Repetitive Transcranial Magnetic Stimulation as a Complementary Treatment for Post-stroke Aphasia

Repetitive Transcranial Magnetic Stimulation as a Complementary Treatment for Post-stroke Aphasia

Heiss Wolf-Dieter, Thiel Alexander, Weiduschat Nora
Published: European Neurology - Volume 3 Issue 2
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Aphasia is an acquired language disorder affecting more than 20% of stroke patients.1–3 Six months post-stroke, 12% of survivors still suffer significantly from this severely incapacitating deficit,1 the prognosis depending mainly on the extent and localisation of the infarction. A Cochrane review could not determine whether speech and language therapy is more effective than informal support.4 Thus, novel therapy options are needed. Transcranial magnetic stimulation (TMS) is a non-invasive method of inducing the depolarisation of cortical neuronal assemblies by delivering short magnetic pulses penetrating the skull. The excitability of the cortex can be either inhibited or facilitated depending on stimulation parameters. High-frequency repetitive TMS (rTMS) (>5Hz) increases cortical excitability, whereas stimulation with frequencies of 4Hz or lower decreases excitability (see Figure 1).5,6 With this in mind, many studies have been conducted in order to determine whether rTMS might be used as a therapeutic option in stroke rehabilitation7–11 and other disorders such as depression12–14 or tinnitus.15–17

Spontaneous Recovery of Post-stroke Aphasia
In most adults language function is extremely lateralised to the left hemisphere.18 Functional studies in healthy subjects suggest that these specialised areas inhibit adjacent cortical areas, as well as more remote regions connected by fibre pathways.19–22 A simultaneous rTMS and positron emission tomography (PET) activation study directly demonstrated collateral (i.e. in adjacent regions) and transcallosal (i.e. in contralateral homotopic regions) inhibition in healthy subjects.23 Suppression of cortical excitability with low–frequent rTMS in the Broca area led to a prolongation of reaction time latencies during a verbgeneration task. In addition, during rTMS the cerebral blood flow was decreased in those regions under the coil but increased in neighbouring regions and in contralateral homologous areas (see Figure 2).

After a stroke damaging specialised regions, the functional and structural networks involved in the affected function have to be modified, which is facilitated by the adaptive plasticity of the cerebral cortex. One prominent finding is that excitability in peri-lesional but also in more remote cortical areas is increased.24 Also in aphasia patients, functional imaging revealed language-related cortical activations in peri-lesional regions, as well as contralateral homologous areas,25–29 suggesting overactivation.30 As it could be shown that unilateral ischaemic lesions led to transcallosal disinhibition,31 the increased activations may be seen as a result of reduced inhibition by the lesioned structures.18,32,33

Several studies demonstrate that aphasic patients with favourable outcomes predominantly activate in regions ipsilateral to the lesion,34–38 although contralateral activations were also observed. Thus, (re-) integration of ipsilesional areas seems to be the most effective reorganisation pattern. Several studies report beneficial effects of the recruitment of peri-lesional regions.32,37–41 In contrast, increased activation in the contralesional hemisphere might represent an inferior strategy,42,43 e.g. in the sense of maladaptive plasticity.44 In a longitudinal study by Richter et al., activation of right hemispheric areas decreased in aphasic patients with better therapy response, whereas activation increased in patients with less clinical improvement.29

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