Paired pulse TMS over the right posterior parietal cortex modulates visuospatial perception

Hemispheric Asymmetry in TMS-Induced Effects on Spatial Attention: A Meta-Analysis

Hemispheric asymmetry is a fundamental principle in the functional architecture of the brain. It plays an important role in attention research where right hemisphere dominance is core to many attention theories. Lesion studies seem to confirm such hemispheric dominance with patients being more likely to develop left hemineglect after right hemispheric stroke than vice versa. However, the underlying concept of hemispheric dominance is still not entirely clear. Brain stimulation studies using transcranial magnetic stimulation (TMS) might be able to illuminate this concept. To examine the putative hemispheric asymmetry in spatial attention, we conducted a meta-analysis of studies applying inhibitory TMS protocols to the left or right posterior parietal cortices (PPC), assessing effects on attention biases with the landmark and line bisection task. A total of 18 studies including 222 participants from 1994 to February 2022 were identified. The analysis revealed a significant shift of the perceived midpoint towards the ipsilateral hemifield after right PPC suppression (Cohen's d = 0.52), but no significant effect after left PPC suppression (Cohen's d = 0.26), suggesting a hemispheric asymmetry even though the subgroup difference does not reach significance (p = .06). A complementary Bayesian meta-analysis revealed a high probability of at least a medium effect size after right PPC disruption versus a low probability after left PPC disruption. This is the first quantitative meta-analysis supporting right hemisphere-specific TMS-induced spatial attention deficits, mimicking hemineglect in healthy participants. We discuss the result in the light of prominent attention theories, ultimately concluding how difficult it remains to differentiate between these theories based on attentional bias scores alone.

Reducing Visuospatial Pseudoneglect in Healthy Subjects by Active Video Gaming

Pseudoneglect phenomenon refers to a condition in which healthy subjects tend to perceive the left side of exactly bisected lines as being slightly longer than the right one. However, behavioural data showed that athletes practising an open-skill sport display less pseudoneglect than the general population. Given the fact that so-called exergames (also known as active video games) are platforms designed to fully mimic sport activity, this work intends to investigate whether and how a one-week training period of exergame open-skill sport can determine a similar decrease in pseudoneglect. Fifteen healthy participants (non-athletes) responded to a visuospatial attention task and a control memory task in basal conditions (t0: Pre-game) and after a short period (one week, one hour/day) of tennis exergaming (t1: Post-game). In the Post-game condition, subjects from this experimental group (ExerGame group: EG) reduced leftward space overestimation and made significantly fewer leftward errors compared to the Pre-game condition. Additionally, two other experimental groups were employed: one evaluated within the same conditions of the main experiment but using a non-exergame (Non-Exergame groups: NEG) and the other one without any video game stimulus (Sedentary group: SE). Our findings suggest that daily training of a tennis exergame seems to be able to improve visuospatial attention isotropy by reducing leftward space overestimation, whereas outcomes from non-exergaming and sedentary activity do not modify subjects' performance.

Effects of Intermittent Theta Burst Stimulation on the Clock Drawing Test Performances in Patients with Alzheimer's Disease

The clock drawing test (CDT) is widely used in clinical neuropsychological practice. However, its neuroanatomical correlates have not been well established. This study investigated the effects of theta burst stimulation (TBS) applied over different brain regions on CDT scores in patients with Alzheimer's disease (AD). The 10-20 positions F3, F4, T3, T4, TP3, TP4, P3, P4, as determined by a 10-20 positioning cap, were targeted. Excitatory intermittent TBS (iTBS) was given over the above-mentioned eight regions to ten AD patients and ten control subjects on separate days. CDT was administered at baseline (T0), during the 5 min following the TBS (T1) and 60 min after TBS (T2), with an inter-session interval of at least 4 days. iTBS over TP4 and P4 transiently increased Rouleau CDT score in AD patients. When targeting TP4 and P4, mainly the area of the supramarginal/angular gyrus and the inferior parietal lobe, corresponding respectively to the Brodmann areas 40/39 and 7/40, are reached. iTBS thus seems able to modulate activity of the right posterior parietal cortex in AD patients performing the CDT. Our results provide physiological evidence that those parietal regions are functionally important for the execution of the Rouleau CDT. This finding suggests that CDT has reliable neuroanatomical correlates, and support the notion that this test can be used as a good marker of right parietal brain dysfunction. The present study also highlights the therapeutic potential of the induction of neuromodulatory effects using non-invasive brain stimulation techniques.

Application of long-interval paired-pulse transcranial magnetic stimulation to motion-sensitive visual cortex does not lead to changes in motion discrimination

The perception of visual motion is dependent on a set of occipitotemporal regions that are readily accessible to neuromodulation. The current study tested if paired-pulse Transcranial Magnetic Stimulation (ppTMS) could modulate motion perception by stimulating the occipital cortex as participants viewed near-threshold motion dot stimuli. In this sham-controlled study, fifteen subjects completed two sessions. On the first visit, resting motor threshold (RMT) was assessed, and participants performed an adaptive direction discrimination task to determine individual motion sensitivity. During the second visit, subjects performed the task with three difficulty levels as TMS pulses were delivered 150 and 50 ms prior to motion stimulus onset at 120% RMT, under the logic that the cumulative inhibitory effect of these pulses would alter motion sensitivity. ppTMS was delivered at one of two locations: 3 cm dorsal and 5 cm lateral to inion (scalp-based coordinate), or at the site of peak activation for "motion" according to the NeuroSynth fMRI database (meta-analytic coordinate). Sham stimulation was delivered on one-third of trials by tilting the coil 90°. Analyses showed no significant active-versus-sham effects of ppTMS when stimulation was delivered to the meta-analytic (p = 0.15) or scalp-based coordinates (p = 0.17), which were separated by 29 mm on average. Active-versus-sham stimulation differences did not interact with either stimulation location (p = 0.12) or difficulty (p = 0.33). These findings fail to support the hypothesis that long-interval ppTMS recruits inhibitory processes in motion-sensitive cortex but must be considered within the limited parameters used in this design.

Visuospatial Neglect - a Theory-Informed Overview of Current and Emerging Strategies and a Systematic Review on the Therapeutic Use of Non-invasive Brain Stimulation

Visuospatial neglect constitutes a supramodal cognitive deficit characterized by reduction or loss of spatial awareness for the contralesional space. It occurs in over 40% of right- and 20% of left-brain-lesioned stroke patients with lesions located mostly in parietal, frontal and subcortical brain areas. Visuospatial neglect is a multifaceted syndrome - symptoms can be divided into sensory, motor and representational neglect - and therefore requires an individually adapted diagnostic and therapeutic approach. Several models try to explain the origins of visuospatial neglect, of which the "interhemispheric rivalry model" is strongly supported by animal and human research. This model proposes that allocation of spatial attention is balanced by transcallosal inhibition and both hemispheres compete to direct attention to the contralateral hemi-space. Accordingly, a brain lesion causes an interhemispheric imbalance, which may be re-installed by activation of lesioned, or deactivation of unlesioned (over-activated) brain areas through noninvasive brain stimulation. Research in larger patient samples is needed to confirm whether noninvasive brain stimulation can improve long-term outcomes and whether these also affect activities of daily living and discharge destination.

Transcranial Magnetic Stimulation of Posterior Parietal Cortex Modulates Line-Length Estimation but Not Illusory Depth Perception

Transcranial Magnetic Stimulation (TMS) may affect attentional processing when applied to the right posterior parietal cortex (PPC) of healthy participants in line with neuropsychological and neuroimaging evidence on the neural bases of this cognitive function. Specifically, the application of TMS to right PPC induces a rightward attentional bias on line length estimation in healthy participants (i.e., neglect-like bias), mimicking the rightward bias shown by patients with unilateral spatial neglect after damage of the right PPC. With the present study, we investigated whether right PPC might play a crucial role in attentional processing of illusory depth perception, given the evidence that a rightward bias may be observed in patients with neglect during perception of the Necker Cube (NC). To this end, we investigated the effects of low-frequency rTMS applied to the right or left PPC on attentional disambiguation of the NC in two groups of healthy participants. To control for the effectiveness of TMS on visuospatial attention, rTMS effects were also assessed on a frequently used line length estimation (i.e., the Landmark Task or LT). Both groups also received sham stimulation. RTMS of the right or left PPC did not affect NC perception. On the other hand, rTMS of the right PPC (but not left PPC) induces neglect-like bias on the LT, in line with previous studies. These findings confirm that right PPC is involved in deployment of spatial attention on line length estimation. Interestingly, they suggest that this brain region does not critically contribute to deployment of visuospatial attention during attentional disambiguation of the Necker Cube. Future investigations, targeting different areas of fronto-parietal circuits, are necessary to further explore the neuro-functional bases of attentional contribution to illusory depth perception.

Causal role of the posterior parietal cortex for two-digit mental subtraction and addition: A repetitive TMS study

Although parietal areas of the left hemisphere are known to be involved in simple mental calculation, the possible role of the homologue areas of the right hemisphere in mental complex calculation remains debated. In the present study, we tested the causal role of the posterior parietal cortex of both hemispheres in two-digit mental addition and subtraction by means of neuronavigated repetitive TMS (rTMS), investigating possible hemispheric asymmetries in specific parietal areas. In particular, we performed two rTMS experiments, which differed only for the target sites stimulated, on independent samples of participants. rTMS was delivered over the horizontal and ventral portions of the intraparietal sulcus (HIPS and VIPS, respectively) of each hemisphere in Experiment 1, and over the angular and supramarginal gyri (ANG and SMG, respectively) of each hemisphere in Experiment 2. First, we found that each cerebral area of the posterior parietal cortex is involved to some degree in the two-digit addition and subtraction. Second, in Experiment 1, we found a stronger pattern of hemispheric asymmetry for the involvement of HIPS in addition compared to subtraction. In particular, results showed a greater involvement of the right HIPS than the left one for addition. Moreover, we found less asymmetry for the VIPS. Taken together, these results suggest that two-digit mental addition is more strongly associated with the use of a spatial mapping compared to subtraction. In support of this view, in Experiment 2, a greater role of left and right ANG was found for addition needed in verbal processing of numbers and in visuospatial attention processes, respectively. We also revealed a greater involvement of the bilateral SMG in two-digit mental subtraction, in response to greater working memory load required to solve this latter operation compared to addition.

Far Space Remapping by Tool Use: A rTMS Study Over the Right Posterior Parietal Cortex

BACKGROUND

In previous studies, rTMS has been successfully employed to interfere with the right posterior parietal cortex (rPPC) inducing neglect-like behavior in healthy subjects. Several studies have shown that the use of tools can modulate the boundaries between near and far space: indeed when far space is reached by the stick, far space can be remapped as near.

OBJECTIVE

The aim of the present study was to investigate whether once that rTMS on the rPPC has selectively induced neglect-like bias in the near space (but not in the far space), neglect can appears also in the far space when the subjects used a tool to perform the task.

METHODS

Fifteen right-handed healthy subjects executed a line length judgment task in two different spatial positions (60 cm: near space and 120 cm: far space), with or without rPPC on-line rTMS. In the far space condition, subjects performed the perceptual task while holding or not a tool.

RESULTS

During rTMS, visuospatial performance significantly shifted toward right when the task was performed in the near space and in the far space when the tool was used. No significant effect was found when rTMS was delivered in the far space condition without tool use.

CONCLUSIONS

Our results demonstrate that the application of rTMS on rPPC, specifically affect the representation of near space because it caused neglect both when the subjects acted in the near space and when they acted in a far space that was remapped as near by the use of a tool.

Hunting for right and left parietal hot spots using single-pulse TMS: modulation of visuospatial perception during line bisection judgment in the healthy brain

A series of studies have consistently reproduced left neglect-like bias on line length estimation tasks in healthy participants by applying transcranial magnetic stimulation (TMS) over the right posterior parietal cortex (PPC), while no significant changes have been reported when stimulating the left PPC. However, a notable inter-individual variability in the right parietal site where TMS modulates visuospatial perception can be observed, and no general agreement exists on how to identify the optimal parietal site of stimulation. In the present study, we propose a new site-finding TMS protocol to easily identify the optimum parietal location, or “hot spot,” where TMS may modulate visuospatial perception on a line length estimation task (the Landmark task). Single-pulse TMS at 115% of motor threshold was applied 150 ms after the visual stimulus onset over nine different sites of a 3 cm × 3 cm grid, centred over right or left PPC (P4 and P3 according to the 10–20 EEG system, respectively) in eight healthy participants. Stimulation of right PPC induced a significant left neglect-like bias, when the coil was applied over the most posterior and dorso-posterior sites. Unexpectedly, TMS over left PPC also produced left neglect-like bias. However, in this case significant effects were found when targeting the most anterior and dorso-anterior portions of the grid. These results are discussed in relation to recent findings on neural networks underlying spatial cognition. The hunting protocol we propose might offer an economical and easy-to-use tool to functionally identify the optimal parietal site where TMS can modulate visuospatial perception, in healthy subjects and possibly in post-stroke patients undergoing repetitive transcranial magnetic stimulation treatment.

The compensatory dynamic of inter-hemispheric interactions in visuospatial attention revealed using rTMS and fMRI

A balance of mutual tonic inhibition between bi-hemispheric posterior parietal cortices is believed to play an important role in bilateral visual attention. However, experimental support for this notion has been mainly drawn from clinical models of unilateral damage. We have previously shown that low-frequency repetitive TMS (rTMS) over the intraparietal sulcus (IPS) generates a contralateral attentional deficit in bilateral visual tracking. Here, we used functional magnetic resonance imaging (fMRI) to study whether rTMS temporarily disrupts the inter-hemispheric balance between bilateral IPS in visual attention. Following application of 1 Hz rTMS over the left IPS, subjects performed a bilateral visual tracking task while their brain activity was recorded using fMRI. Behaviorally, tracking accuracy was reduced immediately following rTMS. Areas ventro-lateral to left IPS, including inferior parietal lobule (IPL), lateral IPS (LIPS), and middle occipital gyrus (MoG), showed decreased activity following rTMS, while dorsomedial areas, such as Superior Parietal Lobule (SPL), Superior occipital gyrus (SoG), and lingual gyrus, as well as middle temporal areas (MT+), showed higher activity. The brain activity of the homologues of these regions in the un-stimulated, right hemisphere was reversed. Interestingly, the evolution of network-wide activation related to attentional behavior following rTMS showed that activation of most occipital synergists adaptively compensated for contralateral and ipsilateral decrement after rTMS, while activation of parietal synergists, and SoG remained competing. This pattern of ipsilateral and contralateral activations empirically supports the hypothesized loss of inter-hemispheric balance that underlies clinical manifestation of visual attentional extinction.

Is neuroenhancement by noninvasive brain stimulation a net zero-sum proposition?

In the past several years, the number of studies investigating enhancement of cognitive functions through noninvasive brain stimulation (NBS) has increased considerably. NBS techniques, such as transcranial magnetic stimulation and transcranial current stimulation, seem capable of enhancing cognitive functions in patients and in healthy humans, particularly when combined with other interventions, including pharmacologic, behavioral and cognitive therapies. The "net zero-sum model", based on the assumption that brain resources are subjected to the physical principle of conservation of energy, is one of the theoretical frameworks proposed to account for such enhancement of function and its potential cost. We argue that to guide future neuroenhancement studies, the net-zero sum concept is helpful, but only if its limits are tightly defined.

Stroke rehabilitation using noninvasive cortical stimulation: hemispatial neglect

The rehabilitation of neuropsychological sequels of cerebral stroke such as hemispatial neglect by noninvasive cortical stimulation (NICS) attracts increasing attention from the scientific community. The NICS techniques include primarily repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). They are based on the concept of either reactivating a hypoactive cortical region affected by the stroke (the right hemisphere in case of neglect) or reducing cortical hyperactivity of the corresponding cortical region in the contralateral hemisphere (the left hemisphere). In the studies published to date on the topic of neglect rehabilitation, rTMS was used to inhibit the left parietal cortex and tDCS to either activate the right or inhibit the left parietal cortex. Sham-controlled NICS studies assessed short-term effects, whereas long-term effects were only assessed in noncontrolled rTMS studies. Further controlled studies of large series of patients are necessary to determine the best parameters of stimulation (including the optimal cortical target location) according to each subtype of neglect presentation and to the time course of stroke recovery. To date, even if there are serious therapeutic perspectives based on imaging data and experimental studies, the evidence is not compelling enough to recommend any particular NICS protocol to treat this disabling condition in clinical practice.

Imaging the neural mechanisms of TMS neglect-like bias in healthy volunteers with the interleaved TMS/fMRI technique: preliminary evidence

Applying a precisely timed pulse of transcranial magnetic stimulation (TMS) over the right posterior parietal cortex (PPC) can produce temporary visuo-spatial neglect-like effects. Although the TMS is applied over PPC, it is not clear what other brain regions are involved. We applied TMS within a functional magnetic resonance imaging (fMRI) scanner to investigate brain activity during TMS induction of neglect-like bias in three healthy volunteers, while they performed a line bisection judgment task (i.e., the landmark task). Single-pulse TMS at 115% of motor threshold was applied 150 ms after the visual stimulus onset. Participants completed two different TMS/fMRI sessions while performing this task: one session while single-pulse TMS was intermittently and time-locked applied to the right PPC and a control session with TMS positioned over the vertex. Perceptual rightward bias was observed when TMS was delivered over the right PPC. During neglect-like behavior, the fMRI maps showed decreased neural activity within parieto-frontal areas, which are often lesioned or dysfunctional in patients with left neglect. Vertex TMS induced behavioral effects compatible with leftward response bias and increased BOLD signal in the left caudate (a site which has been linked to response bias). These results are discussed in relation to recent findings on neural networks subserving attention in space.

Selective modulations of attentional asymmetries after sleep deprivation

Pseudoneglect is a slight but consistent misplacement of attention toward the left visual field, commonly observed in young healthy subjects. This leftward attentional bias is thought to result from a right hemispheric dominance in visuospatial processing. Changes in endogenous levels of alertness may modulate attentional asymmetries and pseudoneglect in particular. In line with this hypothesis, it has been shown that sleep deprived shift-workers present a reversal of their attentional bias in a landmark (LDM) task (Manly, T., Dobler, V. B., Dodds, C. M., & George, M. A. (2005). Rightward shift in spatial awareness with declining alertness. Neuropsychologia, 43(12), 1721-1728). However, circadian disturbances and fatigue effects at the end of a shift work may have contributed to this reversal effect. In a first experiment, we show that sleep deprivation (SD) under controlled conditions does not markedly change the leftward bias, observable both at 21:00 and at 07:00 after SD. In a second experiment, we tested the hypothesis that a drastic reduction or inversion in the attentional bias would be present only when both the circadian drive for sleep propensity is maximal (i.e. around 05:00) and homeostatic sleep pressure is high. Thus participants were tested at 21:00 and under SD conditions at 05:00 and 09:00. Additionally, we used the greyscales (GS) task well-known to evidence a leftward bias in luminance judgments. Although results evidenced a consistent leftward bias both in the LDM and GS, we found a suppression of the leftward bias at the circadian nadir of alertness (05:00) after SD only for the GS, but not for the LDM. Noticeably, the leftward bias in the GS vanished at 05:00 after SD but reappeared at 09:00 despite continued SD, suggesting a predominant circadian influence on attentional asymmetries in the GS. Additionally, inter-sessions correlations evidenced a reproducible, consistent bias both in the LDM and GS, with no consistent relationship between the two tasks, suggesting independence of the neural networks subtending performance in LDM and GS. Overall, our results suggest that SD per se does not impede the leftward bias both in LDM and GS, whereas circadian-related variations in vigilance may impact attentional asymmetries in luminance judgments.

Age-related changes in visual pseudoneglect

Pseudoneglect is a slight but consistent leftward attentional bias commonly observed in healthy young populations, purportedly explained by right hemispheric dominance. It has been suggested that normal aging might be associated with a decline of the right hemisphere. According to this hypothesis, a few studies have shown that elderly tend to exhibit a rightward attentional bias in line bisection. In the present study, we tested this hypothesis in young and older participants using a perceptual landmark task. Results yield evidence for an age-related shift, from a strong attentional leftward bias in young adults toward a suppressed or even a reversed bias in the elderly. Right hemisphere impairment coupled to a left hemispheric compensation might explain the perceptual shift observed in older adults. However, a decline in corpus callosum function cannot be excluded. Alternatively, these results may be in agreement with the hypothesis of an age-related specific inhibition of return dysfunction, an overt attentional orienting mechanism, and/or a decrease of dopamine.

[Transcranial magnetic stimulation (TMS) in basic and clinical neuroscience research]

INTRODUCTION

Non-invasive brain stimulation methods such as transcranial magnetic stimulation (TMS) are starting to be widely used to make causality-based inferences about brain-behavior interactions. Moreover, TMS-based clinical applications are under development to treat specific neurological or psychiatric conditions, such as depression, dystonia, pain, tinnitus and the sequels of stroke, among others.

BACKGROUND

TMS works by inducing non-invasively electric currents in localized cortical regions thus modulating their activity levels according to settings, such as frequency, number of pulses, train and regime duration and intertrain intervals. For instance, it is known for the motor cortex that low frequency or continuous patterns of TMS pulses tend to depress local activity whereas high frequency and discontinuous TMS patterns tend to enhance it. Additionally, local cortical effects of TMS can result in dramatic patterns in distant brain regions. These distant effects are mediated via anatomical connectivity in a magnitude that depends on the efficiency and sign of such connections.

PERSPECTIVES

An efficient use of TMS in both fields requires however, a deep understanding of its operational principles, its risks, its potential and limitations. In this article, we will briefly present the principles through which non-invasive brain stimulation methods, and in particular TMS, operate.

CONCLUSION

Readers will be provided with fundamental information needed to critically discuss TMS studies and design hypothesis-driven TMS applications for cognitive and clinical neuroscience research.

Salience representation in the parietal and frontal cortex

Some objects in the visual field are more likely to attract attention because they are either intrinsically eye catching or relevant in the context of a particular task. These two factors, known as stimulus-driven and goal-directed factors, respectively, are thought to be integrated into a unique salience map, possibly located in the frontal or the parietal cortex. However, the distinct contribution of these two regions to salience representation is difficult to establish experimentally and remains debated. In an attempt to address this issue, we designed several dual tasks composed of a letter reporting task and a visual search task, allowing us to quantify the salience of each visual item by measuring its probability to be selected by attention. In Experiment 1, the salience of the visual search items depended on a combination of conspicuity and relevance factors, whereas in Experiment 2, stimulus-driven and goal-directed factors were tested separately. Then, we used transcranial magnetic stimulation to interfere transiently with the function of the right angular gyrus (ANG) or right FEFs in healthy subjects performing these dual tasks. We found that interfering with the ANG and the FEF function specifically altered the influence of salience on the letter report rate without affecting the overall letter reporting rate, suggesting that these areas are involved in salience representation. In particular, the present study suggests that ANG is involved in goal-directed salience representation, whereas FEF would rather house a global salience map integrating both goal-directed and stimulus-driven factors.

Novel 'hunting' method using transcranial magnetic stimulation over parietal cortex disrupts visuospatial sensitivity in relation to motor thresholds

There is considerable inter-study and inter-individual variation in the scalp location of parietal sites where transcranial magnetic stimulation (TMS) may modulate visuospatial behaviours (e.g. see Ryan, Bonilha, & Jackson, 2006); and no clear consensus on methods for identifying such sites. Here we introduce a novel TMS "hunting paradigm" that allows rapid, reliable identification of a site over the right anterior intraparietal sulcus (IPS), where short trains (at 10 Hz for 0.5 s) of TMS disrupt performance of a visuospatial task. The task involves detection of a small peripheral gap (at 14 degrees eccentricity), on one or other (known) side of an extended (29 degrees ) horizontal line centred on fixation. Signal-detection analysis confirmed that TMS at the right IPS site reduced sensitivity (d') for gap targets in the left visual hemifield. A further experiment showed that the same right-parietal TMS increased sensitivity instead for gaps in the right hemifield. Comparing TMS across a grid of scalp locations around the identified 'hotspot' confirmed the spatial-specificity of the effective site. Assessment of the TMS intensity required to produce the phenomena found this was linearly related to individuals' resting motor TMS threshold over hand M1. Our approach provides a systematic new way to identify an effective site and intensity in individuals, at which TMS over right-parietal cortex reliably changes visuospatial sensitivity.