effects of rtms on ipsilateral corticomotor projections in children with perinatal stroke:...
TRANSCRIPT
Effects of rTMS on Ipsilateral Corticomotor Projections in Children with Perinatal Stroke:Neuromodulation feasibility in the PLASTIC CHAMPS trial
Damji O, Kotsovsky O, Chen R, Kirton A
Disclosures
• No conflicts
• Non-invasive brain stimulation is experimental in kids
Stroke Can Happen in Kids?
• Common– >1:2500 live births =
>1000 Alberta children.– #1 cause hemiplegic CP
• Poorly understood
• Poor outcomes• No prevention or treatment
• Ideal model for studying neuroplasticity in children
Perinatal Stroke
Symptomatic Neonatal AIS
(NAIS)
Arterial Presumed Perinatal Ischemic
Stroke (APPIS)
Periventricular Venous Infarction
(PVI)
Perinatal Stroke = Motor System Injury = Hemiparetic CP
AIS-MCA
PVI
Ipsilateral Projections
> 0.05mV at 120% RMT in >5/20 trials
Aims
• Determine the neurophysiology of ipsilateral connections in perinatal stroke– Hypothesis: The unlesioned hemisphere controls both contra-
and ipsi-lateral physiology
• Investigate the effects of inhibitory rTMS on ipsilateral projections in perinatal stroke– Hypothesis: rTMS inhibits ipsilateral corticomotor projections
Faraday's Law of Magnetic Induction
TMS Neurophysiology
• Rest Motor Threshold (RMT)
• Stimulus Response Curve (SRC)– 100 / 110 / 120 / 130 / 140 / 150%
• Paired-Pulse Methods– Short Interval Intracortical Inhibition (SICI)– Intracortical Facilitation (ICF)
PLASTIC CHAMPS trial
Plastic Adapatation Stimulated by TMS and Induced Constraint for
Congenital Hemiplegia After Motor Perinatal Stroke
PLASTIC CHAMPS Brain CamprTMS: 1Hz x 20 minutes OR shamCIMT: Cast x 90% waking hours
www.clinicaltrials.govNCT01189058
Results
• Interim analysis of 35 children• Mean age 11.25 years, 20 male• 55% arterial, 45% PVI• 15 rTMS versus 20 sham
N = 35
N = 18 excluded
N = 17Met ipsi criteria
Results – Ipsilateral Projections
• 17 (49%) of children had ipsilateral projections
• Presence and intensity correlated with disability – AHA (r=-0.58; p=0.004) and MA (r=-0.45; p=0.013).
• Ipsi SRC slope was lower than contra (p=0.01).
• SICI was present bilaterally – contra -38.5%, ipsi -30.7%
• ICF was present bilaterally – contra +15.4%, ipsi +23.1%
• SICI and ICF differed between sides (p= 0.004)
Results
Non-lesional rTMS affected contralateral as expected:
Increased RMT and lowered SRC slope
Results
Non-lesional rTMS had less effect on ipsilateral physiology:
No change in ICF
Trends to lower SRC slope and increased SICI
Ipsilateral SRC Slope Ipsilateral SICI
Results
Children with ipsilateral projections did not show a decrease in motor function with rTMS
MA improved, AHA unchanged
Results
Changes cortical physiology correlated between contralateral and ipsilateral sides
SICI ICF
Conclusions
• Contralesional inhibitory rTMS is feasible in kids with perinatal stroke and ipsilateral projections
• rTMS effects on corticomotor neurophysiology are more predictable on the contralateral side
• rTMS shifts in corticomotor neurophysiology correlate between contra and ipsi-lateral systems
Acknowledgements
Dr. Aleks MineykoTaryn Bemister
Jessica DenysJacquie Hodge
Jenny Saunders Jamie Roe
Helen CarlsonSiddharth Shinde
Dave CzankTMS
ACH Pediatric TMS LaboratoryOleg KotsovskyOmar DamjiDr. Thilinie Rajapakse
Toronto Western Research Institute Dr. Robert ChenCarolyn Gunraj
PLASTIC CHAMPS
Calgary Stroke Program Dr. Michael HillDr. Sean Dukelow
ACH RMTDr. Alberto Nettel-AguirreDr. Brent Hagel
ACH CIMT Program / Rehab Tamara ThickeGillian Hoyt-HallettClare O’ByrneColleen Lane, Mia Herrero
APSP Stollery Edmonton Dr. Jerome Yager
APSP Glenrose Edmonton Dr. John AndersenKathleen O’Grady
SickKids Stroke Program Dr. Gabrielle deVeber
NeuroimagingDr. Xing-Chang WeiDr. Jayme Kosior
Clinical Research UnitChristina Ma
www.perinatalstroke.ca