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Safety Considerations of the Use of TMS

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Abstract

The application of TMS is increasing over the course of the last 30 years. In this course, the scientific and medical community has felt the need to evaluate the safety record of research studies and clinical applications of TMS and repetitive TMS (rTMS). Thus, the first safety precautions and practice recommendations were published in 1996 after a consensus conference held for this purpose. Since then, issues of risk and safety of conventional and emerging TMS protocols have been reviewed continuously leading to thoroughly established guidelines concerning limits of stimulation parameters, general precautions, monitoring of subjects, expertise of the rTMS team, and ethical issues. The 2009 publication of Rossi et al. in Clinical Neurophysiology still represents nowadays valid recommendations.

Therefore, this chapter will be a summary of the most relevant safety aspects when using TMS in a diagnostic setting and will especially emphasize those new facets that have emerged since 2009.

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References

  • Agosta S, Galante E, Ferraro F, Pascual-Leone A, Oster J, Battelli L. Report of a delayed seizure after low frequency repetitive Transcranial Magnetic Stimulation in a chronic stroke patient. Clin Neurophysiol. 2016;127(2):1736–7.

    Article  PubMed  Google Scholar 

  • Anderson B, Mishory A, Nahas Z, Borckardt J, Yamanaka K, Rastogi K, et al. Tolerability and safety of high daily doses of repetitive transcranial magnetic stimulation in healthy young men. J ECT. 2006;22(1):49–53.

    Article  PubMed  Google Scholar 

  • Bae EH, Schrader LM, Machii K, Alonso-Alonso M, Riviello JJ, Pascual-Leone A, et al. Safety and tolerability of repetitive transcranial magnetic stimulation in patients with epilepsy: a review of the literature. Epilepsy Behav. 2007;10(4):521–8.

    Article  PubMed  Google Scholar 

  • Bakker N, Shahab S, Giacobbe P, Blumberger DM, Daskalakis ZJ, Kennedy SH, Downar J. rTMS of the dorsomedial prefrontal cortex for major depression: safety, tolerability, effectiveness, and outcome predictors for 10 Hz versus intermittent theta-burst stimulation. Brain Stimul. 2015;8(2):208–15.

    Article  PubMed  Google Scholar 

  • Bernabeu M, Orient F, Tormos JM, Pascual-Leone A. Seizure induced by fast repetitive transcranial magnetic stimulation. Clin Neurophysiol. 2004;115:1714–5.

    Article  PubMed  Google Scholar 

  • Boes AD, Stern AP, Bernstein M, Hooker JE, Connor A, Press DZ, Pascual-Leone A. H-coil repetitive transcranial magnetic stimulation induced seizure in an adult with major depression: a case report. Brain Stimul. 2016;9(4):632–3.

    Article  PubMed  Google Scholar 

  • Brasil-Neto JP, De Araújo DP, Teixeira WA, Araújo VP, Boechat-Barros R. Experimental therapy of epilepsy with transcranial magnetic stimulation: lack of additional benefit with prolonged treatment. Arq Neuropsiquiatr. 2004;62(1):21–5.

    Article  PubMed  Google Scholar 

  • Cantello R, Rossi S, Varrasi C, Ulivelli M, Civardi C, Bartalini S, et al. Slow repetitive TMS for drug-resistant epilepsy: clinical and EEG findings of a placebo-controlled trial. Epilepsia. 2007;48(2):366–74.

    Article  PubMed  Google Scholar 

  • Caplan L. Epileptic seizures. In: Lüders H, Noachtar S, editors. Epileptic seizures: pathophysiology and clinical semiology. New York: Churchill Livingstone; 2000. p. 757. (Chapter 75).

    Google Scholar 

  • Chiramberro M, Lindberg N, Isometsä E, Kähkönen S, Appelberg B. Repetitive transcranial magnetic stimulation induced seizures in an adolescent patient with major depression: a case report. Brain Stimul. 2013;6(5):830–1.

    Article  PubMed  Google Scholar 

  • Conca A, Konig P, Hausmann A. Transcranial magnetic stimulation induces ‘pseudoabsence seizure. Acta Psychiat Scand. 2000;101:246–8.

    Article  CAS  PubMed  Google Scholar 

  • Cullen KR, Jasberg S, Nelson B, Klimes-Dougan B, Lim KO, Croarkin PE. Seizure induced by deep transcranial magnetic stimulation in an adolescent with depression. J Child Adolesc Psychopharmacol. 2016;26(7):637–41.

    Article  PubMed  Google Scholar 

  • Daniele O, Brighina F, Piazza A, Giglia G, Scalia S, Fierro B. Low-frequency transcranial magnetic stimulation in patients with cortical dysplasia. J Neurol. 2003;250(6):761–2.

    Article  PubMed  Google Scholar 

  • Deng ZD, Peterchev AV. Transcranial magnetic stimulation coil with electronically switchable active and sham modes. Conf Proc IEEE Eng Med Biol Soc. 2011;2011:1993–6.

    PubMed  Google Scholar 

  • Edwardson M, Fetz EE, Avery DH. Seizure produced by 20 Hz transcranial magnetic stimulation during isometric muscle contraction in a healthy subject. Clin Neurophysiol. 2011;122(11):2326–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Epstein CM. Seizure or convulsive syncope during 1-Hz rTMS? Clin Neurophysiol. 2006;117:2566–8.

    Article  PubMed  Google Scholar 

  • Figiel GS, Epstein C, McDonald WM, Amazon-Leece J, Figiel L, Saldivia A, et al. The use of rapid- rate transcranial magnetic stimulation (rTMS) in refractory depressed patients. J Neuropsychiatry Clin Neurosci. 1998;10:20–5.

    Article  CAS  PubMed  Google Scholar 

  • Fregni F, Thome-Souza S, Bermpohl F, Marcolin MA, Herzog A, Pascual-Leone A, et al. Antiepileptic effects of repetitive transcranial magnetic stimulation in patients with cortical malformations: an EEG and clinical study. Stereotact Funct Neurosurg. 2005;83(2–3):57–62.

    Article  PubMed  Google Scholar 

  • Fregni F, Otachi PTM, DoValle A, Boggio PS, Thut G, Rigonatti SP, et al. A randomized clinical trial of repetitive transcranial magnetic stimulation in patients with refractory epilepsy. Ann Neurol. 2006;60(4):447–55.

    Article  PubMed  Google Scholar 

  • Frey D, Schilt S, Strack V, Zdunczyk A, Rosler J, Niraula B, et al. Navigated transcranial magnetic stimulation improves the treatment outcome in patients with brain tumors in motor eloquent locations. Neuro Oncol. 2014;16:1365–72.

    Article  PubMed  PubMed Central  Google Scholar 

  • Green RM, Pascual-Leone A, Wassermann EM. Ethical guidelines for rTMS research. IRB. 1997;2:1–7.

    Article  Google Scholar 

  • Groiss SJ, Trenado C, Sabel M, Schnitzler A, Wojtecki L. Focal seizure induced by preoperative navigated transcranial magnetic stimulation in a patient with anaplastic oligoastrocytoma. Brain Stimul. 2017;10(2):331–2.

    Article  PubMed  Google Scholar 

  • Groppa S, Oliviero A, Eisen A, Quartarone A, Cohen LG, Mall V, et al. A practical guide to diagnostic transcranial magnetic stimulation: report of an IFCN committee. Clin Neurophysiol. 2012;123:858–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Grossheinrich N, Rau A, Pogarell O, Hennig-Fast K, Reinl M, Karch S, et al. Theta burst stimulation of the prefrontal cortex: safety and impact on cognition, mood, and resting electroencephalogram. Biol Psychiatry. 2009;65:778–84.

    Article  PubMed  Google Scholar 

  • Hallett M, Wassermann EM, Pascual-Leone A, Valls-Solé J, Deuschl G, Eisen A. Recommendations for the practice of clinical neurophysiology: guidelines of the International Federation of Clinical Neurophysiology. Electroencephalogr Clin Neurophysiol Suppl. 1999;52:105–13.

    CAS  PubMed  Google Scholar 

  • Haupts MR, Daum S, Ahle G, Holinka B, Gehlen W. Transcranial magnetic stimulation as a provocation for epileptic seizures in multiple sclerosis. Mult Scler. 2004;10:475–6.

    Article  CAS  PubMed  Google Scholar 

  • Hong YH, Wu SW, Pedapati EV, Horn PS, Huddleston DA, Laue CS, Gilbert DL. Safety and tolerability of theta burst stimulation vs. single and paired pulse transcranial magnetic stimulation: a comparative study of 165 pediatric subjects. Front Hum Neurosci. 2015;9:29.

    Article  PubMed  PubMed Central  Google Scholar 

  • Huang YZ, Edwards MJ, Rounis E, Bhatia KP, Rothwell JC. Theta burst stimulation of the human motor cortex. Neuron. 2005;45:201–6.

    Article  CAS  PubMed  Google Scholar 

  • Illes J, Gallo M, Kirschen MP. An ethics perspective on transcranial magnetic stimulation (TMS) and human neuromodulation. Behav Neurol. 2006;7:149–57.

    Article  Google Scholar 

  • Joo EY, Han SJ, Chung SH, Cho JW, Seo DW, Hong SB. Antiepileptic effects of low-frequency repetitive transcranial magnetic stimulation by different stimulation durations and locations. Clin Neurophysiol. 2007;118(3):702–8.

    Article  PubMed  Google Scholar 

  • Karabanov AN, Ziemann U, Hamada M, George MS, Quartarone A, Classen J, et al. Consensus paper: probing homeostatic plasticity of human cortex with non-invasive transcranial brain stimulation. Brain Stimul. 2015;8:993–1006.

    Article  PubMed  Google Scholar 

  • Kofler M, Leis AA, Sherwood AM, Delapasse JS, Halter JA. Safety of transcranial magnetic stimulation in patients with abdominally implanted electronic devices. Lancet. 1991;338:1275–6.

    Article  CAS  PubMed  Google Scholar 

  • Krieg SM, Shiban E, Buchmann N, Gempt J, Foerschler A, Meyer B, et al. Utility of presurgical navigated transcranial magnetic brain stimulation for the resection of tumors in eloquent motor areas. J Neurosurg. 2012;116:994–1001.

    Article  PubMed  Google Scholar 

  • Krieg SM, Sabih J, Bulubasova L, Obermueller T, Negwer C, Janssen I, et al. Preoperative motor mapping by navigated transcranial magnetic brain stimulation improves outcome for motor eloquent lesions. Neuro Oncol. 2014;16:1274–82.

    Article  PubMed  PubMed Central  Google Scholar 

  • Krieg SM, Sollmann N, Obermueller T, Sabih J, Bulubas L, Negwer C, et al. Changing the clinical course of glioma patients by preoperative motor mapping with navigated transcranial magnetic brain stimulation. BMC Cancer. 2015;15:231.

    Article  PubMed  PubMed Central  Google Scholar 

  • Krings T, Foltys H, Reinges MH, Kemeny S, Rohde V, Spetzger U, et al. Navigated transcranial magnetic stimulation for presurgical planning—correlation with functional MRI. Minim Invasive Neurosurg. 2001;44:234–9.

    Article  CAS  PubMed  Google Scholar 

  • Krishnan C, Santos L, Peterson MD, Ehinger M. Safety of noninvasive brain stimulation in children and adolescents. Brain Stimul. 2015;8(1):76–87.

    Article  PubMed  Google Scholar 

  • Kumar N, Padma Srivastava MV, Verma R, Sharma H, Modak T. Can low-frequency repetitive transcranial magnetic stimulation precipitate a late-onset seizure in a stroke patient? Clin Neurophysiol. 2016;127(2):1734–6.

    Article  PubMed  Google Scholar 

  • Lefaucheur JP, André-Obadia N, Antal A, Ayache SS, Baeken C, Benninger DH, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin Neurophysiol. 2014;125:2150–206.

    Article  PubMed  Google Scholar 

  • Lin JT, Ziegler DK, Lai CW, Bayer W. Convulsive syncope in blood donors. Ann Neurol. 1982;11:525–8.

    Article  CAS  PubMed  Google Scholar 

  • Loo C, Sachdev P, Elsayed H, McDarmont B, Mitchell P, Wilkinson M, et al. Effects of a 2- to 4-week course of repetitive transcranial magnetic stimulation (rTMS) on neuropsychologic functioning, electroencephalogram, and auditory threshold in depressed patients. Biol Psychiatry. 2001;49:615–23.

    Article  CAS  PubMed  Google Scholar 

  • Loo CK, McFarquhar TF, Mitchell PB. A review of the safety of repetitive transcranial magnetic stimulation as a clinical treatment for depression. Int J Neuropsychopharmacol. 2008;11:131–47.

    Article  PubMed  Google Scholar 

  • Loo C, Martin D, Pigot M, Arul-Anandam P, Mitchell P, Sachdev P. Transcranial direct current stimulation priming of therapeutic repetitive transcranial magnetic stimulation: a pilot study. JECT. 2009;25:256–60.

    Google Scholar 

  • Machii K, Cohen D, Ramos-Estebanez C, Pascual-Leone A. Safety of rTMS to non-motor cortical areas in healthy participants and patients. Clin Neurophysiol. 2006;117:455–71.

    Article  PubMed  Google Scholar 

  • Marg E, Rudiak D. Phosphenes induced by magnetic stimulation over the occipital brain: description and probable site of stimulation. Optom Vis Sci. 1994;71:301–11.

    Article  CAS  PubMed  Google Scholar 

  • Mashour GA, Walker EE, Martuza RL. Psychosurgery: past, present, and future. Brain Res Brain Res Rev. 2005;48:409–19.

    Article  PubMed  Google Scholar 

  • Menkes DL, Gruenthal M. Slow-frequency repetitive transcranial magnetic stimulation in a patient with focal cortical dysplasia. Epilepsia. 2000;41(2):240–2.

    Article  CAS  PubMed  Google Scholar 

  • Misawa S, Kuwabara S, Shibuya K, Mamada K, Hattori T. Low-frequency transcranial magnetic stimulation for epilepsia partialis continua due to cortical dysplasia. J Neurol Sci. 2005;234(1–2):37–9.

    Article  PubMed  Google Scholar 

  • Muller-Dahlhaus F, Ziemann U. Metaplasticity in human cortex. Neuroscientist. 2015;21:185–202.

    Article  PubMed  Google Scholar 

  • Nitsche MA. Co-incidence or causality? Seizures after slow rTMS in stroke patients. Clin Neurophysiol. 2016;127(2):1020–1.

    Article  PubMed  Google Scholar 

  • Nowak DA, Hoffmann U, Connemann BJ, Schonfeldt-Lecuona C. Epileptic seizure following 1 Hz repetitive transcranial magnetic stimulation. Clin Neurophysiol. 2006;117:1631–3.

    Article  PubMed  Google Scholar 

  • Oberman L, Edwards D, Eldaief M, Pascual-Leone A. Safety of theta burst transcranial magnetic stimulation: a systematic review of the literature. J Clin Neurophysiol. 2011;28(1):67–74.

    Article  PubMed  PubMed Central  Google Scholar 

  • Obermann LM, Pascual-Leone A. Report of seizure induced by continuous theta burst stimulation. Brain Stimul. 2009;2(4):246–7.

    Article  Google Scholar 

  • Pascual-Leone A, Gates JR, Dhuna A. Induction of speech arrest and counting errors with rapid-rate transcranial magnetic stimulation. Neurology. 1991;41:697–702.

    Article  CAS  PubMed  Google Scholar 

  • Penfield W, Jasper H. Epilepsy and the functional anatomy of the human brain. Boston, MA: Little, Brown; 1954.

    Google Scholar 

  • Pereira LS, Müller VT, da Mota Gomes M, Rotenberg A, Fregni F. Safety of repetitive transcranial magnetic stimulation in patients with epilepsy: a systematic review. Epilepsy Behav. 2016;57(Pt A):167–76.

    Article  PubMed  Google Scholar 

  • Picht T, Mularski S, Kuehn B, Vajkoczy P, Kombos T, Suess O. Navigated transcranial magnetic stimulation for preoperative functional diagnostics in brain tumor surgery. Neurosurgery. 2009;65:93–8.

    Article  PubMed  Google Scholar 

  • Prikryl R, Kucerova H. Occurrence of epileptic paroxysm during repetitive transcranial magnetic stimulation treatment. J Psychopharmacol. 2005;19:313.

    Article  PubMed  Google Scholar 

  • Rosa MA, Odebrecht M, Rigonatti SP, Marcolin MA. Transcranial magnetic stimulation: review of accidental seizures. Rev Bras Psiquiatr. 2004;26:131–4.

    Article  PubMed  Google Scholar 

  • Rossi S, Hallett M, Rossini PM, Pascual-Leone A. Safety of TMS consensus group. Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol. 2009;120:2008–39.

    Article  PubMed  PubMed Central  Google Scholar 

  • Rossi S, Hallett M, Rossini PM, Pascual-Leone A. Screening questionnaire before TMS: An update. Clin Neurophysiol. 2011;122(8):1686.

    Google Scholar 

  • Rossini PM, Barker AT, Berardelli A, Caramia MD, Caruso G, Cracco RQ, et al. Non-invasive electrical and magnetic stimulation of the brain, spinal cord and roots: basic principles and procedures for routine clinical application. Report of an IFCN committee. Electroencephalogr Clin Neurophysiol. 1994;91:79–92.

    Article  CAS  PubMed  Google Scholar 

  • Rossini PM, Burke D, Chen R, Cohen LG, Daskalakis Z, Di Iorio R, et al. Non-invasive electrical and magnetic stimulation of the brain, spinal cord, roots and peripheral nerves: Basic principles and procedures for routine clinical and research application. An updated report from an I.F.C.N. Committee. Clin Neurophysiol. 2015;126(6):1071–107.

    Article  CAS  PubMed  Google Scholar 

  • Santiago-Rodríguez E, Cárdenas-Morales L, Harmony T, Fernández-Bouzas A, Porras-Kattz E, Hernández A. Repetitive transcranial magnetic stimulation decreases the number of seizures in patients with focal neocortical epilepsy. Seizure. 2008;17(8):677–83.

    Article  PubMed  Google Scholar 

  • Schrader LM, Stern JM, Fields TA, Nuwer MR, Wilson CL. A lack of effect from transcranial magnetic stimulation (TMS) on the vagus nerve stimulator (VNS). Clin Neurophysiol. 2005;116:2501–4.

    Article  PubMed  Google Scholar 

  • Sollmann N, Ille S, Hauck T, Maurer S, Negwer C, Zimmer C, et al. The impact of preoperative language mapping by repetitive navigated transcranial magnetic stimulation on the clinical course of brain tumor patients. BMC Cancer. 2015;15:261.

    Article  PubMed  PubMed Central  Google Scholar 

  • Steven MS, Pascual-Leone A. Transcranial magnetic stimulation and the human brain: an ethical evaluation. In: Illes J, editor. 21st century neuroethics: defining the issues in research, practice and policy. Oxford, UK: Oxford University Press; 2006. p. 201–11.

    Google Scholar 

  • Tarapore PE, Tate MC, Findlay AM, Honma SM, Mizuiri D, Berger MS, et al. Preoperative multimodal motor mapping: a comparison of magnetoencephalography imaging, navigated transcranial magnetic stimulation, and direct cortical stimulation. J Neurosurg. 2012;117:354–62.

    Article  PubMed  PubMed Central  Google Scholar 

  • Tarapore PE, Picht T, Bulubas L, Shin Y, Kulchytska N, Meyer B, et al. Safety and tolerability of navigated TMS for preoperative mapping in neurosurgical patients. Clin Neurophysiol. 2016;127(3):1895–900.

    Article  PubMed  Google Scholar 

  • Tergau F, Neumann D, Rosenow F, Nitsche MA, Paulus W, Steinhoff B. Can epilepsies be improved by repetitive transcranial magnetic stimulation? Interim analysis of a controlled study. Suppl Clin Neurophysiol. 2003;56:400–5.

    Article  PubMed  Google Scholar 

  • Tharayil BS, Gangadhar BN, Thirthalli J, Anand L. Seizure with single-pulse transcranial magnetic stimulation in a 35-year-old otherwise-healthy patient with bipolar disorder. J ECT. 2005;21:188–9.

    Article  PubMed  Google Scholar 

  • Theodore WH. Transcranial magnetic stimulation in epilepsy. Epilepsy Curr. 2003;3(6):191–7.

    Article  PubMed  PubMed Central  Google Scholar 

  • Tikka SK, Nizamie SH, Venkatesh Babu GM, Aggarwal N, Das AK, Goyal N. Safety and efficacy of adjunctive theta burst repetitive transcranial magnetic stimulation to right inferior parietal lobule in schizophrenia patients with first-rank symptoms: a pilot, exploratory study. J ECT. 2017;33(1):43–51.

    Article  PubMed  Google Scholar 

  • Vernet M, Walker L, Yoo WK, Pascual-Leone A, Chang BS. EEG onset of a seizure during TMS from a focus independent of the stimulation site. Clin Neurophysiol. 2012;123(10):2106–8.

    Article  PubMed  PubMed Central  Google Scholar 

  • Wassermann EM. Risk and safety of repetitive transcranial magnetic stimulation: report and suggested guidelines from the International Workshop on the Safety of Repetitive Transcranial Magnetic Stimulation, June 5–7, 1996. Electroencephalogr Clin Neurophysiol. 1998;108:1–16.

    Article  CAS  PubMed  Google Scholar 

  • Wolpe PR. Treatment, enhancement, and the ethics of neurotherapeutics. Brain Cogn. 2002;50:387–95.

    Article  PubMed  Google Scholar 

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Correspondence to Paolo Maria Rossini M.D., Ph.D. .

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Di Iorio, R., Rossini, P.M. (2017). Safety Considerations of the Use of TMS. In: M. Krieg, S. (eds) Navigated Transcranial Magnetic Stimulation in Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-319-54918-7_4

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