Vincent Meille

Stroke with neuropsychiatric sequelae after cannabis use in a man: a case report

IntroductionThe outcome of cerebral ischemic stroke associated with cannabis use is usually favorable. Here we report the first case of cannabis-related stroke followed by neuropsychiatric sequelae.Case presentationA 24-year-old Caucasian man was discovered in a deeply comatose non-reactive state after cannabis use. A magnetic resonance imaging scan of his brain showed bilateral multiple ischemic infarcts. The patient remained deeply comatose for four days, after which time he developed other behavioral impairments and recurrent seizures.ConclusionStroke related to cannabis use can be followed by severe neuropsychiatric sequelae. Concomitant alcohol intoxication is essential neither to the occurrence of this neurologic event nor to its severity.

Interest of targeting either cortical area Brodmann 9 or 46 in rTMS treatment for depression: A preliminary randomized study

OBJECTIVE To assess the interest of specifically targeting Brodmann Areas (BA) 9 or 46 for rTMS treatment of depression. METHODS Patients with Treatment-Resistant Depression were randomly assigned to two treatment groups to receive either rTMS on BA 9 or on BA 46. Each patient underwent 10 sessions of 1Hz-rTMS for 2weeks. The Hamilton and Montgomery-Asberg Depression Rating Scales (HDRS, MADRS) were used under blind conditions to assess the therapeutic response (50% improvement). A Wilcoxon signed-rank test was used to compare the depression rating scales scores obtained before and after the 10 rTMS sessions for each of the two groups. The therapeutic results in the two groups were compared using the Mann-Whitney-Wilcoxon test. We also reported the effect sizes using Hedgess g. RESULTS Fifteen patients were included. Stimulation of both BA 9 (n=7) and BA 46 (n=8) led to similar therapeutic responses in the two groups (with moderate effect size), such as the mean decrease in HDRS (BA 9: p=0.015; BA 46: p=0.010) and MADRS (BA 9: p=0.042; BA 46: p=0.038) scores. CONCLUSION Our results do not come out in favor of one or the other BA. SIGNIFICANCE Stimulation of BA 9 and BA 46 appears to be equally effective in the treatment of depression.

Potential influence of Type A personality on plasma C-reactive protein levels in people with diabetes

AIM Type A personality, although classically known as a factor linked to increased vascular risk, has recently been associated with increased survival in patients with diabetes. As low-grade inflammation predicts a poor outcome, the present study explored the potential associations between Type A and plasma levels of C-reactive protein (CRP) in diabetes. METHODS Type A personality was assessed by the Bortner questionnaire in people with diabetes. The association between Type A and plasma CRP levels was examined by multivariable linear regression, and structural equation modelling (SEM) was performed to determine the impact of the major clinical, biological and psychological confounders. RESULTS The study included 626 participants with type 1 and type 2 diabetes from the Diabetes and Psychological Profile study. Multivariable analyses showed an independent inverse association between Type A score and CRP levels. The structural model adjusted for age, gender, diabetes type and duration, body mass index (BMI), smoking status, alcohol abuse, oral antidiabetic and statin treatments, HbA1c levels, lipids, perceived stress, anxiety and depression revealed significant associations between CRP and Type A (β=-0.135, 95% CI: -0.242, -0.028; P=0.014), BMI (β=0.194, 95% CI: 0.038, 0.350; P=0.015) and HDL cholesterol (β=-0.132, 95% CI: -0.245, -0.020; P=0.014). CONCLUSION Our present study data indicate that Type A personality is independently associated with lower CRP levels. This lower level of inflammation might explain the better clinical outcomes associated with Type A personality in patients with diabetes.

Effects of Transcranial Magnetic Stimulation on the Hypothalamic-Pituitary Axis in Depression: Results of a Pilot Study

Some studies have reported that repetitive transcranial magnetic stimulation (rTMS) applied to the dorsolateral prefrontal cortex (DLPFC) is able to induce changes in the hypothalamic-pituitary axis in subjects with major depression. The causes of these neuroendocrine effects are unknown and deserve to be studied. The authors monitored neuroendocrine hormones in 15 subjects with major depression treated by 1-Hz rTMS on the right DLPFC and explored a correlation with mood improvement. Unlike previous studies, no changes in serum cortisol, prolactin, and thyroid hormone levels were found. However, the authors did observe short-term changes in growth hormone levels in nonresponsive subjects.

Does the Intensity of Transcranial Magnetic Stimulation Need to be Adjusted to Scalp-Cortex Distance?

To the Editor: Repetitive Transcranial Magnetic Stimulation (rTMS) therapy can be effective in treating drug-resistant depression. However, rTMS therapy has had up until now limited efficacy in extremely treatment-resistant patients and its effects are not as large as electroconvulsive therapy. The efficacy of rTMS may be increased by improving stimulation parameters, in particular by using more precise coil placement on the scalp to stimulate the Dorsolateral Prefrontal Cortex (DLPFC). This cortical area is the target for treatment of depressive disorders with rTMS. This revised position of the coil is supported by recent results which have found that, rather than using the “5 cm method” to position the coil, a more anterior position improves the rTMS response rate. The positioning of the coil on the scalp is probably not the only stimulation parameter that can be improved. The efficacy of rTMS therapy could also be improved by measuring the depth of the cortex, in order to adjust the motor threshold (MT) to obtain the same degree of excitability at the DLPFC. The MT, used to determine the intensity of stimulation required for each patient according to their own cortical excitability, corresponds to the minimal intensity required to elicit contraction of the thumb when the coil is positioned on the scalp above the motor cortex. Therefore, it only reflects the intensity required for the magnetic field of the coil to reach the motor cortex at a precise distance from the scalp. As the distance from the scalp to the motor cortex can be different from that to the DLPFC, the intensity needs to be adjusted. In fact, by examining 20 brain MRIs of patients (mean age 55) eligible for rTMS in our psychiatric department, we found that for 11 of them, the distance from the scalp to the DLPFC (positioned 5 cm anterior to the motor cortex) was in fact greater by 1 mm to 4.5 mm than from the scalp to the motor cortex. Taking into account the fact that every additional millimeter from the stimulating coil required around 3% of additional stimulator output to induce an equivalent cortical effect, the intensity should have been increased by 3 to 13.5%. We did not use this intensity adjustment because the latest guidelines for the use of rTMS do not recommend it. However, we hypothesize that the efficacy of the therapy could have been improved by adjusting the intensity in these patients. This adjustment of the intensity according to the depth of the cortex combined with a more anterior location of the coil on the scalp may further improve the efficacy of rTMS. Benoit Trojak, M.D. Vincent Meille, M.D. Jean-Christophe ChauvetGelinier, M.D. Bernard Bonin, M.D., Ph.D. Department of Psychiatry and Addictology, University Hospital of Dijon, France

High-Frequency Neuronavigated rTMS in Auditory Verbal Hallucinations: A Pilot Double-Blind Controlled Study in Patients With Schizophrenia

INTRODUCTION Despite extensive testing, the efficacy of low-frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) of temporo-parietal targets for the treatment of auditory verbal hallucinations (AVH) in patients with schizophrenia is still controversial, but promising results have been reported with both high-frequency and neuronavigated rTMS. Here, we report a double-blind sham-controlled study to assess the efficacy of high-frequency (20 Hz) rTMS applied over a precise anatomical site in the left temporal region using neuronavigation. METHODS Fifty-nine of 74 randomized patients with schizophrenia or schizoaffective disorders (DSM-IV R) were treated with rTMS or sham treatment and fully evaluated over 4 weeks. The rTMS target was determined by morphological MRI at the crossing between the projection of the ascending branch of the left lateral sulcus and the superior temporal sulcus (STS). RESULTS The primary outcome was response to treatment, defined as a 30% decrease of the Auditory Hallucinations Rating Scale (AHRS) frequency item, observed at 2 successive evaluations. While there was no difference in primary outcome between the treatment groups, the percentages of patients showing a decrease of more than 30% of AHRS score (secondary outcome) did differ between the active (34.6%) and sham groups (9.1%) (P = .016) at day 14. DISCUSSION This controlled study reports negative results on the primary outcome but demonstrates a transient effect of 20 Hz rTMS guided by neuronavigation and targeted on an accurate anatomical site for the treatment of AVHs in schizophrenia patients.

P20.4 Should the 5 cm method be re-examined in rTMS?

amplitudes to the global/local switch cues. tDCS reduced left hemisphere beta (30 50 Hz) local switch cues oscillations following global cues and increased differences in beta between local and global cues. Anodal stimulation produced no significant EEG differences. Conclusions: These results represent the first successful use of tDCS to modulate attention and indicate and indicate a potential for tDCS as a possible therapeutic intervention for disorders of attention.