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Koch G, Casula EP, Bonnì S, Borghi I, Assogna M, Minei M, Pellicciari MC, Motta C, D’Acunto A, Porrazzini F, Maiella M, Ferrari C, Caltagirone C, Santarnecchi E, Bozzali M, Martorana A. Precuneus magnetic stimulation for Alzheimer's disease: a randomized, sham-controlled trial. Brain 2022; 145:3776-3786. [PMID: 36281767 PMCID: PMC9679166 DOI: 10.1093/brain/awac285] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/27/2022] [Accepted: 07/03/2022] [Indexed: 08/01/2023] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) is emerging as a non-invasive therapeutic strategy in the battle against Alzheimer's disease. Alzheimer's disease patients primarily show alterations of the default mode network for which the precuneus is a key node. Here, we hypothesized that targeting the precuneus with TMS represents a promising strategy to slow down cognitive and functional decline in Alzheimer's disease patients. We performed a randomized, double-blind, sham-controlled, phase 2, 24-week trial to determine the safety and efficacy of precuneus stimulation in patients with mild-to-moderate Alzheimer's disease. Fifty Alzheimer's disease patients were randomly assigned in a 1:1 ratio to either receive precuneus or sham rTMS (mean age 73.7 years; 52% female). The trial included a 24-week treatment, with a 2-week intensive course in which rTMS (or sham) was applied daily five times per week, followed by a 22-week maintenance phase in which stimulation was applied once weekly. The Clinical Dementia Rating Scale-Sum of Boxes was selected as the primary outcome measure, in which post-treatment scores were compared to baseline. Secondary outcomes included score changes in the Alzheimer's Disease Assessment Scale-Cognitive Subscale, Mini-Mental State Examination and Alzheimer's Disease Cooperative Study-Activities of Daily Living scale. Moreover, single-pulse TMS in combination with EEG was used to assess neurophysiological changes in precuneus cortical excitability and oscillatory activity. Our findings show that patients that received precuneus repetitive magnetic stimulation presented a stable performance of the Clinical Dementia Rating Scale-Sum of Boxes score, whereas patients treated with sham showed a worsening of their score. Compared with the sham stimulation, patients in the precuneus stimulation group also showed also significantly better performances for the secondary outcome measures, including the Alzheimer's Disease Assessment Scale-Cognitive Subscale, Mini-Mental State Examination and Alzheimer's Disease Cooperative Study-Activities of Daily Living scale. Neurophysiological results showed that precuneus cortical excitability remained unchanged after 24 weeks in the precuneus stimulation group, whereas it was significantly reduced in the sham group. Finally, we found an enhancement of local gamma oscillations in the group treated with precuneus stimulation but not in patients treated with sham. We conclude that 24 weeks of precuneus rTMS may slow down cognitive and functional decline in Alzheimer's disease. Repetitive TMS targeting the default mode network could represent a novel therapeutic approach in Alzheimer's disease patients.
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Affiliation(s)
- Giacomo Koch
- Correspondence to: Prof. Giacomo Koch, MD, PhD Santa Lucia Foundation IRCCS, Via Ardeatina 306, 00179, Rome, Italy E-mail:
| | - Elias Paolo Casula
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
| | - Sonia Bonnì
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
| | - Ilaria Borghi
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
| | - Martina Assogna
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
- Memory Clinic, Department of Systems Medicine, University of Tor Vergata, 00133, Rome, Italy
| | - Marilena Minei
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
| | | | - Caterina Motta
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
| | - Alessia D’Acunto
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
| | - Francesco Porrazzini
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
| | - Michele Maiella
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
| | - Clarissa Ferrari
- Unit of Statistics, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125, Brescia, Italy
| | - Carlo Caltagirone
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
| | - Emiliano Santarnecchi
- Precision Neuroscience and Neuromodulation program, Gordon Center for Medical Imaging, Massachussets General Hospital; Harvard Medical School, 02114, Boston, MA, USA
| | - Marco Bozzali
- Rita Levi Montalcini Department of Neuroscience, University of Torino, 10124, Turin, Italy
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, BN1 9PX, Brighton, UK
| | - Alessandro Martorana
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 00179, Rome, Italy
- Memory Clinic, Department of Systems Medicine, University of Tor Vergata, 00133, Rome, Italy
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Gourmaud S, Stewart DA, Irwin DJ, Roberts N, Barbour AJ, Eberwine G, O’Brien WT, Vassar R, Talos DM, Jensen FE. The role of mTORC1 activation in seizure-induced exacerbation of Alzheimer's disease. Brain 2022; 145:324-339. [PMID: 34264340 PMCID: PMC9126019 DOI: 10.1093/brain/awab268] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/04/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
The risk of seizures is 10-fold higher in patients with Alzheimer's disease than the general population, yet the mechanisms underlying this susceptibility and the effects of these seizures are poorly understood. To elucidate the proposed bidirectional relationship between Alzheimer's disease and seizures, we studied human brain samples (n = 34) from patients with Alzheimer's disease and found that those with a history of seizures (n = 14) had increased amyloid-β and tau pathology, with upregulation of the mechanistic target of rapamycin (mTOR) pathway, compared with patients without a known history of seizures (n = 20). To establish whether seizures accelerate the progression of Alzheimer's disease, we induced chronic hyperexcitability in the five times familial Alzheimer's disease mouse model by kindling with the chemoconvulsant pentylenetetrazol and observed that the mouse model exhibited more severe seizures than the wild-type. Furthermore, kindled seizures exacerbated later cognitive impairment, Alzheimer's disease neuropathology and mTOR complex 1 activation. Finally, we demonstrated that the administration of the mTOR inhibitor rapamycin following kindled seizures rescued enhanced remote and long-term memory deficits associated with earlier kindling and prevented seizure-induced increases in Alzheimer's disease neuropathology. These data demonstrated an important link between chronic hyperexcitability and progressive Alzheimer's disease pathology and suggest a mechanism whereby rapamycin may serve as an adjunct therapy to attenuate progression of the disease.
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Affiliation(s)
- Sarah Gourmaud
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David A Stewart
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Duke University School of Medicine, Durham, NC 27708, USA
| | - David J Irwin
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Frontotemporal Degeneration Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Nicholas Roberts
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Aaron J Barbour
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Grace Eberwine
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - William T O’Brien
- Neurobehavior Testing Core, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Robert Vassar
- Department of Cell and Molecular Biology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Delia M Talos
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Frances E Jensen
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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