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LETTER TO EDITOR
Year : 2020  |  Volume : 37  |  Issue : 3  |  Page : 152-153

Long-term, bilateral repetitive transcranial magnetic stimulation in a patient with locked-in syndrome


Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea

Date of Submission19-Sep-2019
Date of Decision27-Sep-2019
Date of Acceptance02-Apr-2020
Date of Web Publication16-Sep-2020

Correspondence Address:
Suk Yun Kang
Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, 18450
Republic of Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NSN.NSN_23_20

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How to cite this article:
Jang MU, Kang SY. Long-term, bilateral repetitive transcranial magnetic stimulation in a patient with locked-in syndrome. Neurol Sci Neurophysiol 2020;37:152-3

How to cite this URL:
Jang MU, Kang SY. Long-term, bilateral repetitive transcranial magnetic stimulation in a patient with locked-in syndrome. Neurol Sci Neurophysiol [serial online] 2020 [cited 2020 Sep 28];37:152-3. Available from: http://www.nsnjournal.org/text.asp?2020/37/3/152/295175



Dear Editor,

Locked-in syndrome is a very serious condition with desperate quality of life due to profound paralysis, and there is no effective treatment other than rehabilitation. Repetitive transcranial magnetic stimulation (rTMS) seems to be benefit in motor recovery of stroke patients and other neurological disorders.[1] However, the rTMS effect of brainstem stroke was unclear.[2],[3],[4] Moreover, long-term treatment is important to maintain the rTMS effect, but few information of long-term treatment protocol and safety is available in the literature. Therefore, we like to report our experience of long-term maintenance treatment of rTMS in locked-in syndrome.

A 57-year-old man with bilateral brainstem infarction was administered with rTMS at 3-month after acute stroke. He was severe locked-in-state, and stable without further improvement. Despite active rehabilitation, because there is no further substantial improvement, we decided to apply rTMS to him. On neurological examination, motor power was grade 0/5 in the right upper and lower limbs, grade 1 in the left upper and lower limbs. Brain magnetic resonance imaging showed multiple acute infarctions in the bilateral midbrain, right pons, bilateral cerebellum, right middle cerebellar peduncles, and left parieto-occipital lobe. At first, bilateral rTMS was delivered over bilateral motor cortex on weekdays for 1 week (5 sessions). After that the rTMS was given once a week for 1 month (4 sessions), and then twice a week for 3 months (26 sessions). rTMS protocol was the same as previously described procedure.[5] There was no side effect during the treatment period. After completion of total 35 sessions, there was slight improvement of hand function in the left side, but no improvement in the right side. There was also increased amplitude of MEP on the right motor cortex [Table 1].
Table 1: Electrophysiological parameters and the motor strength of upper extremity

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This study shows that long-term, bilateral high-frequency rTMS may be tolerable and safe, suggesting maintenance treatment may be applicable in stroke patients, and that there might be a possible therapeutic effect of rTMS on severe brainstem stroke with locked-in syndrome. However, because it is only one case study, further studies are needed to confirm our results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

The study was previously submitted as a poster to the 3rd International Brain Stimulation Conference, Vancouver, Canada, and also presented as a poster at the Spring Conference of the 23rd Korea Neurophysiological Society, Seoul, Republic of Korea, in 2019.

Financial support and sponsorship

Nil.

Conflicts of interestb

There are no conflicts of interest.



 
  References Top

1.
Hsu WY, Cheng CH, Liao KK, Lee IH, Lin YY. Effects of repetitive transcranial magnetic stimulation on motor functions in patients with stroke: A meta-analysis. Stroke 2012;43:1849-57.  Back to cited text no. 1
    
2.
Khedr EM, Abo-Elfetoh N. Therapeutic role of rTMS on recovery of dysphagia in patients with lateral medullary syndrome and brainstem infarction. J Neurol Neurosurg Psychiatry 2010;81:495-9.  Back to cited text no. 2
    
3.
Momosaki R, Abo M, Kakuda W. Bilateral repetitive transcranial magnetic stimulation combined with intensive swallowing rehabilitation for chronic stroke dysphagia: A case series study. Case Rep Neurol 2014;6:60-7.  Back to cited text no. 3
    
4.
Thomas F, Bouaziz N, Amengual JL, Andrianisaina PS, Gaudeau-Bosma C, Moulier V, et al. Unexpected improvement of hand motor function with a left temporoparietal low-frequency repetitive transcranial magnetic stimulation regime suppressing auditory hallucinations in a brainstem chronic stroke patient. Front Psychiatry 2017;8:262.  Back to cited text no. 4
    
5.
Kim SJ, Paeng SH, Kang SY. Stimulation in supplementary motor area versus motor cortex for freezing of gait in Parkinson's disease. J Clin Neurol 2018;14:320-6.  Back to cited text no. 5
    



 
 
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