EA 4391, université Paris 12, Créteil, France.
Neurophysiol Clin. 2010 Mar;40(1):27-36. doi: 10.1016/j.neucli.2010.01.001. Epub 2010 Jan 22.
Since about 15 years, transcranial magnetic stimulation (TMS) is used as a technique to investigate the function of specific cortical regions. Single pulse TMS studies have targeted the dorsolateral premotor cortex (dlPMC) to characterize premotor-motor interactions in movement disorders. Repetitive TMS (rTMS) trials have targeted the dorsolateral prefrontal cortex (dlPFC) to treat depression. In almost all previous studies, these targets have been defined according to a "standard" scalp distance to the site of stimulation evoking motor responses of maximal amplitude in the contralateral hand ("hand motor hotspot" corresponding to the primary motor cortex, M1). The "standard" procedure of coil positioning locates the dlPMC and dlPFC as 2-3 and 5cm, respectively, anterior to the "hand motor hotspot". The aim of our study was to compare the locations of M1, dlPMC and dlPFC targets provided by the "standard" procedure of coil positioning and those provided by using a neuronavigation system integrating individual brain magnetic resonance imaging (MRI). Twenty-two patients were enrolled, all being treated for depressive symptoms in the context of chronic pain syndrome. The centers of the dlPMC and dlPFC regions were accurately targeted by the "standard" procedure in 14 and eight patients (64 and 36% of the series), respectively. In the other patients, the "standard" procedure located the dlPMC target on the M1/dlPMC border and the dlPFC target on the dlPMC/dlPFC border. On average, the MRI-guided location of M1, dlPMC, and dlPFC was, respectively, 6.1mm posterior, 31.7mm anterior and 69.0mm anterior to the "hand motor hotspot". The "standard" procedure failed to accurately locate the dlPMC and dlPFC targets by about 1 and 2cm, respectively. A statistical analysis of the MRI coordinates (x, y, z) of the targets revealed that the M1 target was more posterior, the dlPMC target more superficial and the dlPFC target more anterior, lateral, and deeper, using neuronavigation compared to the "standard" procedure. This study confirms that the "standard" procedure of coil positioning is not accurate to target a desired cortical region. Target location can be improved by the use of a navigation system taking individual brain anatomy into account. The present results incline to be cautious on the pathophysiological interpretations of previous results reported in TMS studies based on "standard" targeting, e.g. regarding premotor-motor interactions. Similarly, the inaccuracy of the "standard" procedure of coil positioning could partly explain the between-study variability of the therapeutic effects produced by rTMS in patients with depression. Our results strongly support a more anterior and lateral placement of the TMS coil for dlPFC stimulation in the treatment of depression.
自大约 15 年前以来，经颅磁刺激（TMS）已被用作研究特定皮质区域功能的技术。单脉冲 TMS 研究靶向背外侧运动前皮质（dlPMC），以描述运动障碍中的运动前-运动相互作用。重复经颅磁刺激（rTMS）试验靶向背外侧前额叶皮质（dlPFC）以治疗抑郁症。在几乎所有以前的研究中，这些目标都是根据刺激诱发对侧手最大幅度运动反应的头皮距离的“标准”来定义的（对应于初级运动皮层 M1 的“手运动热点”）。线圈定位的“标准”程序将 dlPMC 和 dlPFC 分别定位在距离“手运动热点”前 2-3cm 和 5cm 的位置。我们研究的目的是比较使用整合个体脑磁共振成像（MRI）的神经导航系统提供的 M1、dlPMC 和 dlPFC 目标位置与线圈定位的“标准”程序提供的目标位置。22 名患者被纳入研究，均在慢性疼痛综合征背景下接受抑郁症治疗。在 14 名患者（系列的 64%）和 8 名患者（系列的 36%）中，“标准”程序准确地靶向了 dlPMC 和 dlPFC 区域的中心。在其他患者中，“标准”程序将 dlPMC 目标定位在 M1/dlPMC 边界上，将 dlPFC 目标定位在 dlPMC/dlPFC 边界上。平均而言，MRI 引导的 M1、dlPMC 和 dlPFC 的位置分别比“手运动热点”后 6.1mm、前 31.7mm 和前 69.0mm。“标准”程序分别无法准确地将 dlPMC 和 dlPFC 目标定位在约 1cm 和 2cm 处。使用神经导航对目标的 MRI 坐标（x、y、z）进行统计学分析，结果显示与“标准”程序相比，M1 目标更靠后，dlPMC 目标更浅表，dlPFC 目标更靠前、更外侧和更深。这项研究证实，线圈定位的“标准”程序不能准确地靶向所需的皮质区域。通过使用考虑个体脑解剖结构的导航系统可以改善目标位置。目前的结果表明，基于“标准”靶向的 TMS 研究中，先前结果的病理生理学解释需要谨慎，例如关于运动前-运动相互作用。同样，“标准”程序的线圈定位不准确可能部分解释了 rTMS 治疗抑郁症患者的治疗效果在研究之间的变异性。我们的结果强烈支持在治疗抑郁症时，将 TMS 线圈更靠前和更外侧放置以刺激 dlPFC。
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