The fast-posterior superior insula (Fast-PSI): A neuronavigation-free targeting method for non-invasive neuromodulation

Cunha, Pedro Henrique Martins da; Tanaka, Harki; Lapa, Jorge Dornellys da Silva; Dongyang, Liu; Júnior, Anselmo Alves Boa Sorte; Pereira, Tamara Maria Ribeiro; Soares, Felipe Henriques Carvalho; Fernandes, Ana Mércia; Silva, Valquíria Aparecida da; Graven‐Nielsen, Thomas; Teixeira, Manoel Jacobsen; Andrade, Daniel Ciampi de

doi:10.1016/j.brs.2022.08.009

Cited by 4 publications

(5 citation statements)

References 9 publications

(10 reference statements)

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“…In humans, direct electric stimulation of the posterior superior insula at ‘inhibitory’ high frequencies (150 Hz) increased heat pain thresholds in patients undergoing stereo‐EEG for focal epilepsy surgery (Denis et al, 2016). Non‐invasive targeting of the posterior insula can be achieved in men with the use of coils allowing for stimulation of deep brain structures, such as the double‐angulated coils used to stimulate the distal leg M1 representation buried between the hemispheres (Ciampi de Andrade et al, 2012; da Cunha, Tanaka, et al, 2022). Using this approach, Lenoir et al (2018) reported a decrease in thermo‐nociceptive perception in healthy volunteers when applying deep rTMS to the posterior insula via continuous theta‐burst, and similar changes in heat pain thresholds (‘anti‐allodynic’ effects) were obtained in patients with central neuropathic pain receiving 10 Hz insular rTMS (Galhardoni et al, 2019).…”

Section: Stimulating Extra‐motor Targetsmentioning

confidence: 99%

“…This strategy showed, for example, that patients responding positively to botulinum toxin clustered into specific sensory phenotypes and not in others (Bouhassira et al, 2021). This same strategy was recently applied to patients receiving rTMS to the posterior insula and disclosed that none of the responders to the intervention had a sensory phenotype characterized by predominant allodynic symptoms (Dongyang et al, 2021; Cunha & de Andrade 2022). Despite the obvious limitations of such post hoc analyses, the results suggest that selecting specific clinical presentations based on symptom profiles may increase the efficacy of rTMS at the individual level.…”

Section: Could It Be Simpler Than It Seems?—a Look At Patient's Symptomsmentioning

confidence: 99%

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Beyond trial‐and‐error: Individualizing therapeutic transcranial neuromodulation for chronic pain

Ciampi de Andrade,

García‐Larrea

2023

European Journal of Pain

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Background and ObjectiveRepetitive transcranial magnetic stimulation (rTMS) applied to the motor cortex provides supplementary relief for some individuals with chronic pain who are refractory to pharmacological treatment. As rTMS slowly enters treatment guidelines for pain relief, its starts to be confronted with challenges long known to pharmacological approaches: efficacy at the group‐level does not grant pain relief for a particular patient. In this review, we present and discuss a series of ongoing attempts to overcome this therapeutic challenge in a personalized medicine framework.Databases and Data TreatmentRelevant scientific publications published in main databases such as PubMed and EMBASE from inception until March 2023 were systematically assessed, as well as a wide number of studies dedicated to the exploration of the mechanistic grounds of rTMS analgesic effects in humans, primates and rodents.ResultsThe main strategies reported to personalize cortical neuromodulation are: (i) the use of rTMS to predict individual response to implanted motor cortex stimulation; (ii) modifications of motor cortex stimulation patterns; (iii) stimulation of extra‐motor targets; (iv) assessment of individual cortical networks and rhythms to personalize treatment; (v) deep sensory phenotyping; (vi) personalization of location, precision and intensity of motor rTMS. All approaches except (i) have so far low or moderate levels of evidence.ConclusionsAlthough current evidence for most strategies under study remains at best moderate, the multiple mechanisms set up by cortical stimulation are an advantage over single‐target ‘clean’ drugs, as they can influence multiple pathophysiologic paths and offer multiple possibilities of individualization.SignificanceNon‐invasive neuromodulation is on the verge of personalised medicine. Strategies ranging from integration of detailed clinical phenotyping into treatment design to advanced patient neurophysiological characterisation are being actively explored and creating a framework for actual individualisation of care.

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Section: Stimulating Extra‐motor Targetsmentioning

confidence: 99%

Section: Could It Be Simpler Than It Seems?—a Look At Patient's Symptomsmentioning

confidence: 99%

Beyond trial‐and‐error: Individualizing therapeutic transcranial neuromodulation for chronic pain

Ciampi de Andrade,

García‐Larrea

2023

European Journal of Pain

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“…The rMT of the TA muscle was determined as the lowest TMS intensity to produce visible muscle responses, and TMS-EEG was performed at 90% of the TA rMT. The PSI target was identified as previously described [27] (Fig 4A ), and stimulation was similarly set at 90% of the TA rMT.…”

Section: Electroencephalographic Recordings Of Tms-evoked Potentialsmentioning

confidence: 99%

Repetitive transcranial magnetic stimulation to the motor cortex leads to a sequential increase in phase synchronization and power of TMS-evoked electroencephalographic recordings

Martino,

Casali,

Nascimento Couto

et al. 2024

Preprint

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Background: High-frequency (10 Hz) repetitive transcranial magnetic stimulation (rTMS) to the primary motor cortex (M1) is used to treat several neuropsychiatric disorders, but its main mechanism of action remains unclear. Objective: To probe four cortical hubs used for rTMS (M1; dorsolateral-prefrontal cortex, DLPFC; anterior cingulate cortex, ACC; posterosuperior insula, PSI) with TMS coupled with high-density electroencephalography (TMS-EEG) and measure cortical excitability and oscillatory dynamics before and after active and sham rTMS to M1. Methods: Before and immediately after active or sham M1-rTMS (15 min, 3,000 pulses at 10 Hz), single-pulse TMS evoked EEG were recorded at the four targets in 20 healthy individuals. Measures of cortical excitability and oscillatory dynamics were extracted at the main frequency bands (α [8-13 Hz], low-β [14-24 Hz], high-β [25-35 Hz]). Results: Comparing active and sham M1 rTMS, M1 TMS-EEG demonstrated an increase in high-β synchronization in electrodes around M1 stimulation area and remotely in the contralateral hemisphere (p=0.026). The increase in high-β synchronization (48-83 ms after TMS-EEG stimulation) was succeeded by an enhancement in low-β power (86-144 ms after TMS-EEG stimulation) both locally and in the contralateral hemisphere (p=0.006). No significant differences were observed in TMS-EEG responses probing DLPFC, ACC, or PSI. Conclusion: M1-rTMS engaged a sequence of enhanced phase synchronization, followed by an increase in power occurring within M1, that spread to remote areas and was measurable after the end of the stimulation session. These results are relevant to understanding the M1 neuroplastic effects of rTMS and associated changes in cortical activity dynamics.

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“…However, targeting the PSI has traditionally required MRI guided neuronavigation, which can be time consuming and cost inefficient. The fast PSI method [18] was developed recently to reduce target identification time, and was shown to produce similar estimates of the PSI target compared to methods requiring neuronavigation, with high intra and inter-rater reliability. The finding that PSI-rTMS produced analgesia using the fast PSI method is promising for clinical application of the fast PSI method as this would greatly reduce time and costs required for targeted brain stimulation.…”

Section: Analgesic Effects Of Psi-rtmsmentioning

confidence: 99%

“…The fast PSI method was used to identify the PSI target without the need for MRI-guided neuronavigation [18]. A recommended rTMS protocol for inducing analgesic effects was used: 1500 pulses (10 Hz, 15 trains of 10 s each, inter-train interval of 20 s, 7.5 minutes total) [16], with the intensity of stimulation set to 80% of the TA RMT [30], and the coil oriented so that the main phase of the biphasic waveform induced a current in the posterior-anterior direction [48].…”

Section: Repetitive Transcranial Magnetic Stimulationmentioning

confidence: 99%

Posterior-Superior Insula Repetitive Transcranial Magnetic Stimulation Reduces Experimental Tonic Pain and Pain-Related Cortical Inhibition in Humans

Chowdhury,

Millard,

de Martino

et al. 2024

Preprint

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High frequency repetitive transcranial magnetic stimulation (rTMS) to the posterosuperior insula (PSI) may produce analgesic effects. However, the neuroplastic changes behind PSI-rTMS analgesia remain poorly understood. The present study aimed to determine whether tonic capsaicin-induced pain and cortical inhibition (indexed using TMS-electroencephalography) are modulated by PSI-rTMS. Twenty healthy volunteers (10 females) attended two sessions randomized to active or sham rTMS. Experimental pain was induced by capsaicin administered to the forearm for 90 minutes, with pain ratings collected every 5 minutes. Left PSI-rTMS was delivered (10Hz, 100 pulses per train, 15 trains) ~50 minutes post-capsaicin administration. TMS-evoked potentials (TEPs) and thermal sensitivity were assessed at baseline, during capsaicin pain prior to rTMS and after rTMS. Bayesian evidence of reduced pain scores and increased heat pain thresholds were found following active rTMS, with no changes occurring after sham rTMS. Pain (prior to active rTMS) led to an increase in the frontal negative peak ~45 ms (N45) TEP relative to baseline. Following active rTMS, there was a decrease in the N45 peak back to baseline levels. In contrast, following sham rTMS, the N45 peak was increased relative to baseline. We also found that the reduction in pain NRS scores following active vs. sham rTMS was partially mediated by decreases in the N45 peak. These findings provide evidence of the analgesic effects of PSI-rTMS and suggest that the TEP N45 peak is a potential marker and mediator of both pain and analgesia.

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The fast-posterior superior insula (Fast-PSI): A neuronavigation-free targeting method for non-invasive neuromodulation

Cited by 4 publications

References 9 publications

Beyond trial‐and‐error: Individualizing therapeutic transcranial neuromodulation for chronic pain

Beyond trial‐and‐error: Individualizing therapeutic transcranial neuromodulation for chronic pain

Repetitive transcranial magnetic stimulation to the motor cortex leads to a sequential increase in phase synchronization and power of TMS-evoked electroencephalographic recordings

Posterior-Superior Insula Repetitive Transcranial Magnetic Stimulation Reduces Experimental Tonic Pain and Pain-Related Cortical Inhibition in Humans

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