TMS-EEG in DOC LUCA meeting
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1 1 LUCA meeting Olivier Bodart, MD, PhD student 25 th february 2015
2 2 I. Outline What is TMS-EEG? How to perform TMS-EEG? Why TMS-EEG? TMS-EEG in HS TMS-EEG and covert cognition
3 3 II. What is TMS-EEG? Napolitani & Bodart et al, Brain injury 2014
4 4 II. What is TMS-EEG? Transcranial magnetic stimulation depolarize superficial axons, leading to the activation of a subgroup of neurons in the same area. The activity from these neurons secondary spreads toward other areas, cortical, subcortical (both hemispheres), or even to the spinal cord. Dedicated compatible EEG amplifiers record this activity using high density cap.
5 5 II. What is TMS-EEG? Rosanova M. et al, Neuronal Network Analysis, 2012
6 6 III. How to perform TMS-EEG? In Liège, we use neuronavigated TMS-EEG: TMS-compatible 64 electrodes EEG cap and amplifier Stimulation coil: figure of 8, air-cooled, pulse of 260µs, field between 1-2 T Infrared stereotactic camera to track subject s head and stimulation coil Software neuronavigation and aiming device Earplugs diffusing white noise
7 7 III. How to perform TMS-EEG? Avoid stimulating over brain lesions using neuronavigation Avoid muscle masses by stimulating next to the midline Avoid auditory evoked potential by using earplugs and thin layer of foam between the coil and the scalp Avoid TMS related artefact by preparing the electrodes to get best impedances Avoid ocular artifact by checking for absence of systematic blinks, asking the subject to keep the eyes opened and to fixate a point Avoid fluctuation of vigilance in patients by using CRS-R arousal protocol as necessary.
8 8 Napolitani & Bodart et al, Brain injury 2014 IV. Why TMS-EEG?
9 9 IV. Why TMS-EEG? Allows to scientifically test current theories of consciousness (IITC) Perturbs the thalamocortical network and register the causal interaction between neurons, aka effective connectivity.
10 10 Wakefulness NREM Sleep REM Sleep Wakefulness Anaesthesia UWS MCS Napolitani M. & Bodart O. et al, Brain Injury 2014 IV. TMS-EEG in HS
11 11 PCI Casali A & Gosseries O et al, Science Transl Med, 2013 IV. TMS-EEG in HS
12 12 IV. TMS-EEG in HS
13 13 Using TEPs IV.
14 14 Using PCI IV.
15 15 IV.? clinical use
16 16 V. TMS-EEG and covert cognition 48 non-acute DOC patients and 4 LIS 15 UWS 26 MCS 7 EMCS Assessed by CRS-R, FDG-PET, PCI, and active fmri
17 17 V. TMS-EEG and covert cognition Patient Best! CRS-R PET PET! CRS-R PCI PCI! CRS-R fmri fmri! CRS-R MJ 23 LIS LIS NA Activation NA RA14 23 LIS LIS NA 0.48 NA NA NA GA 23 EMCS EMCS NA Sedated NA 3BR 22 EMCS EMCS NA 0.45 NA NA NA SR10 17 MCS+ MCS Sedated NA SM 15 MCS+ MCS Sedated NA HR 12 MCS+ MCS NA Activation NA 24 patients had both TMS/EEG and PET results 4 communicative (2 EMCS and 2 LIS), had both high PCI and good PET results 10 MCS (7 MCS+) had high PCI and PET compatible with MCS 4 UWS had both low PCI and PET incompatible with MCS => TMS/EEG is specific CA8 11 MCS+ MCS Sedated NA DSM9 11 MCS+ MCS Sedated NA SA 11 MCS+ MCS Sedated NA PQ 11 MCS+ MCS No activation 9 VP19 13 MCS- MCS Sedated NA PA25 8 MCS- MCS Sedated NA EN7 7 MCS- MCS Sedated NA KV24 10 MCS- MCS Sedated NA SG12 5 UWS MCS Activation 3 JF1 7 UWS MCS Sedated NA DHE13 5 UWS MCS Sedated NA DJ15 5 UWS MCS NA NA DA 7 UWS MCS No activation 5 VN 7 UWS UWS Sedated NA FM4 6 UWS UWS Sedated NA JB 6 UWS UWS Sedated NA MD 5 UWS UWS NA NA
18 18 V. TMS-EEG and covert cognition 4 UWS had both high PCI and PET compatible with MCS TMS/EEG is able to detect covert consciousness 1 UWS had a low PCI but a PET showing preservation of the right hemisphere 1 MCS- had a low PCI but a PET compatible with MCS. MCS- only once, the day of PET, otherwise always UWS TMS/EEG reflects the current state of consciousness, while PET also reflects the potential
19 19 V. TMS-EEG and covert cognition Typical CRS-R, PCI, PET, and active fmri results
20 20 V. TMS-EEG and covert cognition Conclusions: TMS/EEG and PCI could be used in a two-step screening process: FDG-PET is more sensitive, and should be the first screening tool: It s well standardized, easy to record and to analyse, and can detect both potential and actual consciousness TMS/EEG is less sensitive but more specific and could be used as a second pass: It needs to be standardised, and make easier to perform and analyse, but gives an answer about the current state of consciousness
21 21 Thank you for your attention! Olivier Bodart, MD, PhD student 25 th february 2015
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