Abstract
Abstract Even though repetitive transcranial magnetic stimulation (rTMS) is already an FDA approved technique to treat depression, the overall clinical effectiveness is still rather modest. Overly general stimulation protocols that neither consider subject-specific depression symptomology nor individualized brain characteristics such as anatomy, or structural, and functional connections, may be the cause of the high inter- and intra-individual variability in rTMS response rates. This work gives an overview of ways of how we think that multimodal neuroimaging could provide insights into individual brain characteristics and therefore be used to personalize rTMS parameters; coil position, stimulation intensity, and timing. The optimal coil positioning could potentially be derived using a three-step process: 1) identification of the optimal (indirect) target area based on the symptom pattern; 2) derivation of the cortical (direct) target location based on functional and/or structural connectomes derived from functional and diffusion MRI data; 3) determination of the ideal coil position by computational modeling, such that the electric field distribution overlaps with the cortical target. TMS-induced electric field simulations require anatomical, and potentially diffusion, MRI data. Information about the induced field strengths can be used to derive optimal stimulation intensities. Besides MRI, EEG can provide complementary information regarding the ongoing oscillating brain-states. This information could be used to apply timely TMS pulse trains during preferred states or personalize the frequency of the stimulation. The added value of these personalized stimulation protocols is logically reasoned, but speculative. Randomized clinical trials will be required to compare clinical responses from standard rTMS protocols to personalized protocols. Ultimately, we hypothesize that optimized clinical response results from precision protocols derived from combinations of personalized stimulation parameters. Keywords: TMS, personalized medicine, MRI, EEG
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