Seizure risk with repetitive TMS: Survey results from over a half-million treatment sessions

BackgroundSeizures are rare during repetitive transcranial magnetic stimulation (rTMS) treatment, but estimating risk is difficult because of study heterogeneity and sampling limitations. Moreover, there are few studies comparing rates between device manufacturers.ObjectiveThe objective of this study was to calculate rTMS seizure rates across various FDA-cleared devices in naturalistic clinical settings.MethodsIn July and August 2018, approximately 500 members of the Clinical TMS Society (CTMSS) were electronically surveyed about seizures in their practices. Seizures were distinguished from non-seizures by a remote semi-structured interview with a Board-certified neurologist and Co-Chair of the CTMSS Standards Committee. Exact Poisson calculations were used to estimate seizure rates and confidence intervals across the four most widely used manufacturers.ResultsThe survey was completed by 134 members, with 9 responses excluded because of data inconsistencies. In total, 18 seizures were reported in 586,656 sessions and 25,526 patients across all device manufacturers. The overall seizure rate was 0.31 (95% CI: 0.18, 0.48) per 10,000 sessions, and 0.71 (95% CI: 0.42, 1.11) per 1000 patients. The Brainsway H-coil seizure rate of 5.56 per 1000 patients (95% CI: 2.77,9.95) was significantly higher (p < 0.001) than the three most widely used figure- 8 coil devices’ combined seizure rate of 0.14 per 1000 patients (95% CI: 0.01, 0.51).ConclusionThe absolute risk of a seizure with rTMS is low, but generic Brainsway H-coil treatment appears to be associated with a higher relative risk than generic figure- 8 coil treatment. Well-designed prospective studies are warranted to further investigate this risk.     

TMS to the lateral occipital cortex disrupts object processing but facilitates scene processing

The study of brain-damaged patients and advancements in neuroimaging have lead to the discovery of discrete brain regions that process visual image categories, such as objects and scenes. However, how these visual image categories interact remains unclear. For example, is scene perception simply an extension of object perception, or can global scene "gist" be processed independently of its component objects? Specifically, when recognizing a scene such as an "office," does one need to first recognize its individual objects, such as the desk, chair, lamp, pens, and paper to build up the representation of an "office" scene? Here, we show that temporary interruption of object processing through repetitive TMS to the left lateral occipital cortex (LO), an area known to selectively process objects, impairs object categorization but surprisingly facilitates scene categorization. This result was replicated in a second experiment, which assessed the temporal dynamics of this disruption and facilitation. We further showed that repetitive TMS to left LO significantly disrupted object processing but facilitated scene processing when stimulation was administered during the first 180 msec of the task. This demonstrates that the visual system retains the ability to process scenes during disruption to object processing. Moreover, the facilitation of scene processing indicates disinhibition of areas involved in global scene processing, likely caused by disrupting inhibitory contributions from the LO. These findings indicate separate but interactive pathways for object and scene processing and further reveal a network of inhibitory connections between these visual brain regions.     

Unilateral occipital infarction: evaluation of the risks of developing bilateral loss of vision.

Fifty-eight patients with a unilateral infarction in the superficial area supplied by a posterior cerebral artery were followed (mean: 39.6 months). Thirteen (22.4%) developed cortical blindness associated with a delayed contralateral occipital infarction. Advanced age, general vascular risk, a history of strokes, Sylvian border-zone extension of the initial infarct, and an absence of improvement of initial visual field defects were strongly associated with spread to the other side. The lack of visual field improvement most accurately predicted a high risk of cortical blindness. A careful follow-up and controlled medical therapy is particularly indicated in these patients.     

Mortality over a 20-year period in patients with primary polydipsia associated with schizophrenia: a retrospective study

Primary polydipsia, excessive fluid intake without medical cause, is present in over 20% of seriously and persistently ill psychiatric inpatients. The long-term effects of primary polydipsia on longevity have not previously been examined. Inpatients in a psychiatric hospital were screened for polydipsia in 1985. Those identified to be polydipsic, the majority of whom suffered from schizophrenia, were re-evaluated in 2005 and compared with a control group of non-polydipsic patients. Chart reviews were conducted and follow-up data were obtained. Of 172 patients at the time of screening, 48 suffering from schizophrenia either had or went on to develop polydipsia; 42 non-polydipsic patients with schizophrenia from the original survey were randomly selected as controls. Primary polydipsia had a significant negative effect on longevity. The median age at death (age at which 50% of cases have died) was 59 years for polydipsic patients and 68 for non-polydipsic control patients. Adjusting for duration of schizophrenia, smoking, and diagnosis, a patient with polydipsia had a 74% greater chance of dying before a non-polydipsic patient (a hazard ratio of 2.84 [95% Confidence Interval (CI): 1.22-6.64]). Outcome was worst in patients with severe polydipsia: the median age at death was 57 years and a patient with severe polydipsia had a 75% greater chance of dying before a non-polydipsic patient (hazard ratio of 3.36 [95% CI: 1.31-8.60]). When polydipsia is associated with schizophrenia, mortality is increased in comparison to that in patients with schizophrenia who do not drink water to excess.     

Epilepsy with bilateral occipital calcifications: a benign onset with progressive severity

We studied four patients with a focal epilepsy and bilateral occipital corticosubcortical calcifications without any sign of phakomatosis. The clinical course of the disease was similar in all the patients and evolved from a benign onset to a severe encephalopathy with progressive mental impairment. The question of whether these patients have an incomplete and atypical form of Sturge-Weber syndrome or a previously undescribed disorder is addressed.     

Structural correlates of fixation-off sensitivity: Evidences from a case of symptomatic occipital epilepsy with bilateral occipital gliosis

The fixation-off sensitivity (FOS), an epileptic phenomenon induced by elimination of central vision and fixation, is rarely seen in symptomatic occipital lobe epilepsy. The cerebral mechanisms and the structural correlate underlying FOS remain unclear. We describe a 19-year-old male with persistent left sided FOS following perinatal insult. MRI revealed asymmetric changes with more gliosis and ulegyria over the left posterior occipital cortex corresponding to the topographic representation of the macula. We suggest that the extensive denervation of the area representing macula along with the presence of hyperexitable ulegyric cortex is responsible for the phenomenon of FOS.     

Chronic subdural hematoma organized over a short period of time with spontaneous intracranial hypotension: a case report

Spontaneous intracranial hypotension (SIH) can develop after cerebrospinal fluid (CSF) leakage and is accompanied by various symptoms, including headache and neck pain. In recent years, cases of chronic subdural hematoma (CSDH) that develop concomitantly with SIH have been encountered occasionally. Although various reports regarding the priority of treatment exsist, a conclusive opinion has yet to be given. Here, we present a rare case of CSDH that developed concomitantly with SIH in which the hematoma became organized over a short period of time. Organized CSDH results from impairment of the microcirculation due to metabolic or circulatory dysfunction or inflammation after trepanation. The disease is believed to require craniotomy for treatment, while SIH is frequently treated with an epidural blood patch, which may require repeated procedures to achieve success. If CSF leakage cannot be improved, the concomitant CSDH may become organized. Therefore, it is important to thoroughly discuss the therapeutic options in individual cases.     

Viewing the body prepares the brain for touch: effects of TMS over somatosensory cortex

Viewing the body can improve tactile perception. We investigated whether this could be due to a remodeling of somatosensory cortical areas during vision of the body. Single-pulse transcranial magnetic stimulation (TMS) was delivered over the primary and secondary somatosensory areas of subjects who showed clear visual-tactile enhancement while they performed a tactile grating discrimination task. Before the tactile stimulus, subjects viewed either their right index finger through a semisilvered mirror or an object reflected by the mirror and positioned to appear in the same location as the finger. In a first experiment we observed that TMS over primary somatosensory cortex significantly reduced subjects' accuracy whilst viewing the hand. No such reduction was found when subjects viewed a neutral object. In a second experiment, we disrupted the activity of primary and secondary somatosensory areas in different sessions. When stimulating the primary somatosensory cortex, a reduction in accuracy was again found while viewing the hand, but not a neutral object. TMS over secondary somatosensory cortex had no effect in any condition. Our results show that vision of the body may act at an early stage in stimulus elaboration and perception, allowing an anticipatory tuning of the neural circuits in primary somatosensory cortex that underlie tactile acuity.     

Attitudes of mental health center staff: changes over a five-year period

The author compares a study of attitudes of staff toward priorities and problems in eight community mental health centers with a study five years later, using the same questionnaire, of attitudes of staff in one of the centers. Between 1968 and 1973 the number of psychiatrists decreased and the number of psychologists and social workers increased. The most significant change in priorities in 1973 was the higher ranking of consultation and education services. While staff saw their problems in 1968 as a diffusion and inadequate program planning, by 1973 they were concerned with administrative problems and with shortcomings in the quality of clinical care, due to a lack of resources.     

Early-onset psychotic disorders: course and outcome over a 2-year period

OBJECTIVE: To examine the course and outcome of early-onset psychotic disorders. METHOD: These are data from a longitudinal, prospective study of youths with psychotic disorders. Standardized diagnostic and symptom rating measures were used. RESULTS: Fifty-five subjects with the following disorders have been recruited: schizophrenia (n = 18), bipolar disorder (n = 15), psychosis not otherwise specified (n = 15), schizoaffective disorder (n = 6), and organic psychosis (n = 1). Follow-up assessments were obtained on 42 subjects at year 1 and 31 subjects at year 2. Youths with schizophrenia had more chronic global dysfunction, whereas subjects with bipolar disorder overall had better functioning, with a cyclical course of illness. However, according to results of a regression model, premorbid functioning and ratings of negative symptoms, but not diagnosis, significantly predicted the highest level of functioning over years 1 and 2. CONCLUSIONS: Course and level of functioning differentiated bipolar disorder from schizophrenia. However, premorbid functioning and ratings of negative symptoms were the best predictors of functioning over the follow-up period. These findings are consistent with the adult literature, and they further support that psychotic illnesses in young people are continuous with the adult-onset forms.     

Long-term prognosis, by stroke subtypes, after a first-ever stroke: a hospital-based study over a 20-year period

BACKGROUND AND PURPOSE: The influence of stroke subtype on recurrence, and determinants of recurrence-free survival after a first-ever stroke are not fully understood. We aimed to clarify the long-term prognosis by stroke subtypes and to identify determinants for recurrence and death after a first-ever stroke. METHODS: We enrolled 1,732 consecutive patients (men/women = 1,134/598, mean age of 65 years) with a first-ever acute stroke who were admitted to our Stroke Care Unit during a period of 20 years. Stroke subtypes were classified as atherothrombotic brain infarction, lacunar infarction, cardioembolic infarction, other type of infarction, and brain hemorrhage. The prognosis was assessed by stroke subtypes. RESULTS: During the hospital stay (mean 61 days), 99 patients died: 73 died directly from stroke. A total of 198 patients had recurrent strokes, and 286 died within 3 years after the index stroke. The overall recurrence rate within the first year was 6.5%, which was different among stroke subtypes. Patients with cardioembolic infarction (9.0%) as well as other type of infarction (9.1%) had more recurrent strokes within the initial year compared with the other subtypes. A history of transient ischemic attack (relative risk = 1.38), atrial fibrillation (1.52), ischemic heart disease (1.40), and disability at discharge (2.64) were independent predictors for the recurrence and death within 3 years after the first-ever stroke. CONCLUSIONS: The recurrence rate was different among stroke subtypes within 1 year after the index stroke. Atrial fibrillation, ischemic heart disease, history of transient ischemic attack, and disability at discharge were important determinants for stroke recurrence and death.     

Trends in the pharmacological treatment of patients with schizophrenia over a 12 year observation period

In this study we evaluated whether our efforts to promote evidence-based guidelines for the psychopharmacological treatment of patients with schizophrenia have led to measurable changes of treatment practice in our hospital by investigating three primary hypotheses: 1) Polypharmacy has become less common in recent years, 2) Conventional neuroleptics have been replaced by second generation antipsychotics; and 3) Dosing regimes have changed towards lower doses. We have therefore collected data from the clinical records of all in-patients with ICD-9/ICD-10 diagnoses of schizophrenia hospitalized at the Department of Psychiatry of the Medical University Innsbruck in the years 1989, 1995, 1998 and 2001. Data from 1989 to 1998 showed a significant decrease in the use of two or more antipsychotics given simultaneously. Contrary to our hypothesis, there was a significant increase in polypharmacy between 1998 and 2001. The predominant use of second generation antipsychotics became standard in schizophrenia treatment. In this context the decrease of concomitant anticholinergic medication is notable. Doses of conventional antipsychotics like haloperidol as well as doses of risperidone decreased whereas doses of other second generation antipsychotics increased. All in all, the pharmacological management of schizophrenia patients is increasingly in tune with current treatment guidelines.