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Clinical Implications of the Cortical Column Cosine Model

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Clinical Implications of the Cortical Column Cosine Model Clinical Implications of the Cortical Column Cosine model (C3) for rTMS & Neuronavigated rTMS #3042 Rustin Berlow, M.D.1 1Private Practice, Psychiatry & Brain Stimulation Organization for Human Brain Mapping OHBM 2016 Annual Meeting Geneva, Switzerland June 26-30, 2016 rTMS is an established (Reardon 2007) and Because this two week experience was part of This structure is easy to locate (fig 4) and increasingly well understood method of brain clinical care in a real world setting and this stimulate, even at higher power with less stimulation (Pascual-Leone 1999, George 2002, difference was not anticipated, standard state discomfort compared with frontal lobe Baeken 2011, Chervyakov 2015 & Silva 2008). measures were not administered. stimulation. Because the gyri of the cerebral cortex are closer to In the first week of using nn-rTMS aiming at the the surface and the strength of a magnetic field gyral crown, 11 patients demonstrated no decays by the inverse cube of the distance, cortical noticeable clinical improvement. The following gyri have been targeted for stimulation. week, more than half of the same patients Specifically, the FDA approved protocol for rTMS appeared to benefit from stimulation of the sulcus in Depression targets the gyri of the left DLPFC or sulcal ridge. (Reardon 2007). With the advent of neuronavigated rTMS and 1 mm MRI images Why would stimulation of the space between the (high definition MRI (HD-MRI)), stimulation cortical gyri produce better results? accuracy with regard to location has been Intriguing evidence has emerged that stimulation improved (fig 1) (Kim 2014). is more efficient as the cortical column becomes perpendicular to the surface (sulcal ridge) instead of parallel to it (gyral crown) (Salinas 2012). This has been termed the Cortical Column Cosine (C3) model. The proposed mechanism invokes the difference in firing due to the relative angle of the neuron with respect to angle of the electric current. The more the neuron and current are aligned, the greater the increase in neuronal activity. An additional mechanism may be that when stimulating sulci, there are more neurons in the path of the magnetic field therefore, more neurons We are now exploring the use of Deep Medial are likely to be stimulated (fig 3). Longitudinal stimulation of the precuneus both alone and combined with DLPFC stimulation and look forward to assessing its therapeutic potential. Neuronavigated rTMS, although elegant, precise and, inspiring also has added costs including clinician training, ongoing time commitment, software/equipment ($50-60,000), and individual HD-MRI ($450-1,500 each). It may or may not represent a needed improvement for the routine treatment of psychiatric outpatients. Systematic future trials of rTMS of the precuneus vs DLPFC (standard and neuronavigated, and within DLPFC - gyral crown vs sulcul bank) may help provide needed data to intelligently choose among these options. References Baeken, C. (2011) Neurobiological mechanisms of repetitive transcranial magnetic stimulation on the underlying neurocircuitry in unipolar depression., Dialogues Clin Neurosci. 2011;13(1): 139-45. (adapted from Salinas 2012) Chervyakov, AV. (2015) Possible Mechanisms Underlying the Therapeutic Effects of Transcranial Magnetic Stimulation., Front Fig 3: There are more neurons in the path of a Hum Neurosci. Jun 16;9:303. George, M. (2002) Mechanisms and State of the Art of magnetic field which passes through a sulcal bank as Transcranial Magnetic Stimulation., J ECT. Dec;18(4):170-81. opposed to one which passes through a gyral crown Kim, WJ. (2014) Neuronavigated vs. conventional repetitive transcranial magnetic stimulation method for virtual lesioning on This clinical experience, although anecdotal, raises the Broca's area., Neuromodulation. Jan;17(1):16-21;. questions. If the sulci of the DLPFC are targeted, O'Reardon, JP. (2007) Efficacy and Safety of Transcranial Magnetic Stimulation in the Acute Treatment of Major Depression: which sulci and which bank are best to stimulate? A Multi-Site Randomized Controlled Trial. Biol Psychiatry, Four new and seven on-going individuals Also, if sulci are a more appropriate target, if 62:1208-1216. received rTMS stimulation (MagPro X-100 with Pascual-Leone, A. (1999) Transcranial magnetic stimulation and stimulating the maximal number of neurons is neuroplasticity. Neuropsychologia. Feb;37(2):207-17. D-B80 coil) using Neuronavigation (nn-rTMS) advantageous, and if the cortical thickness of the Salinas, F.S. (2011) Baboon validations of the cortical column (Localite, Fraunhofer, Bonn). During the first right precuneus (the medial aspect of the superior cosine aiming model of TMS induced brain activations. In: 17th week, gyri of the Left DLPFC were stimulated. Annual Meeting of the Organization for Human Brain Mapping. parietal lobule) is associated with happiness (Sato Quebec City, Canada; 2011 June 26-30. During the second week, sulci of the Left DLPFC 2015), then stimulation of the largest sulcus of the Sato, W. (2015) The structural neural substrate of subjective were stimulated (both weeks, standard 10Hz, 4 cerebral cortex - the medial longitudinal fissure happiness, Sci Rep. Nov 20;5:16891. sec, 26 sec IPI at 80-100% of measured motor Silva, S. (2008) Elucidating the mechanisms and loci of neuronal (interhemispheric fissure) between the crown and excitation by transcranial magnetic stimulation using a finite threshold). the inion, may be an optimal location. element model of a cortical sulcus.,Clin Neurophysiol. Oct; 119(10): 2405–2413..
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