Vasovagal syncope as a specific side effect of DLPFC-rTMS: A frontal-vagal dose-finding study

Rouwhorst, Renée; Oostrom, Iris van; Dijkstra, Eva; Zwienenberg, Lauren; Arns, Martijn

doi:10.1016/j.brs.2022.08.015

Cited by 6 publications

(5 citation statements)

References 10 publications

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“…In larger samples, it is likely that larger differences will be found, necessitating studies to investigate this method further as an FT technique. The nonlinear and nonsigmoidal dose-response effects suggest possible overstimulation, which is in line with a recent case of TMS-induced syncope ( 25 ) and previous studies that imply that the stimulation intensity sweet spot neither under nor overdoses ( 14 , 15 ). Compared with those studies, we used more and smaller incremental steps in the current study and investigated HBC on an individual level, enabling the determination of an individual fine-grained dose-response curve.…”

Section: Discussionsupporting

confidence: 90%

Transcranial Magnetic Stimulation–Induced Heart-Brain Coupling: Implications for Site Selection and Frontal Thresholding—Preliminary Findings

Dijkstra

Vila-Rodriguez

Zwienenberg

et al. 2023

Biological Psychiatry Global Open Science

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Section: Discussionsupporting

confidence: 90%

Transcranial Magnetic Stimulation–Induced Heart-Brain Coupling: Implications for Site Selection and Frontal Thresholding—Preliminary Findings

Dijkstra

Vila-Rodriguez

Zwienenberg

et al. 2023

Biological Psychiatry Global Open Science

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“…4 One report of a near syncopal episode was attributed to a specific effect of prefrontal rTMS resulting in parasympathetic overdrive. 5 When syncope occurs, it is most often associated with myoclonic movements or other motor activity, which can make it difficult to distinguish from a seizure.…”

Section: Discussionmentioning

confidence: 99%

“…2 The mechanism of syncope induced by rTMS may be related to decreased blood supply to the brain that could occur in the setting of hypotension, bradycardia, or hyperventilation resulting in cerebral vasocontraction due to decreased carbon dioxide levels in the brain. 5 There is also the possibility of syncope due to a vasovagal reaction associated with increased anxiety or psychophysical discomfort associated with rTMS. Notably, this patient reported feeling some discomfort associated with rTMS in the few minutes preceding his syncope, and he had a history of significant comorbid anxiety disorders.…”

Section: Discussionmentioning

confidence: 99%

“…In 1 study, 29 of 174 participants (17%) reported experiencing a syncope or presyncope (a subjective feeling that one is about to pass out, but there is no loss of consciousness) with rTMS, but the participants did not report the number of events 4 . One report of a near syncopal episode was attributed to a specific effect of prefrontal rTMS resulting in parasympathetic overdrive 5 . When syncope occurs, it is most often associated with myoclonic movements or other motor activity, which can make it difficult to distinguish from a seizure.…”

Section: Discussionmentioning

confidence: 99%

“…Most episodes of syncope and seizures induced by TMS occur during the first 3 sessions 2 . The mechanism of syncope induced by rTMS may be related to decreased blood supply to the brain that could occur in the setting of hypotension, bradycardia, or hyperventilation resulting in cerebral vasocontraction due to decreased carbon dioxide levels in the brain 5 . There is also the possibility of syncope due to a vasovagal reaction associated with increased anxiety or psychophysical discomfort associated with rTMS.…”

Section: Discussionmentioning

confidence: 99%

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Distinguishing Convulsive Syncope From Seizure Induced by Repetitive Transcranial Magnetic Stimulation

Mukhtar,

Feuer,

Beynel

et al. 2023

J ECT

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Repetitive transcranial magnetic stimulation (rTMS) is Food and Drug Administration cleared for clinical use in treatment-resistant depression and a growing list of other disorders. The clinical uptake of rTMS has been facilitated by its relatively benign adverse-effect profile compared with other treatment modalities. Seizure is a rare but serious adverse event that has been reported with rTMS, when dosage exceeds safety guidelines or in individuals at increased risk for seizure. Fortunately, most rTMS-induced seizures are typically transient, with no adverse sequelae, but they may lead to treatment discontinuation. Seizure is not the only cause of loss of conscious and abnormal movements induced by rTMS. Convulsive syncope, a more common adverse event that involves loss of consciousness associated with myoclonic movements, can be difficult to differentiate from an rTMS-induced seizure. We report the case of a 52-year-old man with no known seizure risk factors, enrolled in an institutional review board–approved research study who developed what appeared to be a convulsive syncopal episode lasting 10 to 15 seconds during day 2 of a 30-day rTMS protocol (10 Hz, 120% of motor threshold, 4-second pulse train, 26-second intertrain interval, 3000 pulses per session), with no adverse sequelae. The patient's history, screening, physical examination, pertinent laboratory, neurology consult, electroencephalogram, and imaging findings are discussed. This case demonstrates that distinguishing between convulsive syncope and rTMS-induced seizure can be a diagnostic challenge. Clinicians and researchers delivering rTMS should be familiar with the risk factors for rTMS-induced seizures and rTMS-induced convulsive syncope, to screen for predisposing factors and to manage these rare adverse events if they occur.

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Deep TMS: A comprehensive summary of adverse events from five multicenter trials

Tendler¹,

Gersner²,

Roth³

et al. 2023

Brain Stimulation

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Vasovagal syncope as a specific side effect of DLPFC-rTMS: A frontal-vagal dose-finding study

Cited by 6 publications

References 10 publications

Transcranial Magnetic Stimulation–Induced Heart-Brain Coupling: Implications for Site Selection and Frontal Thresholding—Preliminary Findings

Transcranial Magnetic Stimulation–Induced Heart-Brain Coupling: Implications for Site Selection and Frontal Thresholding—Preliminary Findings

Distinguishing Convulsive Syncope From Seizure Induced by Repetitive Transcranial Magnetic Stimulation

Deep TMS: A comprehensive summary of adverse events from five multicenter trials

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