Repetitive Transcranial Magnetic Stimulation Improves Depressive Symptoms and Quality of Life of Poststroke Patients-Prospective Case Series Study

Non-Invasive Brain Stimulation Progression in Post-Stroke Depression Treatment: A Systematic Review

Objective

Post-stroke depression (PSD) is the most common psychological disorder in patients with stroke. It not only seriously affects the patient's functional recovery, quality of life, and ability to return to society but also increases stroke recurrence rate and mortality. However, the effectiveness of drug treatment is unpredictable and associated with certain side effects and low compliance. Pharmacological therapy is limited. The field of noninvasive brain stimulation (NIBS) has recently made great progress in developing specific stimulation protocols to alleviate the symptoms of patients with PSD and might offer valid, alternative strategies.

Methods

We systematically searched PubMed, Embase, and the Cochrane Library for investigating the use of NIBS in the treatment of PSD. The methodological quality of selected studies was assessed according to the Risk of Bias 2 (ROB2).

Results

We identified 814 references in 3 databases. After excluding irrelevant and duplicate studies, 14 studies were included. According to the PRISMA checklist, 4 studies were overall comprehensive, 6 had some problems, and 4 had considerable problems with the presented information. The evidence was evaluated using ROB2, with 5 "low-risk" studies, 5 "some concerns" studies, and 4 "high-risk" studies included.

Conclusion

This review provides a comprehensive overview of the clinical trials reported in PSD. Noninvasive brain stimulation is a potentially promising treatment strategy. However, an optimal stimulation protocol needs to be formulated, and much work is required before NIBS can be widely applied in the clinic.

Depression circuit adaptation in post-stroke depression

BACKGROUND

Lesion locations of post-stroke depression (PSD) mapped to a depression circuit which centered by the left dorsolateral prefrontal cortex (DLPFC). However, it remains unknown whether the compensatory adaptations that may occur in this depression circuit due to the lesions in PSD.

METHODS

Rs-fMRI data were collected from 82 non-depressed stroke patients (Stroke), 39 PSD patients and 74 healthy controls (HC). We tested the existence of depression circuit, examined PSD-related alterations of DLPFC-seeded connectivity and their associations with depression severity, and analyzed the connectivity between each repetitive transcranial magnetic stimulation (rTMS) target and DLPFC to find the best treatment target for PSD.

RESULTS

We found that: 1) the left DLPFC showed significantly stronger connectivity to lesions of PSD than Stroke group; 2) in comparison to both Stroke and HC groups, PSD exhibited increased connectivity with DLPFC in bilateral lingual gyrus, contralesional superior frontal gyrus, precuneus, and middle frontal gyrus (MFG); 3) the connectivity between DLPFC and the contralesional lingual gyrus positively correlated with depression severity; 4) the rTMS target in center of MFG showed largest between-group difference in connectivity with DLPFC, and also reported the highest predicted clinical efficacy.

LIMITATIONS

Longitudinal studies are required to explore the alterations of depression circuit in PSD as the disease progress.

CONCLUSION

PSD underwent specific alterations in depression circuit, which may help to establish objective imaging markers for early diagnosis and interventions of the disease.

Capturing Neuroplastic Changes after iTBS in Patients with Post-Stroke Aphasia: A Pilot fMRI Study

Intermittent theta-burst stimulation (iTBS) is a high-efficiency transcranial magnetic stimulation (TMS) paradigm that has been applied to post-stroke aphasia (PSA). However, its efficacy mechanisms have not been clarified. This study aimed to explore the immediate effects of iTBS of the primary motor cortex (M1) of the affected hemisphere, on the functional activities and connectivity of the brains of PSA patients. A total of 16 patients with aphasia after stroke received iTBS with 800 pulses for 300 s. All patients underwent motor, language, and cognitive assessments and resting-state functional MRI scans immediately before and after the iTBS intervention. Regional, seed-based connectivity, and graph-based measures were used to test the immediate functional effects of the iTBS intervention, including the fractional amplitude of low-frequency fluctuation (fALFF), degree centrality (DC), and functional connectivity (FC) of the left M1 area throughout the whole brain. The results showed that after one session of iTBS intervention, the fALFF, DC, and FC values changed significantly in the patients' brains. Specifically, the DC values were significantly higher in the right middle frontal gyrus and parts of the left parietal lobe (p < 0.05), while fALFF values were significantly lower in the right medial frontal lobe and parts of the left intracalcarine cortex (p < 0.05), and the strength of the functional connectivity between the left M1 area and the left superior frontal gyrus was reduced (p < 0.05). Our findings provided preliminary evidences that the iTBS on the ipsilesional M1 could induce neural activity and functional connectivity changes in the motor, language, and other brain regions in patients with PSA, which may promote neuroplasticity and functional recovery.

Efficacy of repetitive transcranial magnetic stimulation for post-stroke depression: a systematic review and meta-analysis of randomized clinical trials

We aimed to conduct a meta-analysis to evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with post-stroke depression (PSD). Six relevant electronic databases (PubMed, CENTRAL, Embase, Web of Science, CINAHL, and PsycINFO) were searched. Randomized controlled trials (RCTs) that compared rTMS with control condition for PSD were included. The mean change in depression symptom scores was defined as the primary efficacy outcome. Secondary outcomes included the remission rate of depression, stroke recovery, and cognitive function recovery. In total, 7 RCTs with 351 participants were included. At post-treatment, rTMS was significantly more effective than the control condition, with a standardized mean difference (SMD) of -1.15 (95%CI: -1.62 to -0.69; P<0.001, I2=71%) and remission with an odds ratio (OR) of 3.46 (95%CI: 1.68 to 7.12; P<0.001; I2=11%). As for stroke recovery, rTMS was also better than the control condition (SMD=-0.67, 95%CI: -1.02 to -0.32; P<0.001). However, no significant difference was found for cognitive function recovery between the two groups (SMD=4.07, 95%CI: -1.41 to 9.55; P=0.15). To explore the potential moderators for the primary outcome, a series of subgroup and sensitivity analyses were performed. The results implied that rTMS may be more effective in Asian samples than in North American samples (P=0.03). In conclusion, from the current evidence in this study, rTMS could be an effective treatment for patients with PSD. Further clinical studies with larger sample sizes and clearer subgroup definitions are needed to confirm these outcomes.