Neuronavigated rTMS

A Randomized Trial of rTMS Targeted with MRI Based Neuro-Navigation in Treatment-Resistant Depression

Paul B Fitzgerald¹, Kate Hoy¹, Susan McQueen¹, Jerome J Maller¹, Sally Herring¹, Rebecca Segrave¹, Michael Bailey², Greg Been¹, Jayashri Kulkarni¹ and Zafiris J Daskalakis³

1. ¹Alfred Psychiatry Research Centre, The Alfred and Monash University School of Psychology, Psychiatry and Psychological Medicine, Commercial Rd Melbourne, Victoria, Australia
2. ²Monash University Department of Epidemiology and Preventive Medicine, The Alfred Hospital, Commercial Rd Melbourne, Victoria, Australia
3. ³Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada

Correspondence: Professor PB Fitzgerald, Alfred Psychiatry Research Centre, First Floor, Old Baker Building, The Alfred, Commercial Rd Melbourne, Victoria 3004, Australia. Tel: +61 3 9076 6552; Fax: +61 3 9076 6588; E-mail: paul.fitzgerald@med.monash.edu.au

Received 8 August 2008; Revised 14 December 2008; Accepted 16 December 2008; Published online 14 January 2009.

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Abstract

The aim of this study is to investigate whether repetitive transcranial magnetic stimulation (rTMS) targeted to a specific site in the dorsolateral prefrontal cortex (DLPFC), with a neuro-navigational method based on structural MRI, would be more effective than rTMS applied using the standard localization technique. Fifty-one patients with treatment-resistant depression were randomized to receive a 3-week course (with a potential 1-week extension) of high-frequency (10 Hz) left-sided rTMS. Thirty trains (5 s duration) were applied daily 5 days per week at 100% of the resting motor threshold. Treatment was targeted with either the standard 5 cm technique (n=27) or using a neuro-navigational approach (n=24). This involved localizing the scalp location that corresponds to a specific site at the junction of Brodmann areas 46 and 9 in the DLPFC based on each individual subject's MRI scan. There was an overall significant reduction in the Montgomery–Asberg Depression Rating Scale scores over the course of the trial, and a better outcome in the targeted group compared with the standard localization group at 4 weeks (p=0.02). Significant differences were also found on secondary outcome variables. The use of neuro-navigational methods to target a specific DLPFC site appears to enhance response to rTMS treatment in depression. Further research is required to confirm this in larger samples, or to establish whether an alternate method based on surface anatomy, including measurement from motor cortex, can be substituted for the standard 5 cm method.

Keywords:

repetitive transcranial magnetic stimulation, depression, prefrontal cortex, respons