Transcranial Magnetic and Direct Current Stimulation in Children

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

Shortened Motor Evoked Potential Latency in the Epileptic Hemisphere of Children With Focal Epilepsy

PURPOSE

Motor evoked potential (MEP) amplitude and latency are acquired routinely during neuronavigated transcranial magnetic stimulation, a method of functional mapping of the motor cortex before epilepsy surgery. Although MEP amplitude is routinely used to generate a motor map, MEP latency in patients with focal epilepsy has not been studied systematically. Given that epilepsy may alter myelination, we tested whether intrinsic hand muscle MEPs obtained from the hemisphere containing a seizure focus differ in latency from MEPs collected from the opposite hemisphere.

METHODS

Latencies of abductor pollicis brevis MEPs were obtained during routine motor mapping by neuronavigated transcranial magnetic stimulation in children with intractable, unihemispheric focal epilepsy. The primary motor cortex was stimulated bilaterally in all cases. Only data from patients without a lesion involving the corticospinal tract were included. We tested whether abductor pollicis brevis MEP latency varied as a function of seizure focus lateralization.

RESULTS

In the 17 patients who met the inclusion criteria, the mean latency of MEPs with amplitudes in the top and bottom quartiles was shorter in the epileptic hemisphere. Interhemispheric latency difference was greater in patients with lesional epilepsy than in those with nonlesional epilepsy (0.7 ± 0.4 vs. 0.1 ± 0.6 milliseconds, P = 0.02).

CONCLUSIONS

Motor evoked potential latency was shortened in the epileptic hemisphere of children with focal epilepsy.

Therapeutic effects of repetitive transcranial magnetic stimulation in patients with cerebral palsy: a systematic review and network meta-analysis

The purpose of this study was to systematically evaluate the efficacy of repetitive transcranial magnetic stimulation in children with cerebral palsy and to compare the differences in efficacy of different treatment parameters. Computer searches of PubMed, Embase, Cochrane Library, Scopus, Web of Science, China Knowledge Network, Wanfang Data Knowledge Service Platform, Vipshop and China Biomedical Literature Database were conducted to collect randomized controlled trials (RCTs) of TMS to improve function in children with cerebral palsy. The search period was from the establishment of the database to April 2023. Two researchers independently screened the literature and extracted data information, and the risk of bias was assessed for the included studies using the Cochrane Systematic Evaluation Manual 5.1.0. Statistical analysis was performed using RevMan 5.4 and Stata software. A total of 18 studies containing 1675 patients with cerebral palsy were included, and r-TMS did not differ significantly from other treatments in improving language function [MD = 2.80, 95% CI (-1.51, 7.11), Z = 1.27, P = 0.20] after treatment. The results of the reticulated meta-analysis showed the best probability ranking of the effect of three different frequencies of r-TMS on motor function scores in children with cerebral palsy: combined LF-rTMS + HF-rTMS (49.8%) > LF-rTMS (45.6%) > HF-rTMS (4.6%) > conventional rehabilitation (0%). Publication bias showed no significant asymmetry in the inverted funnel plot, but the possibility of publication bias could not be excluded. The results of this study showed that r-TMS was not statistically significant in improving language function in children with cerebral palsy compared to conventional treatment. r-TMS was almost unanimously significantly effective in motor function in children with cerebral palsy according to current literature data, and the combined high- and low-frequency transcranial magnetic therapy was better than low-frequency transcranial magnetic therapy.

Human amniotic mesenchymal stromal cell-derived exosomes promote neuronal function by inhibiting excessive apoptosis in a hypoxia/ischemia-induced cerebral palsy model: A preclinical study

BACKGROUND

Cerebral palsy (CP) is a condition resulting from perinatal brain injury and can lead to physical disabilities. Exosomes derived from human amniotic mesenchymal stromal cells (hAMSC-Exos) hold promise as potential therapeutic options.

OBJECTIVE

This study aimed to investigate the impact of hAMSC-Exos on neuronal cells and their role in regulating apoptosis both in vitro and in vivo.

METHODS

hAMSC-Exos were isolated via ultracentrifugation and characterized via transmission electron microscopy, particle size analysis, and flow cytometry. In vitro, neuronal damage was induced by lipopolysaccharide (LPS). CP rat models were established via left common carotid artery ligation. Apoptosis levels in cells and CP rats were assessed using flow cytometry, quantitative reverse transcription polymerase chain reaction (RT-qPCR), Western blotting, and TUNEL analysis.

RESULTS

The results demonstrated successful isolation of hAMSC-Exos via ultracentrifugation, as the isolated cells were positive for CD9 (79.7%) and CD63 (80.2%). Treatment with hAMSC-Exos significantly mitigated the reduction in cell viability induced by LPS. Flow cytometry revealed that LPS-induced damage promoted apoptosis, but this effect was attenuated by treatment with hAMSC-Exos. Additionally, the expression of caspase-3 and caspase-9 and the Bcl-2/Bax ratio indicated that excessive apoptosis could be attenuated by treatment with hAMSC-Exos. Furthermore, tail vein injection of hAMSC-Exos improved the neurobehavioral function of CP rats. Histological analysis via HE and TUNEL staining showed that apoptosis-related damage was attenuated following hAMSC-Exo treatment.

CONCLUSIONS

In conclusion, hAMSC-Exos effectively promote neuronal cell survival by regulating apoptosis, indicating their potential as a promising therapeutic option for CP that merits further investigation.

Enhanced group-level dorsolateral prefrontal cortex subregion parcellation through functional connectivity-based distance-constrained spectral clustering with application to autism spectrum disorder

The dorsolateral prefrontal cortex (DLPFC) assumes a central role in cognitive and behavioral control, emerging as a crucial target region for interventions in autism spectrum disorder neuroregulation. Consequently, we endeavor to unravel the functional subregions within the DLPFC to shed light on the intricate functions of the brain. We introduce a distance-constrained spectral clustering (SC-DW) methodology that leverages functional connection to identify distinctive functional subregions within the DLPFC. Furthermore, we verify the relationship between the functional characteristics of these subregions and their clinical implications. Our methodology begins with principal component analysis to extract the salient features. Subsequently, we construct an adjacency matrix, which is constrained by the spatial properties of the brain, by linearly combining the distance matrix and a similarity matrix. The quality of spectral clustering is further optimized through multiple cluster evaluation coefficient. The results from SC-DW revealed four uniform and contiguous subregions within the bilateral DLPFC. Notably, we observe a substantial positive correlation between the functional characteristics of the third and fourth subregions in the left DLPFC with clinical manifestations. These findings underscore the unique insights offered by our proposed methodology in the realms of brain subregion delineation and therapeutic targeting.

The use of noninvasive brain stimulation techniques in autism spectrum disorder

Noninvasive brain stimulation (NIBS) techniques, including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), have recently emerged as alternative, nonpharmacological interventions for a variety of psychiatric, neurological, and neurodevelopmental conditions. NIBS is beginning to be applied in both research and clinical settings for the treatment of core and associated symptoms of autism spectrum disorder (ASD) including social communication deficits, restricted and repetitive behaviors, irritability, hyperactivity, depression and impairments in executive functioning and sensorimotor integration. Though there is much promise for these targeted device-based interventions, in other disorders (including adult major depressive disorder (MDD) and obsessive compulsive disorder (OCD) where rTMS is FDA cleared), data on the safety and efficacy of these interventions in individuals with ASD is limited especially in younger children when neurodevelopmental interventions typically begin. Most studies are open-label, small scale, and/or focused on a restricted subgroup of individuals with ASD. There is a need for larger, randomized controlled trials that incorporate neuroimaging in order to develop predictive biomarkers of treatment response and optimize treatment parameters. We contend that until such studies are conducted, we do not have adequate estimates of the safety and efficacy of NIBS interventions in children across the spectrum. Thus, broad off-label use of these techniques in this population is not supported by currently available evidence. Here we discuss the existing data on the use of NIBS to treat symptoms related to ASD and discuss future directions for the field.

The effects of transcranial direct current stimulation on cognitive function for mild cognitive impairment: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Transcranial direct current stimulation (tDCS) emerged as a potential modality for enhancing cognitive functions in patients with cognitive decline, including mild cognitive impairment (MCI). Our systematic review and meta-analysis aim to synthesize the available randomized controlled trials (RCTs) on the effects of tDCS on cognitive functions in patients with MCI.

METHODS

Our review protocol was registered on PROSPERO with ID: CRD42022360587. We conducted a systematic database search until September 2022. Standardized mean difference (SMD) and pooled effect size (ES) for robust variance estimation (RVE) method were used as effect estimates for our meta-analysis.

RESULTS

We included 11 RCTs with a total of 429 participants. The meta-analysis showed that, compared to sham groups, tDCS did not improve global functioning (measured by MOCA) (SMD = 0.02, CI =  - 0.30 to 0.35; p = 0.88), memory domain (ES = 0.681, CI =  - 2.15 to 3.51, p = 0.576), sustained attention (measured by TMT-A) (SMD =  - 0.21, CI =  - 0.52 to 0.10, p = 0.19), and executive function (measured by TMT-B) (SMD =  - 0.53, CI =  - 1.56 to 0.50, p = 0.20).

CONCLUSION

Our meta-analysis found no significant effect of tDCS on cognitive functions in MCI patients, including effects on global functioning, memory, sustained attention, and executive function. Therefore, an important change to be tested in future studies is to look for a better combination with tDCS for patients with MCI.

The Role of Neurophysiology in Managing Patients with Chiari Malformations

Chiari malformation type 1 (CM1) includes various congenital anomalies that share ectopia of the cerebellar tonsils lower than the foramen magnum, in some cases associated with syringomyelia or hydrocephalus. CM1 can cause dysfunction of the brainstem, spinal cord, and cranial nerves. This functional alteration of the nervous system can be detected by various modalities of neurophysiological tests, such as brainstem auditory evoked potentials, somatosensory evoked potentials, motor evoked potentials, electromyography and nerve conduction studies of the cranial nerves and spinal roots, as well as brainstem reflexes. The main goal of this study is to review the findings of multimodal neurophysiological examinations in published studies of patients with CM1 and their indication in the diagnosis, treatment, and follow-up of these patients, as well as their utility in intraoperative monitoring.

Optimizing TMS Coil Placement Approaches for Targeting the Dorsolateral Prefrontal Cortex in Depressed Adolescents: An Electric Field Modeling Study

High-frequency repetitive transcranial magnetic stimulation (rTMS) to the left dorsolateral prefrontal cortex (L-DLPFC) shows promise as a treatment for treatment-resistant depression in adolescents. Conventional rTMS coil placement strategies include the 5 cm, the Beam F3, and the magnetic resonance imaging (MRI) neuronavigation methods. The purpose of this study was to use electric field (E-field) models to compare the three targeting approaches to a computational E-field optimization coil placement method in depressed adolescents. Ten depressed adolescents (4 females, age: 15.9±1.1) participated in an open-label rTMS treatment study and were offered MRI-guided rTMS five times per week over 6-8 weeks. Head models were generated based on individual MRI images, and E-fields were simulated for the four targeting approaches. Results showed a significant difference in the induced E-fields at the L-DLPFC between the four targeting methods (χ2=24.7, p<0.001). Post hoc pairwise comparisons showed that there was a significant difference between any two of the targeting methods (Holm adjusted p<0.05), with the 5 cm rule producing the weakest E-field (46.0±17.4V/m), followed by the F3 method (87.4±35.4V/m), followed by MRI-guided (112.1±14.6V/m), and followed by the computational approach (130.1±18.1V/m). Variance analysis showed that there was a significant difference in sample variance between the groups (K2=8.0, p<0.05), with F3 having the largest variance. Participants who completed the full course of treatment had median E-fields correlated with depression symptom improvement (r=-0.77, p<0.05). E-field models revealed limitations of scalp-based methods compared to MRI guidance, suggesting computational optimization could enhance dose delivery to the target.

Sirtuins: Promising Therapeutic Targets to Treat Ischemic Stroke

Stroke is a major cause of mortality and disability globally, with ischemic stroke (IS) accounting for over 80% of all stroke cases. The pathological process of IS involves numerous signal molecules, among which are the highly conserved nicotinamide adenine dinucleotide (NAD+)-dependent enzymes known as sirtuins (SIRTs). SIRTs modulate various biological processes, including cell differentiation, energy metabolism, DNA repair, inflammation, and oxidative stress. Importantly, several studies have reported a correlation between SIRTs and IS. This review introduces the general aspects of SIRTs, including their distribution, subcellular location, enzyme activity, and substrate. We also discuss their regulatory roles and potential mechanisms in IS. Finally, we describe the current therapeutic methods based on SIRTs, such as pharmacotherapy, non-pharmacological therapeutic/rehabilitative interventions, epigenetic regulators, potential molecules, and stem cell-derived exosome therapy. The data collected in this study will potentially contribute to both clinical and fundamental research on SIRTs, geared towards developing effective therapeutic candidates for future treatment of IS.

The CBIT + TMS trial: study protocol for a two-phase randomized controlled trial testing neuromodulation to augment behavior therapy for youth with chronic tics

BACKGROUND

Comprehensive Behavioral Intervention for Tics (CBIT) is a first-line treatment for tic disorders that aims to improve controllability over tics that an individual finds distressing or impairing. However, it is only effective for approximately half of patients. Supplementary motor area (SMA)-directed neurocircuitry plays a strong role in motor inhibition, and activity in this region is thought to contribute to tic expression. Targeted modulation of SMA using transcranial magnetic stimulation (TMS) may increase CBIT efficacy by improving patients' ability to implement tic controllability behaviors.

METHODS

The CBIT + TMS trial is a two-phase, milestone-driven early-stage randomized controlled trial. The trial will test whether augmenting CBIT with inhibitory, non-invasive stimulation of SMA with TMS modifies activity in SMA-mediated circuits and enhances tic controllability in youth ages 12-21 years with chronic tics. Phase 1 will directly compare two rTMS augmentation strategies (1 Hz rTMS vs. cTBS) vs. sham in N = 60 participants. Quantifiable, a priori "Go/No Go Criteria" guide the decision to proceed to phase 2 and the selection of the optimal TMS regimen. Phase 2 will compare the optimal regimen vs. sham and test the link between neural target engagement and clinical outcomes in a new sample of N = 60 participants.

DISCUSSION

This clinical trial is one of few to date testing TMS augmentation of therapy in a pediatric sample. The results will provide insight into whether TMS is a potentially viable strategy for enhancing CBIT efficacy and reveal potential neural and behavioral mechanisms of change.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04578912 . Registered on October 8, 2020.

The CBIT+TMS Trial: study protocol for a two-phase randomized controlled trial testing neuromodulation to augment behavior therapy for youth with chronic tics

Background

Comprehensive Behavioral Intervention for Tics (CBIT) is a first-line treatment for tic disorders that aims to improve controllability over tics that an individual finds distressing or impairing. However, it is only effective for approximately half of patients. Supplementary motor area (SMA)-directed neurocircuitry plays a strong role in motor inhibition, and activity in this region is thought to contribute to tic expression. Targeted modulation of SMA using transcranial magnetic stimulation (TMS) may increase CBIT efficacy by improving patient ability to implement tic controllability behaviors.

Methods

The CBIT+TMS trial is a two-phase, milestone driven early-stage randomized controlled trial. The trial will test whether augmenting CBIT with inhibitory, noninvasive stimulation of SMA with TMS modifies activity in SMA-mediated circuits and enhances tic controllability in youth ages 12-21 years with chronic tics. Phase 1 will directly compare two rTMS augmentation strategies (1Hz rTMS vs. cTBS) vs. sham in N = 60 participants. Quantifiable, a priori "Go/No Go Criteria" guide the decision to proceed to Phase 2 and selection of the optimal TMS regimen. Phase 2 will compare the optimal regimen vs. sham and test the link between neural target engagement and clinical outcomes in a new sample of N = 60 participants.

Discussion

This clinical trial is one of few to date testing TMS augmentation of therapy in a pediatric sample. Results will provide insight into whether TMS is a potentially viable strategy for enhancing CBIT efficacy and reveal potential neural and behavioral mechanisms of change.

Trial registration

ClinicalTrials.gov Identifier: NCT04578912.

Combined treatment of nerve growth factor and transcranical direct current stimulations to improve outcome in children with vegetative state after out-of-hospital cardiac arrest

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is one of the most dramatic events in pediatric age and, despite advanced neurointensive care, the survival rate remains low. Currently, no effective treatments can restore neuronal loss or produce significant improvement in these patients. Nerve Growth Factor (NGF) is a neurotrophin potentially able to counteract many of the deleterious effects triggered by OHCA. Transcranial Direct Current Stimulation (tDCS) has been reported to be neuroprotective in many neurological diseases, such as motor deficit and cognitive impairment. Children with the diagnosis of chronic vegetative state after OHCA were enrolled. These patients underwent a combined treatment of intranasal administration of human recombinant NGF (hr-NGF), at a total dose of 50 gamma/kg, and tDCS, in which current intensity was increased from zero to 2 mA from the first 5 s of stimulation and maintained constant for 20 min. The treatment schedule was performed twice, at one month distance each. Neuroradiogical evaluation with Positron Emission Tomography scan (PET), Single Photon Emission Computed Tomography (SPECT), Electroencephalography (EEG) and Power Spectral Density of the brain (PSD) was determined before the treatment and one month after the end. Neurological assessment was deepened by using modified Ashworth Scale, Gross Motor Function Measure, and Disability Rating Scale.

RESULTS

Three children with a chronic vegetative state secondary to OHCA were treated. The combined treatment with hr-NGF and tDCS improved functional (PET and SPECT) and electrophysiological (EEG and PSD) assessment. Also clinical conditions improved, mainly for the reduction of spasticity and with the acquisition of voluntary finger movements, improved facial mimicry and reaction to painful stimuli. No side effects were reported.

CONCLUSIONS

These promising preliminary results and the ease of administration of this treatment make it worthwhile to be investigated further, mainly in the early stages from OHCA and in patients with better baseline neurological conditions, in order to explore more thoroughly the benefits of this new approach on neuronal function recovery after OHCA.

A bibliometric analysis of global research status and trends in neuromodulation techniques in the treatment of autism spectrum disorder

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disease which has risen to become the main cause of childhood disability, placing a heavy burden on families and society. To date, the treatment of patients with ASD remains a complicated problem, for which neuromodulation techniques are a promising solution. This study analyzed the global research situation of neuromodulation techniques in the treatment of ASD from 1992 to 2022, aiming to explore the global research status and frontier trends in this field.

METHODS

The Web of Science (WoS) was searched for literature related to neuromodulation techniques for ASD from 1992 to October 2022. A knowledge atlas to analyze collaboration among countries, institutions, authors, publishing journals, reference co-citation patterns, keyword co-occurrence, keyword clustering, and burst keywords was constructed using Rstudio software, CiteSpace, and VOSviewer.

RESULTS

In total, 392 publications related to the treatment of ASD using neuromodulation techniques were included. Despite some fluctuations, the number of publications in this field has shown a growing trend in recent years. The United States and Deakin University are the leading country and institution in this field, respectively. The greatest contributing authors are Peter G Enticott, Manuel F Casanova, and Paul B Fitzgerald et al. The most prolific and cited journal is Brain Stimulation and the most commonly co-cited journal is The Journal of Autism and Developmental Disorders. The most frequently cited article was that of Simone Rossi (Safety, ethical considerations, and application guidelines for the use of transverse magnetic stimulation in clinical practice and research, 2009). "Obsessive-compulsive disorder," "transcranial direct current stimulation," "working memory," "double blind" and "adolescent" were identified as hotspots and frontier trends of neuromodulation techniques in the treatment of ASD.

CONCLUSION

The application of neuromodulation techniques for ASD has attracted the attention of researchers worldwide. Restoring the social ability and improving the comorbid symptoms in autistic children and adults have always been the focus of research. Neuromodulation techniques have demonstrated significant advantages and effects on these issues. Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are new therapeutic methods introduced in recent years, and are also directions for further exploration.

Effects of transcranial direct current stimulation in children and young people with psychiatric disorders: a systematic review

Transcranial direct current stimulation (tDCS) has demonstrated benefits in adults with various psychiatric disorders, but its clinical utility in children and young people (CYP) remains unclear. This PRISMA systematic review used published and ongoing studies to examine the effects of tDCS on disorder-specific symptoms, mood and neurocognition in CYP with psychiatric disorders. We searched Medline via PubMed, Embase, PsychINFO via OVID, and Clinicaltrials.gov up to December 2022. Eligible studies involved multiple session (i.e., treatment) tDCS in CYP (≤ 25 years old) with psychiatric disorders. Two independent raters assessed the eligibility of studies and extracted data using a custom-built form. Of 33 eligible studies (participant N = 517), the majority (n = 27) reported an improvement in at least one outcome measure of disorder-specific symptoms. Few studies (n = 13) examined tDCS effects on mood and/or neurocognition, but findings were mainly positive. Overall, tDCS was well tolerated with minimal side effects. Of 11 eligible ongoing studies, many are sham-controlled RCTs (n = 9) with better blinding techniques and a larger estimated participant enrolment (M = 79.7; range 15-172) than published studies. Although encouraging, the evidence to date is insufficient to firmly conclude that tDCS can improve clinical symptoms, mood, or cognition in CYP with psychiatric disorders. Ongoing studies appear of improved methodological quality; however, future studies should broaden outcome measures to more comprehensively assess the effects of tDCS and develop dosage guidance (i.e., treatment regimens).

Comparison of coil placement approaches targeting dorsolateral prefrontal cortex in depressed adolescents receiving repetitive transcranial magnetic stimulation: an electric field modeling study

Background

A promising treatment option for adolescents with treatment-resistant depression is high-frequency repetitive transcranial magnetic stimulation (rTMS) delivered to the left dorsolateral prefrontal cortex (L-DLPFC). Conventional coil placement strategies for rTMS in adults include the 5-cm rule, the Beam F3 method, and the magnetic resonance imaging (MRI) neuronavigation method. The purpose of this study was to compare the three targeting approaches to a computational E-field optimization coil placement method in depressed adolescents.

Methods

Ten consenting and assenting depressed adolescents (4 females, age: 15.9 ± 1.1) participated in an open-label rTMS treatment study. Participants were offered MRI-guided rTMS 5 times per week over 6-8 weeks. To compute the induced E-field, a head model was generated based on MRI images, and a figure-8 TMS coil (Neuronetics) was placed over the L-DLPFC using the four targeting approaches.

Results

Results show that there was a significant difference in the induced E-field at the L-DLPFC between the four targeting methods ( χ 2 = 24.7, p < 0.001). Post hoc pairwise comparisons show that there was a significant difference between any two of the targeting methods (Holm adjusted p < 0.05), with the 5-cm rule producing the weakest E-field (46.0 ± 17.4 V/m), followed by the F3 method (87.4 ± 35.4 V/m), followed by the MRI-guided (112.1 ± 14.6 V/m), and followed by the computationally optimized method (130.1 ± 18.1 V/m). The Bartlett test of homogeneity of variances show that there was a significant difference in sample variance between the groups ( K 2 = 8.0, p < 0.05), with F3 having the largest variance. In participants who completed the full course of treatment, the median E-field strength in the L-DLPFC was correlated with the change in depression severity ( r = - 0.77, p < 0.05).

Conclusions

The E-field models revealed inadequacies of scalp-based targeting methods compared to MRI-guidance. Computational optimization may further enhance E-field dose delivery to the treatment target.

Effects of repetitive transcranial magnetic stimulation on motor function and language ability in cerebral palsy: A systematic review and meta-analysis

OBJECTIVE

This review was conducted to assess the quality of the evidence of effectiveness of repetitive transcranial magnetic stimulation (rTMS) in treating motor and language ability of cerebral palsy (CP).

METHOD

Medline, Cochrane library, Web of Science, Embase, PubMed, and CNKI databases were searched up to July 2021 by two independent reviewers. Randomized controlled trials (RCTs) that were published in English and Chinese and met the following criteria were included. The population comprised patients who met the diagnostic criteria for CP. Intervention included the following: comparison about rTMS and sham rTMS or comparison about rTMS combine with other physical therapy and other physical therapy. Outcomes included motor function, as follows: gross motor function measure (GMFM), Gesell Development Diagnosis Scale, fine motor function measure (FMFM), Peabody developmental motor scale, and Modified Ashworth scale. For language ability, sign-significant relation (S-S) was included. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Finally, 29 studies were included in the meta-analysis. Results of evaluation using the Cochrane Collaborative Network Bias Risk Assessment Scale showed that 19 studies specifically explained randomization, among which two studies described allocation concealment, four studies blinded participants and persons and had low risk of bias, and six studies explained that the assessment of outcome measures was blinded. Significant improvements in motor function were observed. The GMFM of total score was determined by using the random-effect model [I2= 88%; MD = -1.03; 95% CI (-1.35, -0.71); P < 0.0001] and FMFM was determined by using the fixed-effect model [P = 0.40 and I2 = 3%; SMDs = -0.48, 95% CI (-0.65, -0.30); P < 0.01]. For language ability, the language improvement rate was determined using a fixed-effect model [P = 0.88 and I2 = 0%; MD = 0.37, 95% CI (0.23, 0.57); P < 0.01]. According to the PEDro scale, 10 studies had low-quality, four studies had excellent quality, and the other studies had good quality. Using the GRADEpro GDT online tool, we included a total of 31 outcome indicators, as follows: 22 for low quality, seven for moderate quality, and two for very low quality.

CONCLUSION

The rTMS could improve the motor function and language ability of patients with CP. However, rTMS prescriptions varied, and the studies had low sample sizes. Studies using rigorous and standard research designs about prescriptions and large samples are needed to collect sufficient evidence about the effectiveness of using rTMS to treat patients with CP.

Management of Children with Speech Disorders via Transcranial Magnetic Stimulation: Non-Randomized Controlled Study

Background. Speech development impairment is urgent and common problem in pediatric neurology. Transcranial magnetic stimulation (TMS) is one of the promising treatment variants for children with speech disorders. Objective. The aim of the study is to evaluate efficacy and safety of the developed approaches to TMS usage in the management of children with speech disorders. Methods. It was non-randomized controlled study. It included 46 children with speech disorders aged from 3 to 6.5 years. All children were divided into two groups comparable by gender and age: 26 children of the treatment group received TMS course, 20 children of the control group received treatment with hopantenic acid. All patients with speech disorders underwent psychological and pedagogical evaluation of speech and cognitive development, electroencephalography (EEG) before and after treatment. Moreover, comparative analysis of TMS and nootropic therapy efficacy was carried out. Specialized examination of speech and cognitive development was also performed via E.A. Strebeleva method for psychological and pedagogical diagnosis of children development. Furthermore, we carried out side reactions / adverse events registration according to patients and/or their parents complaints confirmed by physical examination, patient’s behavior observation, data from specially developed questionnaire for assessing child’s behavior and well-being (filled up by parents). Finally, we evaluated brain bioelectric activity recorded by EEG. Results. The study results have shown that it is possible to achieve significant positive dynamics in cognitive and speech development in preschool children with speech disorders in both groups (TMS course and medical treatment). But hereby, TMS treatment has demonstrated significantly higher positive dynamics in two out of the three evaluated parameters. There were no cases of adverse events in TMS group leading to early course discontinuation. Conclusion. TMS is non-invasive and safe method for treatment of children with speech disorders. This study has demonstrated the efficacy of the method in the field of personalized management of children with impaired speech and cognitive development.

Can brain stimulation enhance cognition in clinical populations? A critical review

Many psychiatric and neurological conditions are associated with cognitive impairment for which there are very limited treatment options. Brain stimulation methodologies show promise as novel therapeutics and have cognitive effects. Electroconvulsive therapy (ECT), known more for its related transient adverse cognitive effects, can produce significant cognitive improvement in the weeks following acute treatment. Transcranial magnetic stimulation (TMS) is increasingly used as a treatment for major depression and has acute cognitive effects. Emerging research from controlled studies suggests that repeated TMS treatments may additionally have cognitive benefit. ECT and TMS treatment cause neurotrophic changes, although whether these are associated with cognitive effects remains unclear. Transcranial electrical stimulation methods including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS) are in development as novel treatments for multiple psychiatric conditions. These treatments may also produce cognitive enhancement particularly when stimulation occurs concurrently with a cognitive task. This review summarizes the current clinical evidence for these brain stimulation treatments as therapeutics for enhancing cognition. Acute, or short-lasting, effects as well as longer-term effects from repeated treatments are reviewed, together with potential putative neural mechanisms. Areas of future research are highlighted to assist with optimization of these approaches for enhancing cognition.

Effects of Transcranial Magnetic Stimulation Combined with Computer-Aided Cognitive Training on Cognitive Function of Children with Cerebral Palsy and Dysgnosia

Objective

This study is aimed at researching transcranial magnetic stimulation (TMS) effects combined with computer-aided cognitive training (CACT) on cognitive function of children suffering from cerebral palsy and dysgnosia.

Methods

From December 2019 to October 2021, 86 children with cerebral palsy and dysgnosia who were treated at our hospital were recruited and assigned into observation and control groups (n = 43, each) using the random number table technique. The observation group received TMS combined with CACT (TMS+CACT), whereas the control group received only TMS. Chinese Wechsler Young Children Scale of Intelligence (C-WYCSI) and Chinese-Wechsler Intelligence Scale for Children (C-WISC) were used to evaluate the intelligence level of the two groups; Gross Motor Function Measure-88 (GMFM-88) of Fudan Chinese version was employed for evaluating the gross motor function of the two groups; a comparison was drawn among the two groups for the cerebral hemodynamic parameters before and after the treatment.

Results

For young children, the verbal intelligence quotient (VIQ) scores at 6 and 12 weeks of treatment in the observation group were increased when compared to those in the control group (48.91 ± 3.70 vs. 47.32 ± 3.33, 54.25 ± 4.46 vs. 49.48 ± 3.36), and the observation group's performance intelligence quotient (PIQ) score at 12 weeks of treatment was higher as to that of the control group (65.38 ± 4.23 vs. 62.81 ± 4.74, all P < 0.05). For older age children, the observation group's VIQ and PIQ scores were greater than the control group's at 6 and 12 weeks of treatment, with statistical significance (63.80 ± 3.76 vs. 59.50 ± 5.32, 74.64 ± 12.04 vs. 65.08 ± 6.30; 63.91 ± 5.96 vs. 58.42 ± 3.70, 72.73 ± 5.06 vs. 66.42 ± 5.93; all P < 0.05). The GMFM-88 scale scores in both groups were increased after 6 and 12 weeks of treatment. After treatment for 12 weeks, the observation group's A-E scores were greater than those of the control group (all P < 0.05). The peak systolic velocity (V s), end-diastolic velocity (V d), and mean velocity (V m) at the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) in the observation group were dramatically increased than those in the control group (all P < 0.05) after 12 weeks of treatment.

Conclusion

TMS+CACT can effectively improve the intelligence level, cognitive ability, gross motor function, and cerebral blood flow of children suffering from cerebral palsy and intellectual disability.

Transcranial Direct Current Stimulation in Treatment of Child Neuropsychiatric Disorders: Ethical Considerations

Transcranial direct current stimulation (tDCS) is a noninvasive electrical stimulation performed using low electric currents passing through two electrodes. The provided current passes from the anode to the cathode and induces electric fields in the surface neurons. It then modulates synaptic plasticity and finally changes cortical excitability or improves clinical outcomes, which outlast after a duration of stimulation. Meta-analyses have supported the beneficial effects of tDCS treatments in child neuropsychiatric disorders. However, the study of vulnerable children remains controversial and is a great deal for ethical considerations. Because the developing brain has some important physiological differences from the matured brain, specifically less γ-aminobutyric acid (GABA)ergic inhibition and more myelination, the opportunity to modify neurological disorders to be close to the normal level in childhood after tDCS is likely to be higher than in adults. In contrast, these physiological differences may result in unexpected excitability in children's brains and were criticized to have an unsafe effect, specifically seizures, which is a serious adverse events. As mentioned above, using tDCS in children appears to be a double-edged sword and should be ethically considered prior to wide use. Assessing between benefits of tDCS treatment within the golden period of brain development and the risk of seizure provocation is important. Thus, this perspective article is aimed to exhibit broad concepts about the developing brain, tDCS in children, pathophysiology of neuropsychiatric disorders and tDCS beneficence, tDCS safety and tolerability in children, and missing good opportunities or taking risks in tDCS.

Transcranial Direct Current Stimulation Enhances Cognitive Function in Patients with Mild Cognitive Impairment and Early/Mid Alzheimer’s Disease: A Systematic Review and Meta-Analysis

Transcranial direct current stimulation (tDCS) i a non-invasive brain stimulation which is considered to have the potential to improve cognitive impairment in patients with mild cognitive impairment (MCI) and Alzheimer’s disease (AD). However, previous studies have been controversial on the therapeutic effect of tDCS. This meta-analysis aimed to evaluate the effects of tDCS on cognitive impairment in patients with MCI and mild-to-moderate AD. Five databases, namely PubMed, EMBASE, MEDLINE, Web of Science and The Cochrane Library, were searched with relative terms to extract the cognitive function changes measured by an objective cognitive scale in the included studies. The meta-analysis results showed that, compared with sham tDCS treatment, the overall cognitive function of patients with AD and MCI was significantly improved (weighted mean difference = 0.99; 95% confidence interval, 0.32 to 1.66; p = 0.004) after tDCS treatment, but the behavioral symptoms, recognition memory function, attention and executive function were not significantly improved. The subgroup analysis showed that the treatment would be more efficacious if the temporal-lobe-related brain areas were stimulated, the number of stimulations was greater than or equal to 10 and the current density was 2.5 mA/cm2. Among them, AD patients benefited more than MCI patients. No cognitive improvement was observed in patients with MCI or AD at different follow-up times after treatment. Our meta-analysis provided important evidence for the cognitive enhancement of tDCS in patients with MCI and mild-to-moderate AD and discussed its underlying mechanisms.

Efficacy of transcranial Direct Current Stimulation (tDCS) combined with intensive speech therapy for language production in monozygotic twins with corpus callosum dysgenesis (CCD): A sham-controlled single subject study

The purpose of this single subject study was to investigate whether transcranial direct current stimulation (tDCS) applied to both hemispheres combined with speech therapy can improve language learning in a pair of 5-year-old twins with corpus callosum dysgenesis (CCD). The treatment protocol included anodal tDCS with simultaneous speech therapy in one of the participants (T.D.), and sham-tDCS with the same montage, and stimulation regime concomitant with speech therapy for the other twin (A.D.). Our findings show that T.D. improved in language production when treated with speech therapy in combination with tDCS. A.D. showed evidence for a relatively minor behavioral benefit from speech therapy.

The Sensory Abnormality Mediated Partially the Efficacy of Repetitive Transcranial Magnetic Stimulation on Treating Comorbid Sleep Disorder in Autism Spectrum Disorder Children

Sleep disorder emerges as a common comorbidity in children with autism spectrum disorder (ASD), and the interaction between the core symptoms of ASD and its sleep disorder remains unclear. Repetitive transcranial magnetic stimulation (rTMS) was used on the bilateral dorsolateral prefrontal cortex (DLPFC) to investigate the efficacy of rTMS on the core symptoms of ASD and comorbid sleep problems as well as the mediation role of the ASD symptoms between rTMS intervention and sleep improvement. A total of 41 Chinese children with ASD and who met the criteria in the fifth edition of the American Diagnostic and Statistical Manual of Mental Disorders were recruited, and 39 of them (mean age: 9.0 ± 4.4 years old; the male-female ratio was 3.9: 1) completed the study with the stimulating protocol of high frequency on the left DLPFC and low frequency on the right DLPFC. They were all assessed three times (before, at 4 weeks after, and at 8 weeks after the stimulation) by the Children's Sleep Habits Questionnaire (CSHQ), Strengths and Difficulties Questionnaire (SDQ), Childhood Autism Rating Scale, Repetitive Behavior Questionnaire-2, and Short Sensory Profile (SSP). The repeated-measures ANOVA showed that the main effect of "intervention time" of CSHQ (F = 25.103, P < 0.001), SSP (F = 6.345, P = 0.003), and SDQ (F = 9.975, P < 0.001) was statistically significant. By Bayesian mediation analysis, we only found that the total score of SSP mediated the treating efficacy of rTMS on CSHQ (αβ = 5.11 ± 1.51, 95% CI: 2.50-8.41). The percentage of mediation effect in total effect was 37.94%. Our results indicated the treating efficacy of rTMS modulation on bilateral DLPFC for both autistic symptoms and sleep disturbances. The sensory abnormality of ASD mediated the improvement of rTMS on sleep problems of ASD.

Brain Stimulation for Emotion Regulation in Adolescents With Psychiatric Disorders: Study Protocol for a Clinical-Transdiagnostical, Randomized, Triple-Blinded and Sham-Controlled Neurotherapeutic Trial

BACKGROUND

Anxiety, conduct and depressive disorders represent three highly prevalent psychiatric conditions in adolescents. A shared underpinning of these disorders is a shortcoming in emotion regulation, connected to the functioning of the ventromedial prefrontal cortex. Thus, an intervention able to target the suggested neural correlate seems to be highly desirable, aiming to hinder a maladaptive development of emotion regulation abilities and chronification of associated psychiatric disorders. As transcranial direct current stimulation (tDCS) was repeatedly demonstrated as a safe and non-invasive method to modulate specific brain activity, research is in demand to evaluate neurotherapeutic applications in adolescents with psychiatric disorders.

METHOD

This transdiagnostic, randomized, triple-blind and sham-controlled clinical neurostimulation trial primary aims to investigate if emotion regulation abilities are increased after tDCS in adolescents with psychiatric disorders. Secondly, disorder-specific changes in the anxiety, depression or conduct disorder will be investigated, as well as changes in quality of life, and cognitive and emotional functioning after tDCS intervention. We will include 108 adolescents with psychiatric disorders, displaying a substantial deficit in emotion regulation. Of these, one third each has to be primarily diagnosed with a depressive, anxiety or conduct disorder, respectively. Participants will be randomized to the experimental group (n = 54) receiving real anodal tDCS, or to the control group (n = 54) receiving sham tDCS. Brain stimulation will be applied for 20 min on five consecutive days twice targeting the ventromedial prefrontal cortex (vmPFC). Changes in emotion regulation, together with changes in disorder-specific clinical symptoms will be recorded by multi-informant psychological ratings. To inspect changes in behavior and gaze, computerized tasks and an eye tracker system will be used. Changes in brain responses to emotional and cognitive stimuli will be examined with three functional magnetic resonance imaging (fMRI) paradigms. In addition, a resting state MRI will be acquired to investigate possible changes in brain connectivity.

DISCUSSION

By investigating "emotion regulation" as transdiagnostic treatment target, this project is oriented toward the Research Domain Criteria framework with a dimensional view on mental illness. The study aims at investigating the potential of tDCS as non-invasive intervention for depressive, anxiety and conduct disorders in adolescents and broadening the scientific foundation for its clinical application.

CLINICAL TRIAL REGISTRATION

The study is ongoing and has been registered in the German Registry of Clinical Trials (DRKS-ID: DRKS00025601X) on the 28.06.2021.

Combined effect of hydrotherapy and transcranial direct-current stimulation on children with cerebral palsy: A protocol for a randomized controlled trial

BACKGROUND

Cerebral palsy (CP) is a neurodevelopmental disorder caused by a brain injury resulting in poor coordination and motor control deficits, which is one of the most common physical disabilities in children. CP brings a heavy burden on families and society and becomes a significant public health issue. In recent years, hydrotherapy, and transcranial direct current stimulation (tDCS) as a physical therapy for CP is developing rapidly. When hydrotherapy and tDCS are used to treat separately, it has positive therapeutic effect in children with CP. The development of new therapies in combination with physical rehabilitation approaches is critical to optimize functional outcomes. tDCS has attracted interest in this context, because of significant functional improvements have been demonstrated in individuals with brain injuries after a short period of cerebral stimulation. Since the onset of this work, tDCS has been used in combination with constraint-induced therapy, virtual reality therapy to potentiate the treatment effect. Up to now, there are no studies on the effect of a combined application of hydrotherapy and tDCS in children with CP. We will conduct a 2-arm parallel clinical trial to investigate the effect of a combined application of tDCS and hydrotherapy.

METHODS AND ANALYSIS

This study is an outcome assessor and data analyst-blinded, randomized, controlled superiority trial during the period from October 2021 to December 2023. CP patients meeting the inclusion criteria will be allocated in a 1:1 ratio into the treatment group (hydrotherapy plus tDCS), or the control group (treatment as usual). All participants will receive 30 sessions of treatment over 10 weeks. The primary outcomes will be the difference in the Gross Motor Function Assessment and Pediatric Balance Scale during rest and activity. The secondary outcomes will be the difference in adverse effects between the control and treatment groups.

CONCLUSIONS

This study aims to estimate the efficacy of a combined application of tDCS and hydrotherapy in patients with CP.

TRIAL REGISTRATION

This study protocol was registered in Chinese ClinicalTrials.gov, ID: ChiCTR2100047946.

Transcranial Magnetic Stimulation in Succinic Semialdehyde Dehydrogenase Deficiency: A Measure of Maturational Trajectory of Cortical Excitability

BACKGROUND

Succinic semialdehyde dehydrogenase deficiency (SSADHD) is a disorder of GABA degradation with use-dependent downregulation of postsynaptic GABA_A/B receptors. We aim to measure the resulting cortical excitation: inhibition ratio using transcranial magnetic stimulation.

METHODS

In this single-center observational study, 18 subjects with SSADHD and 8 healthy controls underwent transcranial magnetic stimulation. Resting motor threshold, cortical silent period, and long-interval intracortical inhibition were measured in both groups. Resting motor threshold in focal epilepsy patients from an institutional transcranial magnetic stimulation database were also included.

RESULTS

SSADHD subjects had higher resting motor threshold than healthy controls but lower relative to focal epilepsy patients. Resting motor threshold decreased with age in all groups. Cortical silent period was longer in SSADHD subjects than in healthy controls. No difference was detected in long-interval intracortical inhibition between the 2 groups.

CONCLUSION

Findings suggest abnormal corticospinal tract physiology in SSADHD, but with preserved developmental trajectory for corticospinal tract maturation. Defining features of these transcranial magnetic stimulation metrics in SSADHD will be better elucidated through this ongoing longitudinal study.

Boosting Numerical Cognition in Children and Adolescents with Mathematical Learning Disabilities by a Brain-Based Intervention: A Study Protocol for a Randomized, Sham-Controlled Clinical Trial

Numbers are everywhere, and supporting difficulties in numerical cognition (e.g., mathematical learning disability (MLD)) in a timely, effective manner is critical for their daily use. To date, only low-efficacy cognitive-based interventions are available. The extensive data on the neurobiology of MLD have increased interest in brain-directed approaches. The overarching goal of this study protocol is to provide the scientific foundation for devising brain-based and evidence-based treatments in children and adolescents with MLD. In this double-blind, between-subject, sham-controlled, randomized clinical trial, transcranial random noise stimulation (tRNS) plus cognitive training will be delivered to participants. Arithmetic, neuropsychological, psychological, and electrophysiological measures will be collected at baseline (T0), at the end of the interventions (T1), one week (T2) and three months later (T3). We expect that tRNS plus cognitive training will significantly improve arithmetic measures at T1 and at each follow-up (T2, T3) compared with placebo and that such improvements will correlate robustly and positively with changes in the neuropsychological, psychological, and electrophysiological measures. We firmly believe that this clinical trial will produce reliable and positive results to accelerate the validation of brain-based treatments for MLD that have the potential to impact quality of life.

Non-invasive brain stimulation as therapy: systematic review and recommendations with a focus on the treatment of Tourette syndrome

Tourette syndrome (TS) is a neurodevelopmental condition characterised by tics, which are stereotyped movements and/or vocalisations. Tics often cause difficulties in daily life and many with TS express a desire to reduce and/or gain control over them. No singular effective treatment exists for TS, and while pharmacological and behavioural interventions can be effective, the results are variable, and issues relating to access, availability and side effects can be barriers to treatment. Consequently, over the past decade, there has been increasing interest into the potential benefits of non-invasive brain stimulation (NIBS) approaches. This systematic review highlights work exploring NIBS as a potential treatment for TS. On balance, the results tentatively suggest that multiple sessions of stimulation applied over the supplementary motor area (SMA) may help to reduce tics. However, a number of methodological and theoretical issues limit the strength of this conclusion, with the most problematic being the lack of large-scale sham-controlled studies. In this review, methodological and theoretical issues are discussed, unanswered questions highlighted and suggestions for future work put forward.

Transcranial direct-current stimulation protects against cerebral ischemia-reperfusion injury through regulating Cezanne-dependent signaling

Transcranial direct-current stimulation (tDCS) is proved safe and shows therapeutic effect in cerebral ischemic stroke in clinical trials. But the underlying molecular mechanisms remain unclear. Here we show that tDCS treatment reduces the infarct volume after rat cerebral ischemia-reperfusion (I/R) injury and results in functional improvement of stroke animals. At the cellular and molecular level, tDCS suppresses I/R-induced upregulation of Cezanne in the ischemic neurons. Cezanne inhibition confers neuroprotection after rat I/R and oxygen glucose deprivation (OGD) in the cortical neuronal cultures. Inhibiting Cezanne increases the level of SIRT6 that is downregulated in the ischemic neurons. Suppressing SIRT6 blocks Cezanne inhibition-induced neuroprotective effect and overexpressing SIRT6 attenuates OGD-induced neuronal death. We further show that downregulating Cezanne reduces DNA double-strand break (DSB) through upregulation of SIRT6 in OGD-insulted neurons. Together, this study suggests that Cezanne-dependent SIRT6-DNA DSB signaling pathway may mediate the neuroprotective effect of tDCS in ischemic neurons.

Transcranial direct current stimulation in Autism Spectrum Disorder: A systematic review and meta-analysis

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that has gained relevance in recent years as an alternative treatment for neuropsychiatric conditions. The aim of this study is to conduct a systematic review of the use of tDCS in Autism Spectrum Disorder (ASD). Both electronic and manual searches were conducted to identify studies published in peer-reviewed scientific journals addressing the use of tDCS in ASD population. A total of 16 studies fulfilled the criteria to be included in the review. Studies were conducted both in child and adult population. Anodal stimulation on the left dorsolateral prefrontal cortex was the most commonly chosen methodology. Outcomes addressed ASD symptoms and neuropsychological functions. Meta-analytic synthesis identified improvements in social, health, and behavioral problem domains of the Autism Treatment Evaluation Checklist. Limitations included high heterogeneity in the methodology and low-efficacy study designs (pre-post and single-case studies). Recent controlled trials shed promising results for the use of tDCS in ASD. A standardized stimulation protocol and a consensus in the measures used in the evaluation of the efficacy are imperative.

Neuroplasticity and non-invasive brain stimulation in the developing brain

The brain is a dynamic organ whose growth and organization varies according to each subject's life experiences. Through adaptations in gene expression and the release of neurotrophins and neurotransmitters, these experiences induce a process of cellular realignment and neural network reorganization, which consolidate what is called neuroplasticity. However, despite the brain's resilience and dynamism, neuroplasticity is maximized during the first years of life, when the developing brain is more sensitive to structural reorganization and the repair of damaged neurons. This review presents an overview of non-invasive brain stimulation (NIBS) techniques that have increasingly been a focus for experimental research and the development of therapeutic methods involving neuroplasticity, especially Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS). Due to its safety risk profile and extensive tolerability, several trials have demonstrated the benefits of NIBS as a feasible experimental alternative for the treatment of brain and mind disorders in children and adolescents. However, little is known about the late impact of neuroplasticity-inducing tools on the developing brain, and there are concerns about aberrant plasticity. There are also ethical considerations when performing interventions in the pediatric population. This article will therefore review these aspects and also obstacles related to the premature application of NIBS, given the limited evidence available concerning the extent to which these methods interfere with the developing brain.

Transcranial direct-current stimulation and pediatric attention deficit hyperactivity disorder (ADHD)-Findings from an interview ethics study with children, adolescents, and their parents

INTRODUCTION

Transcranial direct current stimulation (tDCS) is a brain stimulation technique for an alternative or complementary treatment for various neurological disorders, including pediatric ADHD. However, little is known about the experiences of participants undergoing tDCS treatments in clinical trials. Exploration of their views on the matter is an important contribution to the societal debate on ethical issues of tDCS, allowing for a responsible translation into clinical practice and timely identification of potential challenges.

METHODS

in-depth interviews study with children with ADHD undertaking tDCS and their parents (n=32).

RESULTS

Children reported overall good experiences with the stimulation, although they found participation in the clinical study very tiring and time consuming. Their responses to the actual effects of the stimulation were mixed. Parents were very keen for their children to participate in the study as they saw it as a promising and safe alternative to medication. Even though many of them understood the techniques, they often did not see the link between the (current) lack of side effects and an absence of longitudinal studies. Unlike children, interviewed parents were cautious about using tDCS for non-medical/enhancement purposes.

DISCUSSION

There is a need for more transparent information about the state of the art of tDCS, its function and what it actually might be able to offer. It is especially important in order to prevent unrealistic hopes and to make sure that future pediatric patients and their carers are more aware of the potential side-effects and long-term effects of tDCS.

Transcranial brain atlas for school-aged children and adolescents

BACKGROUND

Both fNIRS optodes and TMS coils are placed on the scalp, while the targeted brain activities are inside the brain. An accurate cranio-cortical correspondence is crucial to the precise localization of the cortical area under imaging or stimulation (i.e. transcranial locating), as well as guiding the placement of optodes/coils (i.e. transcranial targeting). However, the existing normative cranio-cortical correspondence data used as transcranial references are predominantly derived from the adult population, and whether and how correspondence changes during childhood and adolescence is currently unclear.

OBJECTIVE

This study aimed to build the age-specific cranio-cortical correspondences for school-aged children and adolescents and investigate its differences to adults.

METHODS

Age-specific transcranial brain atlases (TBAs) were built with age groups: 6-8, 8-10, 10-12, 12-14, 14-16, and 16-18 years. We compared the performance in both transcranial locating and targeting when using the age-appropriate TBA versus the adult TBA (derived from adult population) for children.

RESULTS

These atlases provide age-specific probabilistic cranio-cortical correspondence at a high resolution (average scalp spacing of 2.8 mm). Significant differences in cranio-cortical correspondence between children/adolescents and adults were found: the younger the child, the greater the differences. For children (aged 6-12 years), locating and targeting errors when using the adult TBA reached 10 mm or more in the bilateral temporal lobe and frontal lobe. In contrast, the age-matched TBA reduced these errors to 4-5 mm, an approximately 50% reduction in error.

CONCLUSION

Our work provides an accurate and effective anatomical reference for studies in children and adolescents.

Effect of non-invasive brain stimulation on behavior and serum brain-derived neurotrophic factor and insulin-like growth factor-1 levels in autistic patients

Aberrant neural connectivity and intra-cortical inhibitory dysfunction are key features of autism. Non-invasive brain stimulation (NIBS) protocols have been proposed that modulate this aberrant plasticity. However, additional investigations are needed to evaluate the impact of this intervention on biological biomarkers of the disease. We recently demonstrated alterations in serum insulin-like growth factor-1 (IGF-1) and brain-derived neurotrophic factor (BDNF) immunoreactivity in subjects with autism compared to controls. The aim of this pilot study was to explore the change in serum levels of the neurotrophic factors BDNF and IGF-1 in patients undergoing NIBS therapy. Sixteen subjects with autism spectrum disorder (ASD) were tested 1 week before and 1 week after NIBS to determine the short-term outcome on behavior using the total score on the autism behavior checklist, autism treatment evaluation checklist, clinical global impression severity and the autism diagnostic interview. ASD subjects younger than 11 years old (n = 11) were treated with transcranial direct current stimulation (tDCS), and those 11 years and older (n = 5) were treated with repetitive transcranial magnetic stimulation (rTMS). Serum levels of BDNF and IGF-1 were evaluated by Enzyme-Linked Immuno-Sorbent Assay before and after the intervention with NIBS. A significant reduction in scores on the clinical behavioral scales was observed in patients treated with NIBS (ABC-T p = .002, CGI-S p = .008, ADI-T and ATEC-T p < .0001). There was a trend towards reduced serum BDNF levels after NIBS (p = .061), while there was no change in IGF-1 levels. These data support further studies on the potential of BDNF as a biomarker to measure the effectiveness of NIBS in autism.

Effects of non-invasive brain stimulation in children and young people with psychiatric disorders: a protocol for a systematic review

BACKGROUND

Most psychiatric disorders have their onset in childhood or adolescence, and if not fully treated have the potential for causing life-long psycho-social and physical sequelae. Effective psychotherapeutic and medication treatments exist, but a significant proportion of children and young people do not make a full recovery. Thus, novel, safe, brain-based alternatives or adjuncts to conventional treatments are needed. Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are non-invasive brain stimulation (NIBS) techniques which have shown clinical benefits in adult psychiatric conditions. However, in children and young people their efficacy is not well established. The objective of this study will be to systematically evaluate the evidence on clinical effects of NIBS in children and young people with psychiatric disorders, assessing disorder-specific symptoms, mood and neurocognitive functions.

METHODS

We designed and registered a study protocol for a systematic review. We will include randomised and non-randomised controlled trials and observational studies (e.g. cohort, case-control, case series) assessing the effects of NIBS in children and young people (aged ≤ 24 years old) for psychiatric disorders. The primary outcome will be reduction of disorder-specific symptoms. Secondary outcomes will include effects on mood and cognition. A comprehensive search from database inception onwards will be conducted in MEDLINE, EMBASE and PsycINFO. Grey literature will be identified through searching multiple clinical trial registries. Two reviewers will independently screen all citations, full-text articles and abstract data. The methodological quality of the studies will be appraised using appropriate tools. We will provide a narrative synthesis of the evidence and according to heterogeneity will conduct an appropriate meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity.

DISCUSSION

This systematic review will provide a broad and comprehensive evaluation of the evidence on clinical effects of NIBS in children and young people with psychiatric disorders. Our findings will be reported according to the PRISMA guidelines and will be of interest to multiple audiences (including patients, researchers, healthcare professionals and policy-makers). Results will be published in a peer-reviewed journal.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019158957.

From adults to pediatrics: A review noninvasive brain stimulation (NIBS) to facilitate recovery from brain injury

Stroke is a major problem worldwide that impacts over 100 million adults and children annually. Rehabilitation therapy is the current standard of care to restore functional impairments post-stroke, however its effects are limited and many patients suffer persisting functional impairments and life-long disability. Noninvasive Brain Stimulation (NIBS) has emerged as a potential rehabilitation treatment option in both adults and children with brain injury. In the last decade, Transcranial Magnetic Stimulation (TMS), Transcranial Direct Current Stimulation (tDCS) and Transcutaneous Auricular Vagus Nerve Stimulation (taVNS) have been investigated to improve motor recovery in adults post-stroke. These promising adult findings using NIBS, however, have yet to be widely translated to the area of pediatrics. The limited studies exploring NIBS in children have demonstrated safety, feasibility, and utility of stimulation-augmented rehabilitation. This chapter will describe the mechanism of NIBS therapy (cortical excitability, neuroplasticity) that underlies its use in stroke and motor function and how TMS, tDCS, and taVNS are applied in adult stroke treatment paradigms. We will then discuss the current state of NIBS in early pediatric brain injury and will provide insight regarding practical considerations and future applications of NIBS in pediatrics to make this promising treatment option a viable therapy in children.

Electrophysiology Echoes Brain Dynamics in Children and Adolescents With Tourette Syndrome-A Developmental Perspective

The development of the complex clinical picture of motor and vocal tics in children and adolescents with Tourette syndrome (TS) must be paralleled by changes in the underlying pathophysiology. Electrophysiological methods such as EEG and event-related potentials (ERPs) are non-invasive, safe and easy to apply and thus seem to provide an adequate means to investigate brain dynamics during this brain maturational period. Also, electrophysiology is characterized by a high time resolution and can reflect motor, sensory and cognitive aspects as well as sleep behavior. Hence, this narrative review focuses on how electrophysiology echoes brain dynamics during development of youngsters with TS and might be useful for the treatment of tics. A comprehensive picture of developmental brain dynamics could be revealed showing that electrophysiological parameters evolve concurrently with clinical characteristics of TS. Specifically, evidence for a maturational delay of motor inhibition related to cortico-spinal hyper-excitability and brain mechanisms for its cognitive compensation could be shown. Moreover, deviant sleep parameters and probably a stronger perception-action binding were reported. For neuromodulatory treatments (e.g., neurofeedback; repetitive transcranial magnetic stimulation, rTMS/transcranial direct current stimulation, tDCS) targeting neuronal deficits and/or strengthening compensatory brain mechanisms, pilot studies support the possibility of positive effects regarding tic reduction. Finally, attention-deficit/hyperactivity disorder (ADHD), as a highly frequent co-existing disorder with TS, has to be considered when using and interpreting electrophysiological measures in TS. In conclusion, application of electrophysiology seems to be promising regarding clinical and research aspects in youngsters with TS.

Effect of Anodal Transcranial Direct Current Stimulation Combined With Cognitive Training for Improving Cognition and Language Among Children With Cerebral Palsy With Cognitive Impairment: A Pilot, Randomized, Controlled, Double-Blind, and Clinical Trial

About 30-45% of cerebral palsy (CP) patients have cognitive impairment. Previous studies showed the evidence that transcranial direct current stimulation (tDCS) may have some benefits in attention-deficit/hyperactivity disorder, autism spectrum disorder, and motor development in CP. The aim of this study is to evaluate the effect of tDCS on cognition, language, and activities of daily living (ADL) among children with CP with cognitive impairment. It was a pilot, randomized, controlled, double-blind, clinical trial in a tertiary pediatric hospital, and 13 children with CP and a cognitive age under 42 months were enrolled. tDCS group (n = 8) had active tDCS and cognitive training (20 min/session, total 20 sessions, for 12 weeks) and sham group (n = 5) had sham tDCS and cognitive training. Primary outcome was the Bayley Scales of Infant Development II (BSID II). Secondary outcomes were the Pediatric Evaluation of Disability Inventory (PEDI), the Laboratory Temperament Assessment Battery (Lab-TAB), the Early Childhood Behavior Questionnaire (ECBQ), the Korean version of MacArthur-Bates Communicative Development Inventories (M-B CDI-K), the Sequenced Language Scale for Infants (SELSI) and the Preschool Receptive-Expressive Language Scale (PRES). After intervention, the tDCS group showed significant improvements in all measurements (p < 0.05) except the M-B CDI-K (grammar), whereas the sham group only showed significant improvements in the Lab-TAB (manipulation domain), the ECBQ (attentional shifting), and the M-B CDI-K (comprehension). The between-group differences in the degree of post-intervention improvement were not statistically significant. The degree of improvement was associated with better baseline cognitive function and younger age (p < 0.05). There were no major adverse events after tDCS. The combined application of tDCS and cognitive training was feasible and associated with improvements in cognitive function, ADL, and language among children with CP with cognitive impairment. However, considering that it is a pilot study, further larger-scale systematic investigation is needed. Clinical Trial Registration: The trial was registered in the Clinical Research Information Service database, identifier: KCT0003023.

Effects of transcranial stimulation in developmental neurocognitive disorders: A critical appraisal

Non-invasive brain stimulation (NIBS) has been highlighted as a powerful tool to promote neuroplasticity, and an attractive approach to support cognitive remediation. Here we provide a systematic review of 26 papers using NIBS to ameliorate cognitive dysfunctions in three prevalent neurodevelopmental disorders: Attention-Deficit/Hyperactivity Disorder (ADHD), Developmental Dyslexia and Developmental Dyscalculia. An overview of the state of research shows a predominance of studies using repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) techniques, and an unequal distribution among clinical conditions. Regarding the utility of NIBS, the results are promising but also ambiguous. Twenty-three papers reported beneficial effects, but many of these effects were found only once or were only partially replicated and some studies even reported detrimental effects. Furthermore, most studies differed in at least one core aspect, the NIBS applied, the questionnaires and cognitive tests conducted, or the age group investigated, and sample sizes were mostly small. Hence, further studies are needed to rigorously examine the potential of NIBS in the remediation of cognitive functions. Finally, we discuss potential caveats and future directions. We reason that if adequately addressing these challenges NIBS can be feasible, with potential benefits in treating neurodevelopmental disorders.

Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines

This article is based on a consensus conference, promoted and supported by the International Federation of Clinical Neurophysiology (IFCN), which took place in Siena (Italy) in October 2018. The meeting intended to update the ten-year-old safety guidelines for the application of transcranial magnetic stimulation (TMS) in research and clinical settings (Rossi et al., 2009). Therefore, only emerging and new issues are covered in detail, leaving still valid the 2009 recommendations regarding the description of conventional or patterned TMS protocols, the screening of subjects/patients, the need of neurophysiological monitoring for new protocols, the utilization of reference thresholds of stimulation, the managing of seizures and the list of minor side effects. New issues discussed in detail from the meeting up to April 2020 are safety issues of recently developed stimulation devices and pulse configurations; duties and responsibility of device makers; novel scenarios of TMS applications such as in the neuroimaging context or imaging-guided and robot-guided TMS; TMS interleaved with transcranial electrical stimulation; safety during paired associative stimulation interventions; and risks of using TMS to induce therapeutic seizures (magnetic seizure therapy). An update on the possible induction of seizures, theoretically the most serious risk of TMS, is provided. It has become apparent that such a risk is low, even in patients taking drugs acting on the central nervous system, at least with the use of traditional stimulation parameters and focal coils for which large data sets are available. Finally, new operational guidelines are provided for safety in planning future trials based on traditional and patterned TMS protocols, as well as a summary of the minimal training requirements for operators, and a note on ethics of neuroenhancement.

Functional Mapping for Glioma Surgery, Part 1: Preoperative Mapping Tools

Although intraoperative mapping of brain areas was shown to promote greater extent of resection and reduce functional deficits, this was shown only recently for some noninvasive techniques. Yet, proper surgical planning, indication, and patient consultation require reliable noninvasive techniques. Because functional magnetic resonance imaging, tractography, and neurophysiologic methods like navigated transcranial magnetic stimulation and magnetoencephalography allow identifying eloquent areas prior to resective surgery and tailor the surgical approach, this article provides an overview on the individual strengths and limitations of each modality.

Reliability of robotic transcranial magnetic stimulation motor mapping

Robotic transcranial magnetic stimulation (TMS) is a noninvasive and safe tool that produces cortical motor maps using neuronavigational and neuroanatomical images. Motor maps are individualized representations of the primary motor cortex (M1) topography that may reflect developmental and interventional plasticity. Results of TMS motor map reliability testing have been variable, and robotic measures are undefined. We aimed to determine the short- and long-term reliability of robotic TMS motor maps. Twenty healthy participants underwent motor mapping at baseline, 24 h, and 4 wk. A 12 × 12 grid (7-mm spacing) was placed over the left M1, centered over the hand knob area. Four suprathreshold stimulations were delivered at each grid point. First dorsal interosseous (FDI) motor-evoked potentials (MEPs) were analyzed offline to generate map characteristics of area, volume, center of gravity (COG), and hotspot magnitude. Subsets of each outcome corresponding to 75%, 50%, and 25% of each map were determined. Reliability measures including intraclass correlation coefficient (ICC), minimal detectable change (MDC), and standard error of measure (SEM) were calculated. Map volume, COG, and hotspot magnitude were the most reliable measures (good-to-excellent) over both short- and long-term sessions. Map area reliability was poor-to-moderate for short- and long-term sessions. Smaller map percentile subsets showed decreased variability but only minimal improvements in reliability. MDC for most outcomes was >50%. Procedures were well tolerated with no serious adverse events. Robotic TMS motor mapping is relatively reliable over time, but careful consideration of specific outcomes is required for this method to interrogate plasticity in the human motor system.NEW & NOTEWORTHY Robotic transcranial magnetic stimulation (TMS) is a noninvasive and safe tool that produces cortical motor maps-individualized representations of the primary motor cortex (M1) topography-that may reflect developmental and interventional plasticity. This study is the first to evaluate short- and long-term relative and absolute reliability of TMS mapping outcomes at various M1 excitability levels using novel robotic neuronavigated TMS.

Pediatric navigated transcranial magnetic stimulation motor and language mapping combined with diffusion tensor imaging tractography: clinical experience

OBJECTIVE

In adults, navigated transcranial magnetic stimulation (nTMS) has been established as a preoperative examination method for brain tumors in motor- and language-eloquent locations. However, the clinical relevance of nTMS in children with brain tumors is still unclear. Here, the authors present their initial experience with nTMS-based surgical planning and family counseling in pediatric cases.

METHODS

The authors analyzed the feasibility of nTMS and its influence on counseling and surgical strategy in a prospective study conducted between July 2017 and September 2019. The main inclusion criterion was a potential benefit from functional mapping data derived from nTMS and/or nTMS-enhanced tractography in pediatric patients who presented to the authors' department prior to surgery for lesions close to motor- and/or speech-eloquent areas. The study was undertaken in 14 patients (median age 7 years, 8 males) who presented with different brain lesions.

RESULTS

Motor mapping combined with cortical seed area definition could be performed in 10 children (71%) to identify the corticospinal tract by additional diffusion tensor imaging (DTI). All motor mappings could be performed successfully without inducing relevant side effects. In 7 children, nTMS language mapping was performed to detect language-relevant cortical areas and DTI fiber tractography was performed to visualize the individual language network. nTMS examination was not possible in 4 children because of lack of compliance (n = 2), syncope (n = 1), and preexisting implant (n = 1). After successful mapping, the spatial relation between lesion and functional tissue was used for surgical planning in all 10 patients, and 9 children underwent nTMS-DTI integrated neuronavigation. No surgical complications or unexpected neurological deterioration was observed. In all successful nTMS cases, better function-based counseling was offered to the families. In 6 of 10 patients the surgical strategy was adapted according to nTMS data, and in 6 of 10 cases the extent of resection (EOR) was redefined.

CONCLUSIONS

nTMS and DTI fiber tracking were feasible for the majority of children. Presurgical counseling as well as surgical planning for the approach and EOR were improved by the nTMS examination results. nTMS in combination with DTI fiber tracking can be regarded as beneficial for neurosurgical procedures in eloquent areas in the pediatric population.

Neurophysiological and Genetic Findings in Patients With Juvenile Myoclonic Epilepsy

Objective

Transcranial magnetic stimulation (TMS), a non-invasive procedure, stimulates the cortex evaluating the central motor pathways. The response is called motor evoked potential (MEP). Polyphasia results when the response crosses the baseline more than twice (zero crossing). Recent research shows MEP polyphasia in patients with generalized genetic epilepsy (GGE) and their first-degree relatives compared with controls. Juvenile Myoclonic Epilepsy (JME), a GGE type, is not well studied regarding polyphasia. In our study, we assessed polyphasia appearance probability with TMS in JME patients, their healthy first-degree relatives and controls. Two genetic approaches were applied to uncover genetic association with polyphasia.

Methods

20 JME patients, 23 first-degree relatives and 30 controls underwent TMS, obtaining 10–15 MEPs per participant. We evaluated MEP mean number of phases, proportion of MEP trials displaying polyphasia for each subject and variability between groups. Participants underwent whole exome sequencing (WES) via trio-based analysis and two-case scenario. Extensive bioinformatics analysis was applied.

Results

We identified increased polyphasia in patients (85%) and relatives (70%) compared to controls (47%) and significantly higher mean number of zero crossings (i.e., occurrence of phases) (patients 1.49, relatives 1.46, controls 1.22; p < 0.05). Trio-based analysis revealed a candidate polymorphism, p.Glu270del,in SYT14 (Synaptotagmin 14), in JME patients and their relatives presenting polyphasia. Sanger sequencing analysis in remaining participants showed no significant association. In two-case scenario, a machine learning approach was applied in variants identified from odds ratio analysis and risk prediction scores were obtained for polyphasia. The results revealed 61 variants of which none was associated with polyphasia. Risk prediction scores indeed showed lower probability for non-polyphasic subjects on having polyphasia and higher probability for polyphasic subjects on having polyphasia.

Conclusion

Polyphasia was present in JME patients and relatives in contrast to controls. Although no known clinical symptoms are linked to polyphasia this neurophysiological phenomenon is likely due to common cerebral electrophysiological abnormality. We did not discover direct association between genetic variants obtained and polyphasia. It is likely these genetic traits alone cannot provoke polyphasia, however, this predisposition combined with disturbed brain-electrical activity and tendency to generate seizures may increase the risk of developing polyphasia, mainly in patients and relatives.

Deep transcranial magnetic stimulation for obsessive compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a common psychiatric disorder that can be chronic and debilitating if not properly treated. Current first-line treatments for OCD include cognitive-behavioral therapy with exposure and response prevention and serotonin uptake inhibitor medications; however, these therapies are not effective for all individuals.

AREAS COVERED

Deep transcranial magnetic stimulation (dTMS) has been hypothesized to be an effective alternative for individuals with treatment-resistant OCD. dTMS has thought to be favorable due to its low side effect profile and its minimally invasive nature.

EXPERT OPINION

This review evaluates the current research on effectiveness of dTMS therapy for individuals with treatment-resistant OCD. This review also investigates shortcomings in current dTMS research and the hypothesized future of dTMS therapy.

A double-blind, randomized, sham-controlled study of cranial electrotherapy stimulation as an add-on treatment for tic disorders in children and adolescents

AIM

The aim of this study was to determine the efficacy and safety of cranial electrotherapy stimulation (CES) as an add-on treatment for TD.

METHODS

A randomized, double-blind, sham-controlled trial was conducted at an outpatient, single-center academic setting. A total of 62 patients aged 6-17 years with TD and lack of clinical response to 4 weeks' pharmacotherapy were enrolled. Patients were divided randomly into 2 groups and given 4 weeks' treatment, including 30 min sessions of active CES (500 μA-2 mA) or sham CES (lower than 100 μA) per day for 40 d on weekdays. Change in Yale Global Tic Severity Scale (YGTSS), Clinical Global Impression-severity of illness-severity (CGI-S) and Hamilton Anxiety Scale-14 items (HAMA-14) were performed at baseline, week 2, week 4. Adverse events (AEs) were also evaluated.

RESULTS

53 patients (34 males and 9 females) completed the trial, including 29 in the active CES group and 24 in the sham CES group. Both groups showed clinical improvement in tic severities compared to baseline respectively at week 4. Participants receiving active CES showed a reduction of 31.66 % in YGTSS score, compared with 23.96 % in participants in sham CES group, resulting in no significant difference between the two groups (t = 1.54, p = 0.13).

CONCLUSION

Four-week's treatment of CES for children and adolescents with TD is effective and safe, but the improvement for tic severity may be related to placebo effect.

Posterior Fossa Society Consensus Meeting 2018: a synopsis

PURPOSE

The Posterior Fossa Society (PFS) was founded 4 years ago to systematically gather and exchange information on the post-operative (CMS) and cerebellar cognitive affective syndrome (CCAS). With its consensus meetings, the PFS orchestrates research studies in the field of cerebellar injury and progresses the knowledge of post-operative pediatric cerebellar mutism syndrome (CMS). In this article, we captured the 3-day program of presentations, group discussions, interactive workshops, and dialogue, highlighting the key topic areas of CMS and its research advances.

METHODS

This synopsis is based on the third consensus meeting which was held in Reykjavik, Iceland, in August 2018.

RESULTS

Three working groups have been defined to drive the future research priorities on post-surgical CMS: (i) refining definition and symptoms scoring of CMS; (ii) understanding the pathogenesis and enhancing risk-stratification strategies; and (iii) developing rehabilitation approaches and protocols.

CONCLUSIONS

The third consensus meeting highlighted a unanimous desire for data-driven information to advance the knowledge and guide future research efforts. The PFS constitutes an established and expanding network of multi-disciplinary expertise that can facilitate the development of collaborative studies and produce official guidelines on the topic.

Equipment for Repetitive Transcranial Magnetic Stimulation

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation technique used for the treatment of a great variety of neurological disorders. The technique involves applying a magnetic field in certain areas of the cerebral cortex in order to modify neuronal excitability outside the skull. However, the exact brain mechanisms underlying rTMS effects are not completely elucidated. For that purpose, and in order to generate a pulsed magnetic field, a half-bridge converter controlled by a microcontroller has been designed to apply rTMS in small animals. Moreover, the small size of the rodent head makes it necessary to design a magnetic transducer, with the aim of focusing the magnetic field on selected brain areas using a specific and a small magnetic head. Using such devices, our purpose was to compare the effects of five different rTMS dosages on rat brain metabolic activity. The experimental results showed that one day of stimulation leads to an enhancement of brain metabolic activity in cortical areas, meanwhile with three days of stimulation it is possible to also modify subcortical zones, results that were not found when extending the number of rTMS applications up to seven days. In consequence, the number of pulses delivered might be an important parameter in rTMS protocols, highlighting its importance in rTMS impact.