contribution of early visual cortex to short-term memory consolidation: a transcranial magnetic stimulation study

The neural correlates for retention of visual information in visual short-term memory are considered separate from those of sensory encoding. However, recent findings suggest that sensory areas may play a role also in short-term memory. We investigated the functional relevance, spatial specificity, and temporal characteristics of human early visual cortex in the consolidation of capacity-limited topographic visual memory using transcranial magnetic stimulation (TMS). Topographically specific TMS pulses were delivered over lateralized occipital cortex at 100, 200, or 400 ms into the retention phase of a modified change detection task with low or high memory loads. For the high but not the low memory load, we found decreased memory performance for memory trials in the visual field contralateral, but not ipsilateral to the side of TMS, when pulses were delivered at 200 ms into the retention interval. A behavioral version of the TMS experiment, in which a distractor stimulus (memory mask) replaced the TMS pulses, further corroborated these findings. Our findings suggest that retinotopic visual cortex contributes to the short-term consolidation of topographic visual memory during early stages of the retention of visual information. Further, TMS-induced interference decreased the strength (amplitude) of the memory representation, which most strongly affected the high memory load trials.

Automatic and intentional number processing both rely on intact right parietal cortex: a combined FMRI and neuronavigated TMS study

Practice and training usually lead to performance increase in a given task. In addition, a shift from intentional toward more automatic processing mechanisms is often observed. It is currently debated whether automatic and intentional processing is subserved by the same or by different mechanism(s), and whether the same or different regions in the brain are recruited. Previous correlational evidence provided by behavioral, neuroimaging, modeling, and neuropsychological studies addressing this question yielded conflicting results. Here we used transcranial magnetic stimulation (TMS) to compare the causal influence of disrupting either left or right parietal cortex during automatic and intentional numerical processing, as reflected by the size congruity effect and the numerical distance effect, respectively. We found a functional hemispheric asymmetry within parietal cortex with only the TMS-induced right parietal disruption impairing both automatic and intentional numerical processing. In contrast, disrupting the left parietal lobe with TMS, or applying sham stimulation, did not affect performance during automatic or intentional numerical processing. The current results provide causal evidence for the functional relevance of right, but not left, parietal cortex for intentional, and automatic numerical processing, implying that at least within the parietal cortices, automatic, and intentional numerical processing rely on the same underlying hemispheric lateralization.

Transcranial Direct Current Stimulation of the Frontal Eye Fields during Pro- and Antisaccade Tasks

Transcranial direct current stimulation (tDCS) has been successfully applied to cortical areas such as the motor cortex and visual cortex. In the present study, we examined whether tDCS can reach and selectively modulate the excitability of the frontal eye field (FEF). In order to assess potential effects of tDCS, we measured saccade latency, landing point, and its variability in a simple prosaccade task and in an antisaccade task. In the prosaccade task, we found that anodal tDCS shortened the latency of saccades to a contralateral visual cue. However, cathodal tDCS did not show a significant modulation of saccade latency. In the antisaccade task, on the other hand, we found that the latency for ipisilateral antisaccades was prolonged during the stimulation, whereas anodal stimulation did not modulate the latency of antisaccades. In addition, anodal tDCS reduced the erroneous saccades toward the contralateral visual cue. These results in the antisaccade task suggest that tDCS modulates the function of FEF to suppress reflexive saccades to the contralateral visual cue. Both in the prosaccade and antisaccade tasks, we did not find any effect of tDCS on saccade landing point or its variability. Our present study is the first to show effects of tDCS over FEF and opens the possibility of applying tDCS for studying the functions of FEF in oculomotor and attentional performance.

Electric field calculations in brain stimulation based on finite elements: an optimized processing pipeline for the generation and usage of accurate individual head models

The need for realistic electric field calculations in human noninvasive brain stimulation is undisputed to more accurately determine the affected brain areas. However, using numerical techniques such as the finite element method (FEM) is methodologically complex, starting with the creation of accurate head models to the integration of the models in the numerical calculations. These problems substantially limit a more widespread application of numerical methods in brain stimulation up to now. We introduce an optimized processing pipeline allowing for the automatic generation of individualized high-quality head models from magnetic resonance images and their usage in subsequent field calculations based on the FEM. The pipeline starts by extracting the borders between skin, skull, cerebrospinal fluid, gray and white matter. The quality of the resulting surfaces is subsequently improved, allowing for the creation of tetrahedral volume head meshes that can finally be used in the numerical calculations. The pipeline integrates and extends established (and mainly free) software for neuroimaging, computer graphics, and FEM calculations into one easy-to-use solution. We demonstrate the successful usage of the pipeline in six subjects, including field calculations for transcranial magnetic stimulation and transcranial direct current stimulation. The quality of the head volume meshes is validated both in terms of capturing the underlying anatomy and of the well-shapedness of the mesh elements. The latter is crucial to guarantee the numerical robustness of the FEM calculations. The pipeline will be released as open-source, allowing for the first time to perform realistic field calculations at an acceptable methodological complexity and moderate costs.

Impairment of executive performance after transcranial magnetic modulation of the left dorsal frontal-striatal circuit

The dorsal frontal-striatal circuit is implicated in executive functions, such as planning. The Tower of London task, a planning task, in combination with off-line low-frequency repetitive transcranial magnetic stimulation (rTMS), was used to investigate whether interfering with dorsolateral prefrontal function would modulate executive performance, mimicking dorsal frontal-striatal dysfunction as found in neuropsychiatric disorders. Eleven healthy controls (seven females; mean age 25.5 years) were entered in a cross-over design: two single-session treatments of low-frequency (1 Hz) rTMS (vs. sham rTMS) for 20 min on the left dorsolateral prefrontal cortex (DLPFC). Directly following the off-line rTMS treatment, the Tower of London task was performed during MRI measurements. The low-frequency rTMS treatment impaired performance, but only when the subjects had not performed the task before: we found a TMS condition-by-order effect, such that real TMS treatment in the first session led to significantly more errors (P = 0.032), whereas this TMS effect was not present in subjects who received real TMS in the second session. At the neural level, rTMS resulted in decreased activation during the rTMS versus sham condition in prefrontal brain regions (i.e., premotor, dorsolateral prefrontal and anterior prefrontal cortices) and visuospatial brain regions (i.e., precuneus/cuneus and inferior parietal cortex). The results show that low-frequency off-line rTMS on the DLPFC resulted in decreased task-related activations in the frontal and visuospatial regions during the performance of the Tower of London task, with a behavioral effect only when task experience is limited.

Near and far space: Understanding the neural mechanisms of spatial attention

Visuospatial neglect is a multicomponent syndrome, and one dissociation reported is between neglect for near (peripersonal) and far (extrapersonal) space. Owing to patient heterogeneity and extensive lesions, it is difficult to determine the precise neural mechanisms underlying this dissociation using clinical methodology. In this study, transcranial magnetic stimulation was used to examine the involvement of three areas in the undamaged brain, while participants completed a conjunction search task in near and far space. The brain areas investigated were right posterior parietal cortex (rPPC), right frontal eye field (rFEF), and right ventral occipital cortex (rVO), each of which has been implicated in visuospatial processing. The results revealed a double dissociation, whereby rPPC was involved for search in near space only, whilst rVO only became necessary when the task was completed in far space. These data provide clear evidence for a dorsal and ventral dissociation between the processing of near and far space, which is compatible with the functional roles previously attributed to the two streams. For example, the involvement of the dorsal stream in near space reflects its role in vision for action, because it is within this spatial location that actions can be performed. The results also revealed that rFEF is involved in the processing of visual search in both near and far space and may contribute to visuospatial attention and/or the control of eye-movements irrespective of spatial frame. We discuss our results with respect to their clear ramifications for clinical diagnosis and neurorehabilitation.

Transcranial Magnetic Mapping of the Short-Latency Modulations of Corticospinal Activity from the Ipsilateral Hemisphere during Rest

Skilled hand function relies heavily on the integrity of the primary motor cortex (M1) and on a web of cortico-cortical connections projecting onto it. We used a novel explorative paradigm to map the origin of cortico-M1 pathways assessed by dual transcranial magnetic stimulation (TMS) in three healthy participants. Subthreshold conditioning TMS (cTMS) was delivered over a grid of ≈100 spots. Covering the left hemisphere, and was followed by suprathreshold test (tTMS) delivered over the ipsilateral M1. Grid points were tested eight times, with inter-stimulus intervals between cTMS and tTMS of 4 and 7 ms. Participants were asked to stay relaxed with no particular task. Motor evoked potentials (MEPs) from cTMS + tTMS were normalized to MEPs from tTMS alone and were compared to the value expected from tTMS alone using t-statistics. The t-values from each grid point were then used to plot statistical maps. Several foci of significant cortico-M1 interactions were found in the dorsal–medial frontal cortex, in the ventral frontal cortex, in the superior and inferior parietal lobules and in the parietal operculum. The majority of active foci had inhibitory effects on corticospinal excitability. The spatial location of the network of different subjects overlapped but with some anatomical variation of single foci. TMS statistical mapping during the resting state revealed a complex inhibitory cortical network. The explorative approach to TMS as a brain mapping tool produced results that are self-standing in single subjects overcoming inter-individual variability of cortical active sites.

Causal evidence for frontal involvement in memory target maintenance by posterior brain areas during distracter interference of visual working memory

Dorsolateral prefrontal cortex (DLPFC) is recruited during visual working memory (WM) when relevant information must be maintained in the presence of distracting information. The mechanism by which DLPFC might ensure successful maintenance of the contents of WM is, however, unclear; it might enhance neural maintenance of memory targets or suppress processing of distracters. To adjudicate between these possibilities, we applied time-locked transcranial magnetic stimulation (TMS) during functional MRI, an approach that permits causal assessment of a stimulated brain region's influence on connected brain regions, and evaluated how this influence may change under different task conditions. Participants performed a visual WM task requiring retention of visual stimuli (faces or houses) across a delay during which visual distracters could be present or absent. When distracters were present, they were always from the opposite stimulus category, so that targets and distracters were represented in distinct posterior cortical areas. We then measured whether DLPFC-TMS, administered in the delay at the time point when distracters could appear, would modulate posterior regions representing memory targets or distracters. We found that DLPFC-TMS influenced posterior areas only when distracters were present and, critically, that this influence consisted of increased activity in regions representing the current memory targets. DLPFC-TMS did not affect regions representing current distracters. These results provide a new line of causal evidence for a top-down DLPFC-based control mechanism that promotes successful maintenance of relevant information in WM in the presence of distraction.

Transcranial magnetic stimulation intensities in cognitive paradigms

Background

Transcranial magnetic stimulation (TMS) has become an important experimental tool for exploring the brain's functional anatomy. As TMS interferes with neural activity, the hypothetical function of the stimulated area can thus be tested. One unresolved methodological issue in TMS experiments is the question of how to adequately calibrate stimulation intensities. The motor threshold (MT) is often taken as a reference for individually adapted stimulation intensities in TMS experiments, even if they do not involve the motor system. The aim of the present study was to evaluate whether it is reasonable to adjust stimulation intensities in each subject to the individual MT if prefrontal regions are stimulated prior to the performance of a cognitive paradigm.

Methods and Findings

Repetitive TMS (rTMS) was applied prior to a working memory task, either at the ‘fixed’ intensity of 40% maximum stimulator output (MSO), or individually adapted at 90% of the subject's MT. Stimulation was applied to a target region in the left posterior middle frontal gyrus (pMFG), as indicated by a functional magnetic resonance imaging (fMRI) localizer acquired beforehand, or to a control site (vertex). Results show that MT predicted the effect size after stimulating subjects with the fixed intensity (i.e., subjects with a low MT showed a greater behavioral effect). Nevertheless, the individual adaptation of intensities did not lead to stable effects.

Conclusion

Therefore, we suggest assessing MT and account for it as a measure for general cortical TMS susceptibility, even if TMS is applied outside the motor domain.

An rTMS study into self-face recognition using video-morphing technique

Self-face recognition is a sign of higher order self-awareness. Research into the neuronal network argues that the visual pathway of recognizing one's own face differs from recognizing others. The present study aimed at investigating the cortical network of self-other discrimination by producing virtual lesions over the temporo-parietal junction and the prefrontal cortex using low-frequency repetitive transcranial magnetic stimulation (rTMS) in a sham-controlled design. Frontal and parietal areas were stimulated separately in consecutive sessions one week apart in 10 healthy subjects. We designed a video-task comprising morphings of famous, unfamiliar and the subjects' own faces that transformed into each other over a time period of six seconds. Reaction time (RT) was measured by pushing a mouse-button once a change of identity was recognized. rTMS over the right temporo-parietal junction led to a decrease in RT when a subject's own face emerged from a familiar face; a similar effect was observed after rTMS over right-prefrontal and left-parietal cortices, when the subjects' ratings of own likeability were taken into account. The transition from an unfamiliar face to one's own face indicated a left frontal lateralization.

Impairing somatosensory working memory using rTMS

Numerous studies in animals and humans have related central aspects of somatosensory working memory function to neural activity in the inferior frontal gyrus (IFG). However, as previous studies have almost exclusively used correlational analyses, the question whether sustained neural activity in the IFG is causally involved in successful maintenance of somatosensory information remains unanswered. We used an online repetitive transcranial magnetic stimulation (rTMS) protocol to disrupt neuronal activity in the IFG while participants were maintaining tactile information throughout the delay for later comparison against a probe stimulus. rTMS impaired participants' performance in the working memory task, but not in a physically matched perceptual control task. Targeting the IFG in either hemisphere led to comparable working memory impairment. Our results show that the neural activity in the IFG plays a causal role in successful maintenance of somatosensory information.

Distractibility in daily life is reflected in the structure and function of human parietal cortex

We all appreciate that some of our friends and colleagues are more distractible than others. This variability can be captured by pencil and paper questionnaires in which individuals report such cognitive failures in their everyday life. Surprisingly, these self-report measures have high heritability, leading to the hypothesis that distractibility might have a basis in brain structure. In a large sample of healthy adults, we demonstrated that a simple self-report measure of everyday distractibility accurately predicted gray matter volume in a remarkably focal region of left superior parietal cortex. This region must play a causal role in reducing distractibility, because we found that disrupting its function with transcranial magnetic stimulation increased susceptibility to distraction. Finally, we showed that the self-report measure of distractibility reliably predicted our laboratory-based measure of attentional capture. Our findings distinguish a critical mechanism in the human brain causally involved in avoiding distractibility, which, importantly, bridges self-report judgments of cognitive failures in everyday life and a commonly used laboratory measure of distractibility to the structure of the human brain.

Cross-modal Processing in the Occipito-temporal Cortex: A TMS Study of the Müller-Lyer Illusion

The Müller-Lyer illusion occurs both in vision and in touch, and transfers cross-modally from vision to haptics [Mancini, F., Bricolo, E., & Vallar, G. Multisensory integration in the Müller-Lyer illusion: From vision to haptics. Quarterly Journal of Experimental Psychology, 63, 818–830, 2010]. Recent evidence suggests that the neural underpinnings of the Müller-Lyer illusion in the visual modality involve the bilateral lateral occipital complex (LOC) and right superior parietal cortex (SPC). Conversely, the neural correlates of the haptic and cross-modal illusions have never been investigated previously. Here we used repetitive TMS (rTMS) to address the causal role of the regions activated by the visual illusion in the generation of the visual, haptic, and cross-modal visuo-haptic illusory effects, investigating putative modality-specific versus cross-modal underlying processes. rTMS was administered to the right and the left hemisphere, over occipito-temporal cortex or SPC. rTMS over left and right occipito-temporal cortex impaired both unisensory (visual, haptic) and cross-modal processing of the illusion in a similar fashion. Conversely, rTMS interference over left and right SPC did not affect the illusion in any modality. These results demonstrate the causal involvement of bilateral occipito-temporal cortex in the representation of the visual, haptic, and cross-modal Müller-Lyer illusion, in favor of the hypothesis of shared underlying processes. This indicates that occipito-temporal cortex plays a cross-modal role in perception both of illusory and nonillusory shapes.

Transcranial magnetic stimulation in cognitive rehabilitation

Repetitive transcranial magnetic stimulation (rTMS) can generate an increase or a decrease of neuronal excitability, which can modulate cognition and behaviour. Transcranial magnetic stimulation-induced cortical changes have been shown to result in neural plasticity. Thus, TMS provides an important opportunity to gain more insight into the mechanisms responsible for the remarkable flexibility of the central nervous system. The aim of this review was to cover the topics that could be useful when using TMS in the cognitive rehabilitation field after brain damage. The basic TMS principles are introduced, together with the clinical application for diagnosis and prognosis, the biological aspects, and the use in cognitive neuroscience studies. Finally, several hypotheses are discussed to explain the likely mechanisms induced by TMS that favour the recovery of a function after brain damage and cause the adult brain to undergo plasticity. The possibility of non-invasively interacting with the functioning of the brain and its plasticity mechanisms - a possibility that may eventually lead to cognitive and behavioural modifications - opens new and exciting scenarios in the cognitive neurorehabilitation field.