RESUMEN
BACKGROUND: Recently, a small literature has emerged suggesting that repetitive transcranial magnetic stimulation (rTMS) may offer benefit for MDD even in BPD patients, perhaps by enhancing cognitive control, and/or disrupting excessive 'non-reward' activity in right orbitofrontal regions. This study aimed primarily to assess the therapeutic effects of dorsomedial prefrontal cortex (DMPFC)-rTMS against MDD symptoms in BPD patients, and secondarily to assess whether the therapeutic effects ensued via mechanisms of reduced impulsivity and core BPD pathology on clinical scales (BIS-11, ZAN-BPD) or of reduced alpha- and theta-band activity on EEG recordings of right orbitofrontal cortex.. METHODS: In a crossover-design trial, 20 BPD patients with MDD underwent 2 × 30 session/15 day blocks of either active-then-sham or sham-then-active bilateral 20 Hz DMPFC-rTMS. RESULTS: Sixteen out of 20 patients completed treatment. A significant (p = 0.00764) crossover effect was detected, with overall reductions in HamD17 score from 23.1±SD3.1 to 10.75±SD5.8. Nine out of 16 (56.3%) treatment completers achieved response (>50% improvement) and 6/16 (37.5%) achieved remission (HamD≤7), maintained at 1 month followup. BIS-11 scores remained unchanged, and ZAN-BPD scores improved similarly in both groups with no significant crossover effect. Change in low-band power over right orbitofrontal regions correlated with clinical improvement. LIMITATIONS: This was a crossover study with a small sample size. A randomized controlled trial with larger sample size will be needed to establish the efficacy more definitively. CONCLUSIONS: The results suggest efficacy for DMPFC-rTMS in treating MDD in BPD, and provide a foundation for a larger future trial.
Asunto(s)
Trastorno de Personalidad Limítrofe , Trastorno Depresivo Mayor , Trastorno de Personalidad Limítrofe/etiología , Trastorno de Personalidad Limítrofe/terapia , Estudios Cruzados , Depresión , Trastorno Depresivo Mayor/psicología , Humanos , Proyectos Piloto , Corteza Prefrontal , Estimulación Magnética Transcraneal/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Accurate neuronavigation is essential for optimal outcomes in therapeutic brain stimulation. MRI-guided neuronavigation, the current gold standard, requires access to MRI and frameless stereotaxic equipment, which is not available in all settings. Scalp-based heuristics depend on operator skill, with variable reproducibility across operators and sessions. An intermediate solution would offer superior reproducibility and ease-of-use to scalp measurements, without requiring MRI and frameless stereotaxy. OBJECTIVE: We present and assess a novel neuronavigation method using commercially-available, inexpensive 3D head scanning, computer-aided design, and 3D-printing tools to fabricate form-fitted headsets for individuals that hold a stimulator, such as an rTMS coil, in the desired position over the scalp. METHODS: 20 individuals underwent scanning for fabrication of individualized headsets designed for rTMS of the left dorsolateral prefrontal cortex (DLPFC). An experienced operator then performed three trials per participant of three neuronavigation methods: MRI-guided, scalp-measurement (BeamF3 method), and headset placement, and marked the sites obtained. Accuracy (versus MRI-guidance) and reproducibility were measured for each trial of each method. RESULTS: Within-subject accuracy (against a gold-standard centroid of three MRI-guided localizations) for MRI-guided, scalp-measurement, and headset methods was 3.7 ± 1.6 mm, 14.8 ± 7.1 mm, and 9.7 ± 5.2 mm respectively, with headsets significantly more accurate (M = 5.1, p = 0.008) than scalp-measurement methods. Within-subject reproducibility (against the centroid of 3 localizations in the same modality) was 3.7 ± 1.6 mm (MRI), 4.2 ± 1.4 (scalp-measurement), and 1.4 ± 0.7 mm (headset), with headsets achieving significantly better reproducibility than either other method (p < 0.0001). CONCLUSIONS: 3D-printed headsets may offer good accuracy, superior reproducibility and greater ease-of-use for stimulator placement over DLPFC, in settings where MRI-guidance is impractical.