ROAST: An Open-Source, Fully-Automated, Realistic Volumetric-Approach-Based Simulator For TES

Transcranial direct current stimulation suggests a causal role of the medial prefrontal cortex in learning social hierarchy

Social hierarchies can be inferred through observational learning of social relationships between individuals. Yet, little is known about the causal role of specific brain regions in learning hierarchies. Here, using transcranial direct current stimulation, we show a causal role of the medial prefrontal cortex (mPFC) in learning social versus non-social hierarchies. In a Training phase, participants acquired knowledge about social and non-social hierarchies by trial and error. During a Test phase, they were presented with two items from hierarchies that were never encountered together, requiring them to make transitive inferences. Anodal stimulation over mPFC impaired social compared with non-social hierarchy learning, and this modulation was influenced by the relative social rank of the members (higher or lower status). Anodal stimulation also impaired transitive inference making, but only during early blocks before learning was established. Together, these findings demonstrate a causal role of the mPFC in learning social ranks by observation.

Brain-behavior analysis of transcranial direct current stimulation effects on a complex surgical motor task

Transcranial Direct Current Stimulation (tDCS) has demonstrated its potential in enhancing surgical training and performance compared to sham tDCS. However, optimizing its efficacy requires the selection of appropriate brain targets informed by neuroimaging and mechanistic understanding. Previous studies have established the feasibility of using portable brain imaging, combining functional near-infrared spectroscopy (fNIRS) with tDCS during Fundamentals of Laparoscopic Surgery (FLS) tasks. This allows concurrent monitoring of cortical activations. Building on these foundations, our study aimed to explore the multi-modal imaging of the brain response using fNIRS and electroencephalogram (EEG) to tDCS targeting the right cerebellar (CER) and left ventrolateral prefrontal cortex (PFC) during a challenging FLS suturing with intracorporeal knot tying task. Involving twelve novices with a medical/premedical background (age: 22-28 years, two males, 10 females with one female with left-hand dominance), our investigation sought mechanistic insights into tDCS effects on brain areas related to error-based learning, a fundamental skill acquisition mechanism. The results revealed that right CER tDCS applied to the posterior lobe elicited a statistically significant (q < 0.05) brain response in bilateral prefrontal areas at the onset of the FLS task, surpassing the response seen with sham tDCS. Additionally, right CER tDCS led to a significant (p < 0.05) improvement in FLS scores compared to sham tDCS. Conversely, the left PFC tDCS did not yield a statistically significant brain response or improvement in FLS performance. In conclusion, right CER tDCS demonstrated the activation of bilateral prefrontal brain areas, providing valuable mechanistic insights into the effects of CER tDCS on FLS peformance. These insights motivate future investigations into the effects of CER tDCS on error-related perception-action coupling through directed functional connectivity studies.

Multi-compartment head modeling in EEG: Unstructured boundary-fitted tetra meshing with subcortical structures

This paper introduces an automated approach for generating a finite element (FE) discretization of a multi-compartment human head model for electroencephalographic (EEG) source localization. We aim to provide an adaptable FE mesh generation tool for EEG studies. Our technique relies on recursive solid angle labeling of a surface segmentation coupled with smoothing, refinement, inflation, and optimization procedures to enhance the mesh quality. In this study, we performed numerical meshing experiments with the three-layer Ary sphere and a magnetic resonance imaging (MRI)-based multi-compartment head segmentation which incorporates a comprehensive set of subcortical brain structures. These experiments are motivated, on one hand, by the sensitivity of non-invasive subcortical source localization to modeling errors and, on the other hand, by the present lack of open EEG software pipelines to discretize all these structures. Our approach was found to successfully produce an unstructured and boundary-fitted tetrahedral mesh with a sub-one-millimeter fitting error, providing the desired accuracy for the three-dimensional anatomical details, EEG lead field matrix, and source localization. The mesh generator applied in this study has been implemented in the open MATLAB-based Zeffiro Interface toolbox for forward and inverse processing in EEG and it allows for graphics processing unit acceleration.

Neuronavigated Cerebellar 50 Hz tACS: Attenuation of Stimulation Effects by Motor Sequence Learning

Cerebellar transcranial alternating current stimulation (tACS) is an emerging non-invasive technique that induces electric fields to modulate cerebellar function. Although the effect of cortical tACS seems to be state-dependent, the impact of concurrent motor activation and the duration of stimulation on the effects of cerebellar tACS has not yet been examined. In our study, 20 healthy subjects received neuronavigated 50 Hz cerebellar tACS for 40 s or 20 min, each during performance using a motor sequence learning task (MSL) and at rest. We measured the motor evoked potential (MEP) before and at two time points after tACS application to assess corticospinal excitability. Additionally, we investigated the online effect of tACS on MSL. Individual electric field simulations were computed to evaluate the distribution of electric fields, showing a focal electric field in the right cerebellar hemisphere with the highest intensities in lobe VIIb, VIII and IX. Corticospinal excitability was only increased after tACS was applied for 40 s or 20 min at rest, and motor activation during tACS (MSL) cancelled this effect. In addition, performance was better (shorter reaction times) for the learned sequences after 20 min of tACS, indicating more pronounced learning under 20 min of tACS compared to tACS applied only in the first 40 s.

Transcranial Direct Current Stimulation for Chronic Stroke: Is Neuroimaging the Answer to the Next Leap Forward?

During rehabilitation, a large proportion of stroke patients either plateau or begin to lose motor skills. By priming the motor system, transcranial direct current stimulation (tDCS) is a promising clinical adjunct that could augment the gains acquired during therapy sessions. However, the extent to which patients show improvements following tDCS is highly variable. This variability may be due to heterogeneity in regions of cortical infarct, descending motor tract injury, and/or connectivity changes, all factors that require neuroimaging for precise quantification and that affect the actual amount and location of current delivery. If the relationship between these factors and tDCS efficacy were clarified, recovery from stroke using tDCS might be become more predictable. This review provides a comprehensive summary and timeline of the development of tDCS for stroke from the viewpoint of neuroimaging. Both animal and human studies that have explored detailed aspects of anatomy, connectivity, and brain activation dynamics relevant to tDCS are discussed. Selected computational works are also included to demonstrate how sophisticated strategies for reducing variable effects of tDCS, including electric field modeling, are moving the field ever closer towards the goal of personalizing tDCS for each individual. Finally, larger and more comprehensive randomized controlled trials involving tDCS for chronic stroke recovery are underway that likely will shed light on how specific tDCS parameters, such as dose, affect stroke outcomes. The success of these collective efforts will determine whether tDCS for chronic stroke gains regulatory approval and becomes clinical practice in the future.

Neural Correlates of Delay Discounting in the Light of Brain Imaging and Non-Invasive Brain Stimulation: What We Know and What Is Missed

In decision making, the subjective value of a reward declines with the delay to its receipt, describing a hyperbolic function. Although this phenomenon, referred to as delay discounting (DD), has been extensively characterized and reported in many animal species, still, little is known about the neuronal processes that support it. Here, after drawing a comprehensive portrait, we consider the latest neuroimaging and lesion studies, the outcomes of which often appear contradictory among comparable experimental settings. In the second part of the manuscript, we focus on a more recent and effective route of investigation: non-invasive brain stimulation (NIBS). We provide a comprehensive review of the available studies that applied transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) to affect subjects’ performance in DD tasks. The aim of our survey is not only to highlight the superiority of NIBS in investigating DD, but also to suggest targets for future experimental studies, since the regions considered in these studies represent only a fraction of the possible ones. In particular, we argue that, based on the available neurophysiological evidence from lesion and brain imaging studies, a very promising and underrepresented region for future neuromodulation studies investigating DD is the orbitofrontal cortex.

Non-linear dose response effect of cathodal transcranial direct current stimulation on muscle strength in young healthy adults: a randomized controlled study

BACKGROUND

Transcranial direct current stimulation (tDCS) is a technique that modulates brain excitability in humans. Increasing the stimulation intensity or duration within certain limits could enhance tDCS efficacy with a polarity-dependent effect; anodal stimulation increases cortical excitability, whereas cathodal stimulation decreases excitability. However, recent studies have reported a non-linear effect of cathodal tDCS on neuronal excitability in humans, and there is no conclusive result regarding the effect of cathodal tDCS on muscle performance.

METHODS

Our study aimed to investigate the immediate effects of different intensities (i.e., 1, 1.5, and 2 mA and sham tDCS) of cathodal tDCS on muscle strength in healthy participants. All participants [mean age 23.17 (3.90) years] were recruited and randomly allocated into four groups (1, 1.5, and 2 mA cathodal tDCS and sham tDCS). Muscle strength in bilateral upper and lower extremities was measured before and immediately after tDCS using a handheld dynamometer.

RESULTS

Our results showed that cathodal tDCS at 1 and 1.5 mA reduced muscle strength bilaterally in upper and lower extremity muscles, whereas stimulation at 2 mA tended to increase muscle strength on the dominant limb.

CONCLUSION

These findings support the non-linear effects of cathodal tDCS on muscle strength, which should be considered for the clinical use of tDCS in motor rehabilitation.

TRIAL REGISTRATION

NCT04672122, date of first registration 17/12/2020.

High-Definition Transcranial Direct Current with Electrical Theta Burst on Post-Stroke Motor Rehabilitation: A Pilot Randomized Controlled Trial

BACKGROUND

High-definition transcranial electrical theta burst superimposing direct current stimulation (HD-tDCS-eTBS) not only incorporates the therapeutic advantages of tDCS and TBS but enhances stimulation focality and practicality. However, the applicability of this innovative neuromodulatory device in post-stroke rehabilitation remains uncertain.

OBJECTIVE

This study aimed to assess the efficacy and safety of the HD-tDCS-eTBS on upper extremity (UE) motor function in patients with chronic stroke.

METHODS

A patient-blinded, randomized controlled study was conducted. Twenty-four participants were randomly assigned into either the active HD-tDCS-eTBS group or sham HD-tDCS-eTBS group. Both groups received 20 minutes of active/sham HD-tDCS-eTBS combined with 30 minutes of conventional UE rehabilitation each time, 3 times a week for 4 weeks. Outcome measures including the Fugl-Meyer Assessment of Upper Extremity, Wolf Motor Function Test, Jebsen-Taylor Hand Function Test, Finger-Nose Test, and Modified Ashworth Scale were assessed before and immediately after the intervention period.

RESULTS

Spasticity of shoulder adductor (P = .05), elbow extensor (P = .04), and thumb flexor (P < .01) were significantly reduced in the active HD-tDCS-eTBS group versus the sham group. Nonsignificant trends in the improvements of most other outcome measures were in favor of the active HD-tDCS-eTBS group with moderate to large effect sizes (P = .06-.26, η_p² = 0.06-0.16). No severe adverse events except for slight skin redness under the stimulus electrode was detected after the HD-tDCS-eTBS.

CONCLUSIONS

Our findings support that HD-tDCS-eTBS is safe and has therapeutic potential for post-stroke UE motor rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT04278105).

Facilitation and inhibition effects of anodal and cathodal tDCS over areas MT+ on the flash-lag effect

The perceived position of a moving object in vision entails an accumulation of neural signals over space and time. Due to neural signal transmission delays, the visual system can not acquire immediate information about the moving object's position. Although physiological and psychophysical studies on the flash-lag effect (FLE), a moving object is perceived ahead of a flash even they are aligned at the same location, have shown that the visual system develops the mechanisms of predicting the object's location to compensate for the neural delays, the neural mechanisms of motion-induced location prediction are not still understood well. Here, we investigated the role of neural activity changes in areas MT+ (specialized for motion processing) and the potential contralateral processing preference of MT+ in modulating the FLE. Using transcranial direct current stimulations (tDCS) over the left and right MT+ between pre-and post-tests of the FLE in different motion directions, we measured the effects of tDCS on the FLE. The results found that anodal and cathodal tDCS enhanced and reduced the FLE with the moving object heading to but not deviating from the side of the brain stimulated, respectively, compared to sham tDCS. These findings suggest a causal role of area MT+ in motion-induced location prediction, which may involve the integration of position information.

Multidimensional Assessment of Electroencephalography in the Neuromodulation of Disorders of Consciousness

In the present study, we aimed to elucidate changes in electroencephalography (EEG) metrics during recovery of consciousness and to identify possible clinical markers thereof. More specifically, in order to assess changes in multidimensional EEG metrics during neuromodulation, we performed repeated stimulation using a high-density transcranial direct current stimulation (HD-tDCS) protocol in 42 patients with disorders of consciousness (DOC). Coma Recovery Scale-Revised (CRS-R) scores and EEG metrics [brain network indicators, spectral energy, and normalized spatial complexity (NSC)] were obtained before as well as fourteen days after undergoing HD-tDCS stimulation. CRS-R scores increased in the responders (R +) group after HD-tDCS stimulation. The R + group also showed increased spectral energy in the alpha2 and beta1 bands, mainly at the frontal and parietal electrodes. Increased graphical metrics in the alpha1, alpha2, and beta1 bands combined with increased NSC in the beta2 band in the R + group suggested that improved consciousness was associated with a tendency toward stronger integration in the alpha1 band and greater isolation in the beta2 band. Following this, using NSC as a feature to predict responsiveness through machine learning, which yielded a prediction accuracy of 0.929, demonstrated that the NSC of the alpha and gamma bands at baseline successfully predicted improvement in consciousness. According to our findings reported herein, we conclude that neuromodulation of the posterior lobe can lead to an EEG response related to consciousness in DOC, and that the posterior cortex may be one of the key brain areas involved in the formation or maintenance of consciousness.

Effects of cathodal transcranial direct current stimulation on inhibitory and attention control in children and adolescents with attention-deficit hyperactivity disorder: A pilot randomized sham-controlled crossover study

The pathophysiological of attention-deficit hyperactivity disorder (ADHD) includes hypoactivation of the dorso-lateral prefrontal cortex (DLPFC). Most studies have used anodal (excitatory) transcranial direct current stimulation (tDCS) to improve ADHD symptoms, however, a meta-analysis showed limited effect on improving inhibition, and no evidence of attention improvement. We thus present a pilot protocol for investigating the effect of other montage i.e. cathodal (inhibitory) tDCS on neurophysiological and behavioral measures in ADHD. Eleven participants underwent active (1.5 mA, 20 min) and sham cathodal tDCS over the left DLPFC for 5 consecutive days at a 1-month interval. Quantitative electroencephalography was recorded in a resting state with the eyes opened and closed during visual go/no-go and auditory continuous performance tasks at baseline, after five sessions, and at 1-week and 1-month follow-ups. Correct responses and omission errors were recorded. After five active sessions, alpha power increased in the right frontal area when the eyes were opened, and delta power in the left frontal area and omission errors decreased during go/no-go tasks, with no differences at follow-ups. The results revealed improvements in inhibitory control, but not for attention. No aftereffects were observed in either outcomes. However, the changes found in both hemispheres would probably support the hypothesis that cathodal stimulation over the left DLPFC may increase the activity of the right DLPFC via transcallosal inhibition. Results of this pilot trial would help to design and implement a full-scale randomized control trials for further ADHD research. This study was registered on ClinicalTrials.gov (NCT03955692).

P300 Modulation via Transcranial Alternating Current Stimulation in Adult Attention-Deficit/Hyperactivity Disorder: A Crossover Study

OBJECTIVE

A repeated finding regarding event-related potentials (ERPs) is that patients with ADHD show a reduced P300 amplitude. This raises the question of whether the attention of ADHD patients can be increased by stabilizing the P300. Assuming that the P300 is generated by event-related oscillations (EROs) in the low frequency range (0-8 Hz), one approach to increase the P300 could be to stimulate the patient's P300 underlying ERO by means of transcranial alternating current stimulation (tACS). The aim of this follow-up study was to investigate this hypothesized mechanism of action in adult ADHD patients.

MATERIALS AND METHODS

Undergoing a crossover design, 20 adult ADHD patients (10 female) received an actual stimulation via tACS on one day and a sham stimulation on another day. Before and after each intervention, EEG characteristics (P300 amplitudes, low frequency power) and attention performances (d2 attention test, visual oddball task (VOT)) were recorded.

RESULTS

Electrophysiological analyses revealed no evidence for an enhanced P300 amplitude or low frequency power increase after actual stimulation compared to sham stimulation. Instead, a significant effect was found for a stronger N700 amplitude increase after actual stimulation compared to sham stimulation. Consistent with the P300 null results, none of the examined neuropsychological performance measures indicated a tACS-induced improvement in attentional ability.

CONCLUSION

Contrary to a previous study using tACS to modulate the P300 in adult ADHD patients, the current study yields no evidence that tACS can increase the P300 amplitude in adult ADHD patients and that such P300 enhancement can directly improve neuropsychological parameters of attention.

A Future of Current Flow Modelling for Transcranial Electrical Stimulation?

Purpose of Review

Transcranial electrical stimulation (tES) is used to non-invasively modulate brain activity in health and disease. Current flow modeling (CFM) provides estimates of where and how much electrical current is delivered to the brain during tES. It therefore holds promise as a method to reduce commonplace variability in tES delivery and, in turn, the outcomes of stimulation. However, the adoption of CFM has not yet been widespread and its impact on tES outcome variability is unclear. Here, we discuss the potential barriers to effective, practical CFM-informed tES use.

Recent Findings

CFM has progressed from models based on concentric spheres to gyri-precise head models derived from individual MRI scans. Users can now estimate the intensity of electrical fields (E-fields), their spatial extent, and the direction of current flow in a target brain region during tES. Here. we consider the multi-dimensional challenge of implementing CFM to optimise stimulation dose: this requires informed decisions to prioritise E-field characteristics most likely to result in desired stimulation outcomes, though the physiological consequences of the modelled current flow are often unknown. Second, we address the issue of a disconnect between predictions of E-field characteristics provided by CFMs and predictions of the physiological consequences of stimulation which CFMs are not designed to address. Third, we discuss how ongoing development of CFM in conjunction with other modelling approaches could overcome these challenges while maintaining accessibility for widespread use.

Summary

The increasing complexity and sophistication of CFM is a mandatory step towards dose control and precise, individualised delivery of tES. However, it also risks counteracting the appeal of tES as a straightforward, cost-effective tool for neuromodulation, particularly in clinical settings.

An Optimization Approach for Transcranial Direct Current Stimulation Using Nondominated Sorting Genetic Algorithm II

Transcranial direct current stimulation (tDCS) delivers weak current into the brain to modulate neural activities. Many methods have been proposed to determine electrode positions and stimulation intensities. Due to the trade-off between intensity and focality, it is actually a multi-objective optimization problem that has a set of optimal solutions. However, traditional methods can produce only one solution at each time, and many parameters need to be determined by experience. In this study, we proposed the nondominated sorting genetic algorithm II (NSGA-II) to solve the current optimization problem of multi-electrode tDCS. We also compared the representative solutions with LCMV solutions. The result shows that a group of solutions close to the optimal front can be obtained just in only one run without any prior knowledge.

Dataset of concurrent EEG, ECG, and behavior with multiple doses of transcranial electrical stimulation

We present a dataset combining human-participant high-density electroencephalography (EEG) with physiological and continuous behavioral metrics during transcranial electrical stimulation (tES). Data include within participant application of nine High-Definition tES (HD-tES) types, targeting three cortical regions (frontal, motor, parietal) with three stimulation waveforms (DC, 5 Hz, 30 Hz); more than 783 total stimulation trials over 62 sessions with EEG, physiological (ECG, EOG), and continuous behavioral vigilance/alertness metrics. Experiment 1 and 2 consisted of participants performing a continuous vigilance/alertness task over three 70-minute and two 70.5-minute sessions, respectively. Demographic data were collected, as well as self-reported wellness questionnaires before and after each session. Participants received all 9 stimulation types in Experiment 1, with each session including three stimulation types, with 4 trials per type. Participants received two stimulation types in Experiment 2, with 20 trials of a given stimulation type per session. Within-participant reliability was tested by repeating select sessions. This unique dataset supports a range of hypothesis testing including interactions of tDCS/tACS location and frequency, brain-state, physiology, fatigue, and cognitive performance.

Feasibility of Cerebellar Transcranial Direct Current Stimulation to Facilitate Goal-Directed Weight Shifting in Chronic Post-Stroke Hemiplegics

Neurological disorder such as stroke can adversely affect one's weight-bearing symmetry leading to dysfunctional postural control. Recovery after stroke is facilitated through functionally-relevant neuroplastic modulation. Functionally-relevant cerebellum coordinates voluntary movements. Specifically, the dentate nuclei and lower limb representations (lobules VII-IX) of the cerebellum are involved in error-correction, crucial for postural control. It is postulated that cerebellar transcranial direct current stimulation (ctDCS) of the dentate nuclei and lobules VII-IX can modulate postural control in chronic stroke survivors. The objectives of this work were to (1) present a refined Virtual Reality (VR)-based balance training platform (VBaT) that can measure Center of Pressure (CoP) and (2) carry out a study to understand the implication of ctDCS stimulating the dentate nuclei (Phase_D) and lobules VII-IX (Phase_L) on the postural control of chronic stroke patients when they interacted with VBaT. Also, we investigated whether hemiplegic patients (with intact cerebellum) having Basal Ganglia (BG) infarction had any differential abilities to correct postural sway from those with no BG infarction (while shifting weight to the Affected side). Results of a single-session single-blind crossover study on randomized Phase_D and Phase_L stimulation (with an intermediate resting state bipolar bilateral ctDCS) on 12 chronic hemiplegic patients on separate days indicated differentiated findings (post stimulation) on CoP-related indices. We observed an incremental effect on one's postural control during Phase_D and inhibitory effect on the dentate nuclei during Phase_L. Clustering analysis showed that those with BG infarction demonstrated poor postural control and deficit in error correction ability irrespective of the ctDCS Phase.

Designing and pilot testing a novel high-definition transcranial burst electrostimulation device for neurorehabilitation

Objective.Non-invasive brain stimulation has been promoted to facilitate neuromodulation in treating neurological diseases. Recently, high-definition (HD) transcranial electrical stimulation and a novel electrical waveform combining a direct current (DC) and theta burst stimulation (TBS)-like protocol were proposed and demonstrated high potential to enhance neuroplastic effects in a more-efficient manner. In this study, we designed a novel HD transcranial burst electrostimulation device and to preliminarily examined its therapeutic potential in neurorehabilitation.Approach.A prototype of the transcranial burst electrostimulation device was developed, which can flexibly output a waveform that combined a DC and TBS-like protocol and can equally distribute the current into 4 × 1 HD electrical stimulation by automatic impedance adjustments. The safety and accuracy of the device were then validated in a series ofin vitroexperiments. Finally, a pilot clinical trial was conducted to assess its clinical safety and therapeutic potential on upper-extremity rehabilitation in six patients with chronic stroke, where patients received either active or sham HD transcranial burst electrostimulation combined with occupational therapy three times per week for four weeks.Main results.The prototype was tested, and it was found to comply with all safety requirements. The output parameters were accurate and met the clinical study needs. The pilot clinical study demonstrated that the active HD transcranial burst electrostimulation group had greater improvement in voluntary motor function and coordination of the upper extremity than the sham control group. Additionally, no severe adverse events were noted, but slight skin redness under the stimulus electrode immediately after stimulation was seen.Conclusions.The results demonstrated the feasibility of incorporating the HD electrical DC and TBS-like protocol in our device; and the novel neuromodulatory device produced positive neurorehabilitation outcomes in a safe fashion, which could be the basis for the future clinical implementation for treating neurological diseases.Trial registration:ClinicalTrials.gov Identifier: NCT04278105. Registered on 20 February 2020.

Transcranial alternating current stimulation (tACS): from basic mechanisms towards first applications in psychiatry

Transcranial alternating current stimulation (tACS) is a unique form of non-invasive brain stimulation. Sinusoidal alternating electric currents are delivered to the scalp to affect mostly cortical neurons. tACS is supposed to modulate brain function and, in turn, cognitive processes by entraining brain oscillations and inducing long-term synaptic plasticity. Therefore, tACS has been investigated in cognitive neuroscience, but only recently, it has been also introduced in psychiatric clinical trials. This review describes current concepts and first findings of applying tACS as a potential therapeutic tool in the field of psychiatry. The current understanding of its mechanisms of action is explained, bridging cellular neuronal activity and the brain network mechanism. Revisiting the relevance of altered brain oscillations found in six major psychiatric disorders, putative targets for the management of mental disorders using tACS are discussed. A systematic literature search on PubMed was conducted to report findings of the clinical studies applying tACS in patients with psychiatric conditions. In conclusion, the initial results may support the feasibility of tACS in clinical psychiatric populations without serious adverse events. Moreover, these results showed the ability of tACS to reset disturbed brain oscillations, and thus to improve behavioural outcomes. In addition to its potential therapeutic role, the reactivity of the brain circuits to tACS could serve as a possible tool to determine the diagnosis, classification or prognosis of psychiatric disorders. Future double-blind randomised controlled trials are necessary to answer currently unresolved questions. They may aim to detect response predictors and control for various confounding factors.

Investigating the feasibility of cerebellar transcranial direct current stimulation to facilitate post-stroke overground gait performance in chronic stroke: a partial least-squares regression approach

Background

Investigation of lobule-specific electric field effects of cerebellar transcranial direct current stimulation (ctDCS) on overground gait performance has not been performed, so this study aimed to investigate the feasibility of two lobule-specific bilateral ctDCS montages to facilitate overground walking in chronic stroke.

Methods

Ten chronic post-stroke male subjects participated in this repeated-measure single-blind crossover study, where we evaluated the single-session effects of two bilateral ctDCS montages that applied 2 mA via 3.14 cm² disc electrodes for 15 min targeting (a) dentate nuclei (also, anterior and posterior lobes), and (b) lower-limb representations (lobules VIIb-IX). A two-sided Wilcoxon rank-sum test was performed at a 5% significance level on the percent normalized change measures in the overground gait performance. Partial least squares regression (PLSR) analysis was performed on the quantitative gait parameters as response variables to the mean lobular electric field strength as the predictors. Clinical assessments were performed with the Ten-Meter walk test (TMWT), Timed Up & Go (TUG), and the Berg Balance Scale based on minimal clinically important differences (MCID).

Results

The ctDCS montage specific effect was found significant using a two-sided Wilcoxon rank-sum test at a 5% significance level for 'Step Time Affected Leg' (p = 0.0257) and '%Stance Time Unaffected Leg' (p = 0.0376). The changes in the quantitative gait parameters were found to be correlated to the mean electric field strength in the lobules based on PLSR analysis (R² statistic = 0.6574). Here, the mean electric field strength at the cerebellar lobules, Vermis VIIIb, Ipsi-lesional IX, Vermis IX, Ipsi-lesional X, had the most loading and were positively related to the 'Step Time Affected Leg' and '%Stance Time Unaffected Leg,' and negatively related to the '%Swing Time Unaffected Leg,' '%Single Support Time Affected Leg.' Clinical assessments found similar improvement in the TMWT (MCID: 0.10 m/s), TUG (MCID: 8 s), and BBS score (MCID: 12.5 points) for both the ctDCS montages.

Conclusion

Our feasibility study found an association between the lobular mean electric field strength and the changes in the quantitative gait parameters following a single ctDCS session in chronic stroke. Both the ctDCS montages improved the clinical outcome measures that should be investigated with a larger sample size for clinical validation.

Trial registration: Being retrospectively registered.

Effects of Electrode Configurations and Injected Current Intensity on the Electrical Field of Transcranial Direct Current Stimulation: A Simulation Study

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technology that modulates the excitability of the brain by delivering weak electric currents to the brain via scalp electrodes. Electrode configuration and injected current intensity are two important parameters in the tDCS design. This simulation study examined three commercially available electrode configurations, i.e. conventional low definition rectangular pad, high-definition Disc, and high-definition 4 x 1 with different electrode distances and different injected current intensity. Simulation results show that increasing the injected current intensity of HD-tDCS mainly increases the electrical field strength for all configurations. Both Disc and 4 x 1 high definition tDCS (HD-tDCS) have better focality than the conventional low-definition rectangular pad. Increasing the inter-electrode distance in HD-tDCS enlarges the electrical field strength and the depth of stimulation but reduces the focality. In motor rehabilitation, a trade-off needs to be made in the tDCS design to allow the electrical field reaching the white matter to facilitate the usage of the cortico-spinal tract without influencing other undesirable regions in the brain.

Impact of brain atrophy on tDCS and HD-tDCS current flow: a modeling study in three variants of primary progressive aphasia

BACKGROUND

During transcranial direct current stimulation (tDCS), the amount and distribution of current that reaches the brain depends on individual anatomy. Many progressive neurodegenerative diseases are associated with cortical atrophy, but the importance of individual brain atrophy during tDCS in patients with progressive atrophy, including primary progressive aphasia (PPA), remains unclear.

OBJECTIVE

In the present study, we addressed the question whether brain anatomy in patients with distinct cortical atrophy patterns would impact brain current intensity and distribution during tDCS over the left IFG.

METHOD

We developed state-of-the-art, gyri-precise models of three subjects, each representing a variant of primary progressive aphasia: non-fluent variant PPA (nfvPPA), semantic variant PPA (svPPA), and logopenic variant PPA (lvPPA). We considered two exemplary montages over the left inferior frontal gyrus (IFG): a conventional pad montage (anode over F7, cathode over the right cheek) and a 4 × 1 high-definition tDCS montage. We further considered whether local anatomical features, specifically distance of the cortex to skull, can directly predict local electric field intensity.

RESULTS

We found that the differences in brain current flow across the three PPA variants fall within the distribution of anatomically typical adults. While clustering of electric fields was often around individual gyri or sulci, the minimal distance from the gyri/sulci to skull was not correlated with electric field intensity.

CONCLUSION

Limited to the conditions and assumptions considered here, this argues against a specific need to adjust the tDCS montage for these patients any more than might be considered useful in anatomically typical adults. Therefore, local atrophy does not, in isolation, reliably predict local electric field. Rather, our results are consistent with holistic head anatomy influencing brain current flow, with tDCS producing diffuse and individualized brain current flow patterns and HD-tDCS producing targeted brain current flow across individuals.

Accurate anatomical head segmentations: a data set for biomedical simulations

Detailed computational anatomical models of the entire head are needed for accurate in silico modeling in a variety of transcranial stimulation applications. Models from different subjects help to understand and account for population variability. To this end, we have developed a new library of head models of 20 individuals, segmented from co-aligned multi-modal medical image data. The acquired image modalities allow to accurately model tissues with different material properties, such as electrical conductivity or spatially varying acoustic properties. The usefulness of the models is illustrated for two example applications.

Modulation of auditory gamma-band responses using transcranial electrical stimulation

Auditory gamma-band (>30 Hz) activity is a biomarker of cortical excitation/inhibition (E/I) balance in autism, schizophrenia, and bipolar disorder. We provide a comprehensive account of the effects of transcranial alternating current stimulation (tACS) and transcranial direct current stimulation (tDCS) on gamma responses. Forty-five healthy young adults listened to 40-Hz auditory click trains while electroencephalography (EEG) data were collected to measure stimulus-related gamma activity immediately before and after 10 min of 1 mA tACS (40 Hz), tDCS, or sham stimulation to left auditory cortex. tACS, but not tDCS, increased gamma power and phase locking to the auditory stimulus. However, both tACS and tDCS strengthened the gamma phase connectome, and effects persisted beyond the stimulus. Finally, tDCS strengthened the coupling of gamma activity to alpha oscillations after termination of the stimulus. No effects were observed in prestimulus gamma power, the gamma amplitude connectome, or any band-limited alpha measure. Whereas both stimulation techniques synchronize gamma responses between regions, tACS also tunes the magnitude and timing of gamma responses to the stimulus. Results reveal dissociable neurophysiological changes following tACS and tDCS and demonstrate that clinical biomarkers can be altered with noninvasive neurostimulation, especially frequency-tuned tACS.NEW & NOTEWORTHY Gamma frequency-tuned transcranial alternating current stimulation (tACS) adjusts the magnitude and timing of auditory gamma responses, as compared with both sham stimulation and transcranial direct current stimulation (tDCS). However, both tACS and tDCS strengthen the gamma phase connectome, which is disrupted in numerous neurological and psychiatric disorders. These findings reveal dissociable neurophysiological changes following two noninvasive neurostimulation techniques commonly applied in clinical and research settings.

Methodology for tDCS integration with fMRI

Understanding and reducing variability of response to transcranial direct current stimulation (tDCS) requires measuring what factors predetermine sensitivity to tDCS and tracking individual response to tDCS. Human trials, animal models, and computational models suggest structural traits and functional states of neural systems are the major sources of this variance. There are 118 published tDCS studies (up to October 1, 2018) that used fMRI as a proxy measure of neural activation to answer mechanistic, predictive, and localization questions about how brain activity is modulated by tDCS. FMRI can potentially contribute as: a measure of cognitive state-level variance in baseline brain activation before tDCS; inform the design of stimulation montages that aim to target functional networks during specific tasks; and act as an outcome measure of functional response to tDCS. In this systematic review, we explore methodological parameter space of tDCS integration with fMRI spanning: (a) fMRI timing relative to tDCS (pre, post, concurrent); (b) study design (parallel, crossover); (c) control condition (sham, active control); (d) number of tDCS sessions; (e) number of follow up scans; (f) stimulation dose and combination with task; (g) functional imaging sequence (BOLD, ASL, resting); and (h) additional behavioral (cognitive, clinical) or quantitative (neurophysiological, biomarker) measurements. Existing tDCS-fMRI literature shows little replication across these permutations; few studies used comparable study designs. Here, we use a representative sample study with both task and resting state fMRI before and after tDCS in a crossover design to discuss methodological confounds. We further outline how computational models of current flow should be combined with imaging data to understand sources of variability. Through the representative sample study, we demonstrate how modeling and imaging methodology can be integrated for individualized analysis. Finally, we discuss the importance of conducting tDCS-fMRI with stimulation equipment certified as safe to use inside the MR scanner, and of correcting for image artifacts caused by tDCS. tDCS-fMRI can address important questions on the functional mechanisms of tDCS action (e.g., target engagement) and has the potential to support enhancement of behavioral interventions, provided studies are designed rationally.

Concurrent Imaging of Markers of Current Flow and Neurophysiological Changes During tDCS

Despite being a popular neuromodulation technique, clinical translation of transcranial direct current stimulation (tDCS) is hampered by variable responses observed within treatment cohorts. Addressing this challenge has been difficult due to the lack of an effective means of mapping the neuromodulatory electromagnetic fields together with the brain's response. In this study, we present a novel imaging technique that provides the capability of concurrently mapping markers of tDCS currents, as well as the brain's response to tDCS. A dual-echo echo-planar imaging (DE-EPI) sequence is used, wherein the phase of the acquired MRI-signal encodes the tDCS current induced magnetic field, while the magnitude encodes the blood oxygenation level dependent (BOLD) contrast. The proposed technique was first validated in a custom designed phantom. Subsequent test-retest experiments in human participants showed that tDCS-induced magnetic fields can be detected reliably in vivo. The concurrently acquired BOLD data revealed large-scale networks characteristic of a brain in resting-state as well as a 'cathodal' and an 'anodal' resting-state component under each electrode. Moreover, 'cathodal's BOLD-signal was observed to significantly decrease with the applied current at the group level in all datasets. With its ability to image markers of electromagnetic cause as well as neurophysiological changes, the proposed technique may provide an effective means to visualize neural engagement in tDCS at the group level. Our technique also contributes to addressing confounding factors in applying BOLD fMRI concurrently with tDCS.

Transcranial electrical stimulation motor threshold can estimate individualized tDCS dosage from reverse-calculation electric-field modeling

Background:

Unique amongst brain stimulation tools, transcranial direct current stimulation (tDCS) currently lacks an easy or widely implemented method for individualizing dosage.

Objective:

We developed a method of reverse-calculating electric-field (E-field) models based on Magnetic Resonance Imaging (MRI) scans that can estimate individualized tDCS dose. We also evaluated an MRI-free method of individualizing tDCS dose by measuring transcranial magnetic stimulation (TMS) motor threshold (MT) and single pulse, suprathreshold transcranial electrical stimulation (TES) MT and regressing it against E-field modeling. Key assumptions of reverse-calculation E-field modeling, including the size of region of interest (ROI) analysis and the linearity of multiple E-field models were also tested.

Methods:

In 29 healthy adults, we acquired TMS MT, TES MT, and anatomical T1-weighted MPRAGE MRI scans with a fiducial marking the motor hotspot. We then computed a “reverse-calculated tDCS dose” of tDCS applied at the scalp needed to cause a 1.00 V/m E-field at the cortex. Finally, we examined whether the predicted E-field values correlated with each participant’s measured TMS MT or TES MT.

Results:

We were able to determine a reverse-calculated tDCS dose for each participant using a 5 × 5 x 5 voxel grid region of interest (ROI) approach (average = 6.03 mA, SD = 1.44 mA, range = 3.75–9.74 mA). The Transcranial Electrical Stimulation MT, but not the Transcranial Magnetic Stimulation MT, significantly correlated with the ROI-based reverse-calculated tDCS dose determined by E-field modeling (R² = 0.45, p < 0.001).

Conclusions:

Reverse-calculation E-field modeling, alone or regressed against TES MT, shows promise as a method to individualize tDCS dose. The large range of the reverse-calculated tDCS doses between subjects underscores the likely need to individualize tDCS dose. Future research should further examine the use of TES MT to individually dose tDCS as an MRI-free method of dosing tDCS.

Discordant Alpha-Band Transcranial Alternating Current Stimulation Affects Cortico-Cortical and Cortico-Cerebellar Connectivity

Synchronization of oscillatory brain activity is believed to play a critical role in linking distributed neuronal populations into transient functional networks. Alpha-band alternating current stimulation (tACS) was applied over bilateral parietal cortex in a double-blind sham-controlled study to test the notion that widespread alpha mediates causal relationships in the gamma-band both within local neuronal populations and also across distant brain regions. Causal relationships of oscillatory alpha- and gamma-band activity were characterized during performance of a visual global/local attention task. Nonfocal and nonphase-locked tACS, discordant with endogenous oscillatory activity, was hypothesized to induce a performance deficit and differences in network-level causal relationships between both cortical and subcortical brain regions. Although modulation of fronto-parieto-cerebellar causal relationships was observed following stimulation, there was no evidence for a behavioral deficit. We propose that olivo-cerebellar circuits may have responded to the discordant tACS-induced currents as if they were "error signals" in the context of ongoing functional alpha-band brain dynamics. Compensatory cerebellar activity may have contributed to the lack of behavioral deficits and to differences in causal relationships observed following stimulation. Understanding a potential compensatory mechanism involving short-term plasticity in the cerebellum may be critical to developing potential clinical applications of tACS, particularly for disorders such as autism that are characterized by both atypical cortical and cerebellar dynamics.

Deep Cerebellar Transcranial Direct Current Stimulation of the Dentate Nucleus to Facilitate Standing Balance in Chronic Stroke Survivors-A Pilot Study

Objective: Cerebrovascular accidents are the second leading cause of death and the third leading cause of disability worldwide. We hypothesized that cerebellar transcranial direct current stimulation (ctDCS) of the dentate nuclei and the lower-limb representations in the cerebellum can improve functional reach during standing balance in chronic (>6 months’ post-stroke) stroke survivors. Materials and Methods: Magnetic resonance imaging (MRI) based subject-specific electric field was computed across a convenience sample of 10 male chronic (>6 months) stroke survivors and one healthy MRI template to find an optimal bipolar bilateral ctDCS montage to target dentate nuclei and lower-limb representations (lobules VII–IX). Then, in a repeated-measure crossover study on a subset of 5 stroke survivors, we compared 15 min of 2 mA ctDCS based on the effects on successful functional reach (%) during standing balance task. Three-way ANOVA investigated the factors of interest– brain regions, montages, stroke participants, and their interactions. Results: “One-size-fits-all” bipolar ctDCS montage for the clinical study was found to be PO9h–PO10h for dentate nuclei and Exx7–Exx8 for lobules VII–IX with the contralesional anode. PO9h–PO10h ctDCS performed significantly (alpha = 0.05) better in facilitating successful functional reach (%) when compared to Exx7–Exx8 ctDCS. Furthermore, a linear relationship between successful functional reach (%) and electric field strength was found where PO9h–PO10h montage resulted in a significantly (alpha = 0.05) higher electric field strength when compared to Exx7–Exx8 montage for the same 2 mA current. Conclusion: We presented a rational neuroimaging based approach to optimize deep ctDCS of the dentate nuclei and lower limb representations in the cerebellum for post-stroke balance rehabilitation. However, this promising pilot study was limited by “one-size-fits-all” bipolar ctDCS montage as well as a small sample size.

Frontoparietal theta-gamma interactions track working memory enhancement with training and tDCS

Despite considerable interest in enhancing, preserving, and rehabilitating working memory (WM), efforts to elicit sustained behavioral improvements have been met with limited success. Here, we paired WM training with transcranial direct current stimulation (tDCS) to the frontoparietal network over four days. Active tDCS enhanced WM performance by modulating interactions between frontoparietal theta oscillations and gamma activity, as measured by pre- and post-training high-density electroencephalography (EEG). Increased phase-amplitude coupling (PAC) between the prefrontal stimulation site and temporo-parietal gamma activity explained behavioral improvements, and was most effective when gamma occurred near the prefrontal theta peak. These results demonstrate for the first time that tDCS-linked WM training elicits lasting changes in behavior by optimizing the oscillatory substrates of prefrontal control.

Realistic volumetric-approach to simulate transcranial electric stimulation-ROAST-a fully automated open-source pipeline

OBJECTIVE

Research in the area of transcranial electrical stimulation (TES) often relies on computational models of current flow in the brain. Models are built based on magnetic resonance images (MRI) of the human head to capture detailed individual anatomy. To simulate current flow on an individual, the subject's MRI is segmented, virtual electrodes are placed on this anatomical model, the volume is tessellated into a mesh, and a finite element model (FEM) is solved numerically to estimate the current flow. Various software tools are available for each of these steps, as well as processing pipelines that connect these tools for automated or semi-automated processing. The goal of the present tool-realistic volumetric-approach to simulate transcranial electric simulation (ROAST)-is to provide an end-to-end pipeline that can automatically process individual heads with realistic volumetric anatomy leveraging open-source software and custom scripts to improve segmentation and execute electrode placement.

APPROACH

ROAST combines the segmentation algorithm of SPM12, a Matlab script for touch-up and automatic electrode placement, the finite element mesher iso2mesh and the solver getDP. We compared its performance with commercial FEM software, and SimNIBS, a well-established open-source modeling pipeline.

MAIN RESULTS

The electric fields estimated with ROAST differ little from the results obtained with commercial meshing and FEM solving software. We also do not find large differences between the various automated segmentation methods used by ROAST and SimNIBS. We do find bigger differences when volumetric segmentation are converted into surfaces in SimNIBS. However, evaluation on intracranial recordings from human subjects suggests that ROAST and SimNIBS are not significantly different in predicting field distribution, provided that users have detailed knowledge of SimNIBS.

SIGNIFICANCE

We hope that the detailed comparisons presented here of various choices in this modeling pipeline can provide guidance for future tool development. We released ROAST as an open-source, easy-to-install and fully-automated pipeline for individualized TES modeling.

Cerebellar Lobules Optimal Stimulation (CLOS): A Computational Pipeline to Optimize Cerebellar Lobule-Specific Electric Field Distribution

OBJECTIVE

Cerebellar transcranial direct current stimulation (ctDCS) is challenging due to the complexity of the cerebellar structure which is reflected by the well-known variability in ctDCS effects. Therefore, our objective is to present a freely available computational modeling pipeline for cerebellar lobules' optimal stimulation (CLOS).

METHODS

CLOS can optimize lobule-specific electric field distribution following finite element analysis (FEA) using freely available computational modeling pipelines. We modeled published ctDCS montages with 5 cm × 5 cm anode placed 3 cm lateral to inion, and the same sized cathode was placed on the: (1) contralateral supra-orbital area (called Manto montage), and (2) buccinators muscle (called Celnik montage). Also, a published (3) 4×1 HD-ctDCS electrode montage was modeled. We also investigated the effects of the subject-specific head model versus Colin 27 average head model on lobule-specific electric field distribution. Three-way analysis of variance (ANOVA) was used to determine the effects of lobules, montage, and head model on the electric field distribution. The differences in lobule-specific electric field distribution across different freely available computational pipelines were also evaluated using subject-specific head model. We also presented an application of our computational pipeline to optimize a ctDCS electrode montage to deliver peak electric field at the cerebellar lobules VII-IX related to ankle function.

RESULTS

Eta-squared effect size after three-way ANOVA for electric field strength was 0.05 for lobule, 0.00 for montage, 0.04 for the head model, 0.01 for lobule∗montage interaction, 0.01 for lobule∗ head model interaction, and 0.00 for montage∗head model interaction. The electric field strength of both the Celnik and the Manto montages affected the lobules Crus I/II, VIIb, VIII, and IX of the targeted cerebellar hemisphere where Manto montage had a spillover to the contralateral cerebellar hemisphere. The 4×1 HD-ctDCS montage primarily affected the lobules Crus I/II of the targeted cerebellar hemisphere. All three published ctDCS montages were found to be not optimal for ankle function (lobules VII-IX), so we presented a novel HD-ctDCS electrode montage.

DISCUSSION

Our freely available CLOS pipeline can be leveraged to optimize electromagnetic stimulation to target cerebellar lobules related to different cognitive and motor functions.

Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness

Severe brain injury is a common cause of coma. In some cases, despite vigilance improvement, disorders of consciousness (DoC) persist. Several states of impaired consciousness have been defined, according to whether the patient exhibits only reflexive behaviors as in the vegetative state/unresponsive wakefulness syndrome (VS/UWS) or purposeful behaviors distinct from reflexes as in the minimally conscious state (MCS). Recently, this clinical distinction has been enriched by electrophysiological and neuroimaging data resulting from a better understanding of the physiopathology of DoC. However, therapeutic options, especially pharmacological ones, remain very limited. In this context, electroceuticals, a new category of therapeutic agents which act by targeting the neural circuits with electromagnetic stimulations, started to develop in the field of DoC. We performed a systematic review of the studies evaluating therapeutics relying on the direct or indirect electro-magnetic stimulation of the brain in DoC patients. Current evidence seems to support the efficacy of deep brain stimulation (DBS) and non-invasive brain stimulation (NIBS) on consciousness in some of these patients. However, while the latter is non-invasive and well tolerated, the former is associated with potential major side effects. We propose that all chronic DoC patients should be given the possibility to benefit from NIBS, and that transcranial direct current stimulation (tDCS) should be preferred over repetitive transcranial magnetic stimulation (rTMS), based on the literature and its simple use. Surgical techniques less invasive than DBS, such as vagus nerve stimulation (VNS) might represent a good compromise between efficacy and invasiveness but still need to be further investigated.

Challenges of P300 Modulation Using Transcranial Alternating Current Stimulation (tACS)

The P300 component of the event-related potential (ERP) is a well investigated phenomenon in the human electroencephalogram (EEG) and has been related to stimulus processing and attentional mechanisms. Event-related oscillations (ERO) represent a potential mechanism responsible for generating the ERP. In particular, oscillatory activity in the delta and theta frequency range has been associated with the generation of the P300 component. Transcranial Alternating Current Stimulation (tACS) is capable of modulating oscillatory brain activity in a frequency-specific manner. In this study, we aimed to modulate P300 amplitude using tACS by stimulating the individual ERO involved in the generation of the P300 component. TACS was applied precisely in time to the target P300 occurring in a visual oddball task. In order to achieve an appropriate current distribution, we designed an electrode configuration consisting of two clusters of stimulation electrodes on central-parietal locations. We could not demonstrate a group difference in P300 amplitude after applying tACS in the stimulation condition (N = 17) vs. the sham condition (N = 11). TACS condition and sham condition did not differ regarding their reaction times in response to target stimuli or their event-related spectral perturbation (ERSP) at stimulation frequency. Although a significant influence of stimulation could not yet be revealed on a statistical level, we suggest that the proposed method of using tACS for modulating EROs merits further investigation. Modulation of the P300 component in the ERP could help to gain further insights in the role of EROs generating ERPs and the functional relevance of the P300 component. In this study, we propose a novel approach of applying tACS and provide advice on using tACS for the modulation of EROs.

Cortico-Muscular Coherence Modulated by High-Definition Transcranial Direct Current Stimulation in People With Chronic Stroke

High-definition transcranial direct current stimulation (HD-tDCS) is a potential neuromodulation apparatus for stroke rehabilitation. However, its modulatory effects in stroke subjects is still not well understood. In this paper, the offline modulatory effects of HD-tDCS on the ipsilesional primary motor cortex were investigated by performing wrist isometric contraction tasks before and after HD-tDCS in eleven unilateral chronic stroke subjects using a synchronized HD-tDCS and electroencephalogram/electromyography measurement system. This paper is a randomized, single blinded, and sham-controlled crossover study. Each subject randomly received three HD-tDCS (anode, cathode, and sham) with at least one-week washout period. Online feedback-guided medium-level wrist isometric contraction tasks were conducted for the affected upper limbs before stimulation and 10, 30, and 50 min after the end of 10-min 1-mA HD-tDCS. The characteristics of corticomuscular coherence (CMC), cortical oscillation power spectral density, and power spectral entropy were analyzed during tasks and compared across all sessions and stimulation conditions. Anode HD-tDCS induced significant CMC changes in stroke subjects, while cathode and sham stimulation did not induce significant CMC changes. The largest neuromodulation effects were observed at 10 min immediately after anodal HD-tDCS.