M. Fichera

Excitatory deep repetitive transcranial magnetic stimulation with H-coil as add-on treatment of motor symptoms in Parkinson's disease: an open label, pilot study.

BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) has been proposed as a potential treatment for Parkinsons disease (PD). H-coils, inducing deeper and wider magnetic fields compared to traditional coils, may be potentially useful in PD, characterized by widespread, bilateral involvement of cortico-subcortical circuits. OBJECTIVE To evaluate the safety of repetitive deep TMS (rDTMS) with H-coil as add-on treatment of motor symptoms in PD. METHODS Twenty-seven PD patients (aged 60.1 ± 6.8 y; PD-duration: 6.3 ± 2.8 y; motor-UPDRS: 39.6 ± 10.1) underwent 12 rDTMS sessions over 4 weeks at excitatory (10 Hz) frequency over primary motor (M1) and bilateral prefrontal (PF) regions. Motor UPDRS off therapy was assessed before and after the last rDTMS session, together with safety records at each treatment session. RESULTS No drop-outs or adverse events were recorded. Motor UPDRS significantly improved after rDTMS (10.8 points average reduction; P < 0.0001). CONCLUSIONS High-frequency rDTMS might be a safe treatment for PD motor symptoms. Further placebo-controlled, randomized studies are warranted.

Deep magnetic stimulation in a progressive supranuclear palsy patient with speech involvement

In the last few years, several dementia conditions have been recognized as responsible for speech disorders [1]. The underlying pathology is variable and encompasses Alzheimer’s disease (AD) [2] and frontotemporal lobar degeneration, including its variants such as corticobasal degeneration and progressive supranuclear palsy (PSP) [3]. Particularly, beside the classical symmetric parkinsonism and gaze supranuclear palsy, PSP patients may present apraxia of speech (AOS) and progressive nonfluent aphasia (PNFA) [4]. AOS represents a motor speech disorder showing slow speech rate, prolonged intervals between words, decreased articulatory accuracy and sound distortions [4]. PNFA is a language disorder with dysfluent, effortful and agrammatic speech, often accompanied by similar difficulty with writing and comprehension [1]. Regardless of aetiology, AOS and PNFA usually co-occur, eventually leading to a complete mutism. Cortical atrophy predominantly shows a perisylvian distribution [1]. Unfortunately despite the recent advantages in diagnostic accuracy, the therapeutic options for these patients are disappointing. Repetitive TMS (rTMS) is based on the application of transient electromagnetic fields to induce electric currents in the brain and consequently transynaptic depolarization of neurons located in superficial cortical layers. Increased cortical excitability has been reported after high-frequency rTMS (5 Hz or higher), while the opposite after low-frequency (\1 Hz) [5]. Evidence is accumulating about a possible beneficial role of high-frequency left prefrontal rTMS on cognitive performances in subjects with dementia [7]. For example, improved naming was observed after stimulation of the dorsolateral prefrontal cortex (DLPF) [6]. This non-invasive technique has also been applied to improve both motor and non-motor symptoms in Parkinson’s disease (PD) [8]. However, one main feature of rTMS applied with traditional focal coils is its relatively narrow and superficial magnetic field, which can be a limiting factor when aiming to target deep or widespread brain regions, as could be the case in neurodegenerative disorders. Deep transcranial magnetic stimulation (DTMS) can be obtained with the H-coil, capable of generating broader and deeper magnetic field than the figure-of-8 coil, without significantly increasing superficial stimulation intensities [9]. The broader and deeper stimulation of H-coils may increase the risk for side effects, [10] however no significant safety concerns have been reported so far with the H2-coil, used in this study [11]. Electronic supplementary material The online version of this article (doi:10.1007/s00415-012-6772-3) contains supplementary material, which is available to authorized users.

Bi-hemispheric repetitive transcranial magnetic stimulation for upper limb motor recovery in chronic stroke: A feasibility study

With the emerging of a crucial role of non-primary and contralesional motor areas in the recovery of upper extremity (UE) after acute stroke [1,2], the ‘‘bimodal-balance recovery model“ has been proposed [3], with the hypothesis that the contribution of ipsiand contralesional primary and secondary motor areas might vary according to the structural reserve of the ipsilesional corticospinal tract. This model opens to novel non-invasive brain stimulation approaches for improving the effects of neurorehabilitation, targeting bilateral, wide motor cortical regions rather than focusing on the ipsilateral or contralesional M1. We tested safety, feasibility and efficacy of simultaneous high-frequency rTMS of bilateral motor/premotor areas using the H5-coil, associated with unilateral motor training of the paretic UE.

61. Patients with progressive supranuclear palsy show abnormal response to conditioned and unconditioned TMS stimuli compared to patients with Parkinson’s disease and healthy subjects

Progressive supranuclear palsy-PSP is the second most common parkinsonian syndrome after Parkinson’s disease-PD, with some overlapping clinical features in the early phases. Non-invasive neurophysiological techniques, such as transcranial magnetic stimulation-TMS, could be useful for the differential diagnosis. Seventeen PD, 13 PSP and 11 healthy controls-HC subjects were included in this study. TMS evaluation included resting motor threshold-RMT, motor evoked potentials-MEP amplitude and latency, response to inhibitory-SICI and facilitating-ICF conditioned stimuli, cortical silent period-CSP, and ipsilateral silent period-iSP. Statistical analysis was performed using either parametric or non-parametric ANOVA according to data distribution. PSP and PD groups did not significantly differ in UPDRS. TMS assessment showed different distribution of RMT across the groups (p.008), with PSP patients showing the highest values and PD the lowest (PSP vs PD p.002). Group also affected iSP duration (p.016), being longest in PSP and lowest in HC (PSP vs HC p.005). On paired-pulse inhibition and facilitation, a significant effect for ISI ( p

ID 278 – Motor cortical disinhibition is more pronounced in Progressive Supranuclear Palsy than in Parkinson’s disease: Evidence from TMS

Objective Progressive Supranuclear Palsy-PSP is the second most common parkinsonian syndrome after Parkinson’s disease-PD. Non-invasive neurophysiological techniques, such as transcranial magnetic stimulation-TMS, could prove useful to gain insight into these pathologies and for differential diagnosis. Methods Seventeen PD, 13 PSP and 11 healthy controls-CT were included in this study. TMS evaluation included resting motor threshold-RMT, motor evoked potentials-MEP amplitude, response to inhibitory-SICI and facilitating-ICF conditioning stimuli, cortical-CSP and ipsilateral silent period-iSP. Statistical analysis was performed using either parametric or non-parametric ANOVA and post-hoc tests according to data distribution. Results PSP and PD groups did not significantly differ in UPDRS. RMT distributed differently across groups (p.008), with PSP patients showing highest values and PD lowest (PSPvs.PD p.002). Group also affected iSP duration (p.016), being longest in PSP and lowest in HC (PSPvs.CT p.005). On paired-pulse inhibition and facilitation, a significant effect for inter-stimulus interval-ISI ( p Conclusions This study suggests that TMS can help differentiate PD and PSP. PSP patients displayed different response to the perturbation induced by conditioning stimuli and iSP elongation, probably due to impairment of GABA-mediated neurotransmission.

Drawing in Alzheimer-type dementia

A 76-year-old woman had progressive memory loss for 2 years. Neurologic examination confirmed the memory deficit and also demonstrated ideative-ideomotor apraxia and visuospatial disturbances (Mini-Mental State Examination 17/30). A diagnosis of probable Alzheimer disease dementia (AD) was formulated. She showed us notebooks filled with drawings she had completed as a hobby, covering a period form before the illness (figure 1) to the present (figure 2). These sketches provide an inside into AD-related changes in creativity and visuospatial skills.1 Drawing performance is related to perceptual and executive dysfunctions in the visuospatial domain.

Secondary cervical dystonic tremor after Japanese encephalitis

Japanese encephalitis (JE) represents a major health problem in Southeast Asia where it remains the most important cause of viral encephalitis. Rare in the developed countries, JE is caused by a mosquito-born flavi virus able to procure an extensive damage to the basal ganglia, which is accompanied by a very high mortality in the acute phase [1, 2]. In 20–60 % of JE survivors a variety of movement disorders have been reported [1, 2], especially transient parkinsonian features and dystonia, reminiscent of post encephalitic sequelae following encephalitic lethargica. In the endemic areas, JE infection mainly affects children, declining after the age of 14, owing to herd immunity probably effect of continuous subclinical JE expositions [1]. Although JE regional predilection, the clinicians should be aware of this aetiology in patients returning from Asia, presenting with an acute febrile illness, as the travellers to endemic areas may have devastating JE infections due to the absence of protective antibodies. Moreover, it is not infrequent to deal with post-acute consequences of JE infection. Here, we report on a young patient showing clinical and radiological sequelae of JE infection. Case report

P569: Corticospinal reserve predicts the effect of deep repetitive brain stimulation with h-coil and neurorehabilitation on walking impairment in progressive multiple sclerosis: results from two randomized, double blind studies

S.-M. Kim1, S.-Y. Park2, J.Y. Kim3, J.-J. Sung1, K.S. Park3, O. Kwon4, S.H. Kim5, J. Park5, K.-W. Lee1 1Seoul Nationl University Hospital, Neurology, Seoul, Republic of Korea; 2National cancer center, Neurology, Seoul, Republic of Korea; 3Seoul National University, Bundang Hospital, Neurology, Gyeonggi, Republic of Korea; 4Eulji General Hospital, Neurology, Seoul, Republic of Korea; 5Seoul National University Hospital, Medical Research Collaborating Center, Seoul, Republic of Korea