Comparison of "standard" and "navigated" procedures of TMS coil positioning over motor, premotor and prefrontal targets in patients with chronic pain and depression
Comparison of "standard" and "navigated" procedures of TMS coil positioning over motor, premotor and prefrontal targets in patients with chronic pain and depression
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DOI：
10.1016/j.neucli.2010.01.001
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发表时间：
2010-03-01
影响因子：
3
通讯作者：
Lefaucheur, J. -P.
中科院分区：
文献类型：
--
作者：
Ahdab, R.;Ayache, S. S.;Lefaucheur, J. -P.
大约15年来，经颅磁刺激（TMS）被用作研究特定皮质区域功能的技术。单脉冲TMS研究已经针对背外侧运动前皮层（dlPMC）来表征运动障碍中的运动前相互作用。重复性经颅磁刺激（rTMS）试验针对背外侧前额叶皮层（dlPFC）治疗抑郁症。在之前的几乎所有研究中，这些靶点都是根据头皮到刺激部位的“标准”距离来定义的，该刺激部位能唤起对侧手的最大振幅运动反应（“手运动热点”对应初级运动皮层，M1）。线圈定位的“标准”程序将dlPMC和dlPFC分别定位在“手部运动热点”前方2-3 cm和5 cm处。我们的研究目的是比较“标准”线圈定位程序提供的M1， dlPMC和dlPFC目标的位置与使用神经导航系统集成个人脑磁共振成像（MRI）提供的目标的位置。22名患者入组，均在慢性疼痛综合征的背景下接受抑郁症状治疗。dlPMC和dlPFC区域的中心分别在14名和8名患者（占该系列的64%和36%）中通过“标准”程序精确定位。在其他患者中，“标准”程序将dlPMC靶标定位在M1/dlPMC边界上，将dlPFC靶标定位在dlPMC/dlPFC边界上。mri引导下，M1、dlPMC和dlPFC的平均位置分别在“手部运动热点”后6.1 mm、前31.7 mm和前69.0 mm。“标准”程序未能准确定位dlPMC和dlPFC目标，误差分别约为1厘米和2厘米。对目标的MRI坐标（x, y, z）的统计分析显示，与“标准”程序相比，使用神经导航的M1目标更后侧，dlPMC目标更浅表，dlPFC目标更前侧和更深。这项研究证实，线圈定位的“标准”程序并不准确，无法瞄准所需的皮质区域。目标定位可以通过使用考虑到个体大脑解剖结构的导航系统来改进。目前的结果倾向于对先前基于“标准”靶向的经颅磁刺激研究结果的病理生理解释持谨慎态度，例如关于前运动-运动相互作用。同样，线圈定位“标准”程序的不准确性可以部分解释rTMS对抑郁症患者产生的治疗效果在研究间的差异。我们的研究结果有力地支持在抑郁症的治疗中，将TMS线圈置于更前部和外侧的位置以刺激dlPFC。(C) 2010 Elsevier Masson SAS。版权所有。
Since about 15 years, transcranial magnetic stimulation (TMS) is used as a technique to investigate the function of specific cortical regions. Single pulse TMS studies have targeted the dorsolateral premotor cortex (dlPMC) to characterize premotor motor interactions in movement disorders. Repetitive TMS (rTMS) trials have targeted the dorsolateral prefrontal cortex (dlPFC) to treat depression. In almost all previous studies, these targets have been defined according to a "standard" scalp distance to the site of stimulation evoking motor responses of maximal amplitude in the contralateral hand ("hand motor hotspot" corresponding to the primary motor cortex, M1). The "standard" procedure of coil positioning locates the dlPMC and dlPFC as 2-3 and 5 cm, respectively, anterior to the "hand motor hotspot". The aim of our study was to compare the locations of M1, dlPMC and dlPFC targets provided by the "standard" procedure of coil positioning and those provided by using a neuronavigation system integrating individual brain magnetic resonance imaging (MRI). Twenty-two patients were enrolled, all being treated for depressive symptoms in the context of chronic pain syndrome. The centers of the dlPMC and dlPFC regions were accurately targeted by the "standard" procedure in 14 and eight patients (64 and 36% of the series), respectively. In the other patients, the "standard" procedure located the dlPMC target on the M1/dlPMC border and the dlPFC target on the dlPMC/dlPFC border. On average, the MRI-guided location of M1, dlPMC, and dlPFC was, respectively, 6.1 mm posterior, 31.7 mm anterior and 69.0 mm anterior to the "hand motor hotspot". The "standard" procedure failed to accurately locate the dlPMC and dlPFC targets by about 1 and 2 cm, respectively. A statistical analysis of the MRI coordinates (x, y, z) of the targets revealed that the M1 target was more posterior, the dlPMC target more superficial and the dlPFC target more anterior, lateral, and deeper, using neuronavigation compared to the "standard" procedure. This study confirms that the "standard" procedure of coil positioning is not accurate to target a desired cortical region. Target location can be improved by the use of a navigation system taking individual brain anatomy into account. The present results incline to be cautious on the pathophysiological interpretations of previous results reported in TMS studies based on "standard" targeting, e.g. regarding premotor-motor interactions. Similarly, the inaccuracy of the "standard" procedure of coil positioning could partly explain the between-study variability of the therapeutic effects produced by rTMS in patients with depression. Our results strongly support a more anterior and lateral placement of the TMS coil for dlPFC stimulation in the treatment of depression. (C) 2010 Elsevier Masson SAS. All rights reserved.