Guide to Mag netic Stim u la tion - PSICOMAG.COM MagSrtim/mguide.pdf · Guide to Mag netic Stim u la tion ... ducted by Pascual-et al. Leone [Lan cet, 1996b, 348: 233- 238] ... plied

Guide to Mag netic Stim u la tion

The re cent years have seen a large in crease in both the de vel op ment and use of mag netic stimu la torsworld- wide. Com mer cial stimu la tors can achieve pulse rates up to 100Hz with stimu lus in ter vals as low as1msec and full com put eri sa tion. A growth in re search in ter est has pro duced a marked spread into theclini cal ar eas of di ag no sis, prog no sis, moni tor ing and ther apy. As with other tech nolo g ies, the world wideweb is act ing as a cata lyst to speed the spread of in for ma tion amongst re search ers and cli ni cians.

The abil ity of mag netic stimu la tion to in duce elec tri cal cur rents toflow within body tis sue per mits the cli ni cian to in flu ence ormoni tor many of these func tions. It is able to reach deep neu ralstruc tures such as the mo tor cor tex and spi nal nerve rootsnon- invasively and with out pain. As a re sult the tech nique hasbe come of great in ter est in psy chia try and is pro vid ing fur ther aidsto the cli ni cian for the thera peu tic treat ment of spas tic ity inmul ti ple scle ro sis and stroke pa tients, and other forms ofre ha bili tation.

This guide has been writ ten to pro vide an over view of thetech nique of mag netic stimu la tion from the first prin ci ple throughto some of the clini cal ap pli ca tionsnow fea si ble. Also in cluded arede tails about dif fer ent stimu la tor types and a look at more re centde vel op ments. A list of some 500 pa pers is pro vided or gan ised bydis ci pline. We thank our read ers who have con trib uted help fulin for ma tionor sug ges tions to wards this edi tion. Reza Jali nous, Ph.D.

What’s New in Psy chia try 2

Part 1: Fun da men tal and Tech ni cal As pects 3

Brief His tory 3Prin ci ples of Mag netic Stimu la tion 4Stimu lat ing Coils 6Mag netic Field Strength vs. Stimu lus Strength 8

Part 2: Clini cal As pects 9

Mo tor Evoked Po ten tials 9Mag netic Pulse Pairs 12

Sen sory Evoked Po ten tials 13Sam ple Ap pli ca tions 13Op er at ing Room Moni tor ing 13Cer vi cal Spon dy lo sis 17Phrenic Nerve Stimu la tion 18Urol ogy 19Stroke 20Fa cial Nerve 21Rapid Rate Mag netic Stimu la tion 22Safety Pre cau tions & Issues 25

Part 3: Ref er ence List 27

What’s New 2869 Sec tions in Al pha beti cal Or der 35

Ta ble of Con tents

Cover Page: Induced electric field profile of the double cone coil. The colours

yellow, red, blue and green on the frontcover signify decreasing fields strength.

Please note that this guide de scribes the state of the art in mag netic stimu la tion and is in te nded for a world- wideread er ship. Some tech niques and mag netic stimu la tor de vices de scribed rep re sent uses that are con sid ered asin ves ti ga tional in the USA. In par ticu lar this ap plies to the use of cor ti cal mag netic stimu la tion. Fur ther de tailson the regu la tions gov ern ing the use of in ves ti ga tional de vices can be ob tained from the FDA (www.fda.gov).

This sec tion de scribes one of the emerg ing ap pli ca tionsin mag netic stimu la tion, that of the use of re peti tivetran scra nial mag netic stimu la tion, or rTMS, in the treat -ment of mood dis or ders.

Mod est bene fit in the treat ment of de pres sion was first demon strated in 1995 by George et al. [Neu roRe -port, 1995, 6: 1853- 1856] wheresub- motor thresh old mag neticstim uli were de liv ered cor ti cally.The ap proach is radi cally dif fer ent from elec tro con vul sive ther apy,ECT, in that the pa tients are alertand do not need to be an aes the -tised. There have been a numberof other stud ies (see ref er encelist’s sec tion on psychiatry) with ano ta ble one hav ing been con -ducted by Pascual- Leone et al.[Lan cet, 1996b, 348: 233- 238]where pa tients re ceiv ing left dor -sal lat eral pre fron tal cortex rTMSshowed a sig nifi cant im prove -ment when com pared with stimu -la tion of other ar eas.

Un like sin gle pulse mag netic stim u la tion, where risksof in duc ing a sei zure are ex tremely low, cor ti cally ap -plied rTMS can in duce a sei zure un der cer tain cir cum -stances. The risk can, how ever, be mini mised throughthe use of care fully se lected pa ram e ters. Be fore the ini -ti a tion of rTMS the cli ni cian is rec om mended to study a mile stone pa per cov er ing safety is sues [Was ser mannEM, Electroencephalogr Clin Neurophysiol, 1998,108: 1-16]. As well as a com pre hen sive set of guide linesthe pa per con tains one ta ble which sets a train du ra tionlimit based on stim u lat ing power and fre quency. This is an ex cel lent start ing point for a study.

Cur rently there are two ap proaches with re gards to thetreat ment of de pres sion: (a) re pet i tive high fre quencystim u la tion, and (b) re pet i tive low fre quency stim u la -tion. The two train mo dal i ties are shown in the two fig -ures A and B on this page. Be ing more re cent, re pet i tive low fre quency stim u la tion is less well stud ied but ap -pears to have sim i lar ben e fi cial ef fects to rTMS. If theini tial data can be con firmed, the sig nif i cantly lowerrisk of in duc ing a sei zure will prove an un doubted plusover rTMS.

The ma jor ity of rTMS work has been done at 10Hzwith the other fre quen cies be ing 1Hz, 5Hz, 15Hz and20Hz. There ap pears to be lit tle dif fer ence in the ef fec -tive ness of the dif fer ent rTMS fre quen cies so long as thenum ber of stim uli per train re main the same.

It is stan dard prac tice to nor mal ise power lev els used tothe thresh old of a mo tor re sponse in a re laxed mus cle.This is a rough in di ca tor of stimu lat ing power and is area son able start ing point in the ab sence of im me di ate in -di ca tors fol low ing rTMS of the pre fron tal cor tex. Thepower lev els have ranged from 80% to 120% of mo torthresh old. Ac cord ing to the afore men tioned study byWas ser mann et al. the safe limit, at 10Hz, is as fol lows:

Safe Limit Example: 10Hz Protocol

80% of motor threshold Limit unknown100% of motor threshold 5 seconds (50 stimuli)120% of motor threshold 4.2 seconds (42 stimuli)130% of motor threshold 2.9 seconds (29 stimuli)

In the same pa per it was sug gested that stud ies in nor mal volunteers should be con ducted with a 25% safety mar -gin to re duce sei zure risk. Para phrased, it states that:“These safe limits should only be ex ceeded in caseswhere ad verse ef fects are ex pected and pre pared for,and the risks out weigh the po ten tial bene fit where al ter -na tive thera pies also have sig nifi cant risk.”

Also see the Safety sec tion and the Ref er ences.

Reza Jalinous Guide to Magnetic Stimulation Page 2

What’s New in Psychiatry

Fig ure A. Common high frequency rTMS protocols currently applied in the treatment ofmood disorders. Brief trains are applied once per minute for twenty minutes. Patient

receives ten treatments over a two week period.

Fig ure B. New treatment modality, low frequency rTMS, appears to have similar benefitsto high frequency rTMS. Note: Unlike high frequency rTMS, benefits are observed for

stimulation of the right prefrontal cortex.

Brief His tory

Elec tro mag netic in duc tion, pro duc ing a cur rent in acon duc tive ob ject by us ing a mov ing or time- varyingmag netic field, was first de scribed by Mi chael Fara day in1831 at the Royal In sti tu tion of Great Brit ain, and isproba bly the most rele vant ex peri men tal ob ser va tionfor mag netic stimu la tion. Fara day wound two coils onan iron ring and found that when ever the coil on oneside was con nected or dis con nected from a bat tery, anelec tri cal cur rent passed through the coil on the otherside. The iron ring acted as a chan nel link ing the mag -netic field from the first coil to the sec ond. A change inthe mag netic field, re lated to the chang ing cur rent in thefirst coil, in duced a cur rent in the sec ond coil. In fact theiron ring only im proved the cou pling ef fi ciency be tweenthe two coils mak ing the ex peri ment more prac ti cal toper form, and given suf fi cient pri mary cur rent it could be dis pensed with. This is the case in noninvasive mag -netic stimu la tion where the stimu lat ing coil acts as onecoil, space as the me dium for the flow of the mag neticfield and the elec tri cally con duc tive liv ing body as thesec ond coil.

In 1896 d’Ar son val [C R Soc Biol; 1896, 3: 450- 51] re -ported phos phe nes (flick er ing lights in the vis ual field)when plac ing his head in a coil driven from an al ter nat ing 110 volt sup ply at 30 am peres. It is now known that thiswas due to the di rect stimu la tion of the ret ina. Bick fordand Frem ming in 1965 [Di gest 6th Int Conf Med ElecBiol Eng, 1965, p112] dem on strated noninvasive mag -netic stimu la tion of fa cial nerves. In 1982 Pol son et al.pro duced a mag netic stimu la tor ca pa ble of pe riph eralstimu la tion and re corded the first mus cle evoked po ten -tial [Med Biol Eng Com put, 20: 243-4]. The tech nique of mag netic stimu la tion came of age in 1985 when Barker et al. in Shef field [Lan cet, 1985, 1106- 1107] achieved mag -netic stimu la tion of the hu man mo tor cor tex. For a more de tailed his tori cal re view the reader is re ferred to a pub li -ca tion by Ged des LA [J Clin Neu ro physiol, 1991, 8:1-9].

Pro gress has been rapid since 1985 with sev eral new ar -eas of re search us ing new de vel op ments. These in cludecoils with mul ti ple wind ings for ac cu rate stimu la tion;train of pulses for in traop era tive moni tor ing and treat -ment of de pres sion and other psy chi at ric dis or ders; useof fast re peti tive stim uli to de ter mine the lat er al ity ofspeech cen tres; and high en ergy stim uli to re start the fib -ril lated heart.


Figure 2: Magnetic stimuli are produced by passingstrong electric current pulses through a coil of wire.

Part 1: Fun da men tal and Tech ni cal As pects

Figure 3: The time varying magnetic field produces anelectric field surrounding the stimulating coil which in

turn induces small eddy currents in a conductive mediumsuch as the human tissue.

Figure 4: Magstim Model 200 shown above is amagnetic stimulator with a monophasic output pulse.

The unit weighs 17kg with the heaviest items being thestorage capacitor, transformers and thyristor.

Prin ci ples of Mag netic Stim u la tion

Mag netic nerve stimu la tors typ i cally con sist of twodis tinct parts: a high cur rent pulse gen er a tor pro duc -ing dis charge cur rents of 5,000 amps or more; and astim u lat ing coil pro duc ing mag netic pulses with fieldstrengths of 1 tesla or more with a pulse du ra tion ofsome 1ms.

The dis charge cur rent flow ing through the stim u lat -ing coil gen er ates the nec es sary mag netic pulse as isshown in Fig ures 2 and 3. This pulse in duces cur rentsin an elec tri cally con duc tive re gions, such as the hu -man body. If the in duced cur rent is of suf fi cient am -pli tude and du ra tion it will stim u late neuromusculartis sue in the same way as with con ven tional elec tri calstim u la tion.

The first com mer cial mag netic stimu la tors were pro -duced in Shef field in 1985. The Magstim Model 200 isbased on the orig i nal Shef field de sign and is re ferred toin this doc u ment to pro vide de tailed in for ma tion onreal sys tems used in mag netic stim u la tion. TheMagstim in Fig ure 4 con sists of a ca pac i tor charge/dis -charge sys tem to gether with the as so ci ated con trol andsafety elec tron ics. Using the charg ing cir cuitry the en -ergy stor age ca pac i tor is charged to a set level de ter -mined by front panel con trols up to a max i mum of2,800 volts (2.8kV). When the Magstim re ceives atrig ger in put sig nal the en ergy stored in the ca pac i toris dis charged into the stim u lat ing coil. The stored en -ergy, apart from that lost in the wir ing and ca pac i tor, is trans ferred to the coil and then re turned to the in stru -ment to re duce coil heat ing. The dis charge switchcon sists of an elec tronic de vice, which is called a thy -ris tor, is ca pa ble of switch ing large cur rents in a fewmi cro sec onds. Thyristors con duct cur rent only in


Circular 40mm Type 9594

Circular50mm

Type 9993

Circular70mm

Type 9762

Circular90mm

Type 9784

Double Small25mm

Type 1165

Double50mm

Prototype

Double70mm

Type 9925

DoubleCone

Type 9902

Inside Diameter (mm) 20 25 40 66 18 (x2) 34 (x2) 56 (x2) 96 (x2)

Outside Diameter (mm) 62 77 94 123 42 (x2) 74 (x2) 87 (x2) 125 (x2)

Number of Turns 21 18 15 14 14 (x2) 11 (x2) 9 (x2) 7 (x2)

Peak Magnetic FieldStrength (Tesla)

4.1 3.6 2.6 2.0 4.6 N/A 2.2 1.4

Peak Electric Field Strength (V/m)

530 600 530 530 660 N/A 660 N/A

Table 1: The physical characteristics and maximum calculated outputs of the coils used with the Magstim 200.

Figure 5: The above waveforms are those produced by thecircular 70mm Coil (see Table 1 for winding detail)

showing a fast rise and slow decay culminating in inducedcharge which depolarises the nerve.

one di rec tion and hence the MagstimModel 200 pro duces a monophasicdis charge cur rent with no cur rent re -ver sal. Monophasic dis charge cur -rents re duce heat dis si pa tion in thecoil, dis charge click noise, the stim u -lus arte fact and in crease stim u lus ac -cu racy. In ad di tion, the sta ble andwell de fined monophasic pulse al -lows for a better un der stand ing ofthe mech a nisms in volved in mag -netic nerve stim u la tion. The wave -forms of coil cur rent through toin duced charge are shown in fig ure 5for the 70mm cir cu lar coil (Type9762 in Ta ble 1).

Al though the fig ures usu ally quotedfor the to tal en ergy stored in mag -netic stimu la tors typ i cally range from 500J to 10kJ or more, the im por tantfac tor in the ef fec tive ness of a mag -netic nerve stimulator is the maxi mi -sa tion of the peak coil en ergy. Thiscan be achieved by us ing a large en ergystor age ca pac i tor and/or by hav ing anef fi cient en ergy trans fer from the ca -pac i tor to the coil. Typically 500J of en -ergy has to be trans ferred from theen ergy stor age ca pac i tor into the stim -u lat ing coil in around 100µs. Power,mea sured in watts, is equiv a lent tojoules per sec ond. From this, the im -pulse power out put of a typ i cal mag -netic stimulator dur ing the dis chargephase is 5,000,000 watts (5MW). Dur -ing the dis charge, en ergy ini tiallystored in the ca pac i tor in the form ofelec tro static charge is con verted intomag netic en ergy in the stim u lat ingcoil in ap prox i mately 100µs. This fastrate of en ergy trans fer is nec es sary toachieve a rapid rate of rise of mag netic field. The cur rent in duced as a re sultof the time vary ing mag netic field is inthe or der of 1-20mA/cm2 which is the same as that used in con ven tionalelec tri cal stim u la tion.

Since the mag netic field strength falls off with dis -tance from the stim u lat ing coil, the stim u lus strength is at its high est close to the coil sur face. The stim u la -tion char ac ter is tics of the mag netic pulse, such as

depth of pen e tra tion, strength and ac cu racy, de pendon the rise time, peak mag netic en ergy trans ferred tothe coil and the spa tial dis tri bu tion of the field. Therise time and peak coil en ergy are gov erned by theelec tri cal char ac ter is tics of the mag netic stimulator


Figure 5b: The above diagram shows the three main types of magnetic fieldoutput from stimulators together with their characteristics. Only one device

appears to utilise polyphasic output with the remainder using mono andbiphasic output in similar numbers. Some units have multiple output types.

Figure 5a: The above diagram shows the outputs of the three main types ofmagnetic stimulators. Conventional recharger and close interval pulse train

units have high output capability whereas rapid-rate stimulators have mediumoutput power at repetition rates of 10-30Hz. It must be noted that rapid-rate

trains of five or more pulses applied cortically have been shown to be capableof inducing seizures. This is, of course, not surprising as ECT is also capableof inducing seizures using similar parameters. Single stimuli delivered at lessthan 5Hz or pulse trains containing four or fewer pulses, on other hand are

highly unlikely to induce a seizure.

Mag netic stimu la tor types

and stim u lat ing coil, whereas the spa tial dis tri bu tionof the in duced elec tric field de pends on the coil ge -om e try and the anat omy of the re gion of in ducedcur rent flow.

Stimu lat ing Coils

The stim u lat ing coil, nor mally housed in moulded plas -tic cov ers, con sists of one or more tightly wound andwell in su lated cop per coils to gether with other elec -tronic cir cuitry such as tem per a ture sen sors and safetyswitches. The phys i cal de scrip tion of the coils usedwith the Magstim Model 200, which was de scribed ear -lier, to gether with the es ti mated mag netic and elec tri cal fields for these coils are shown in Ta ble 1 . The Magstim 200 is sup plied with a cir cu lar 90mm mean di am e tercoil as stan dard. This is most ef fec tive in the stim u la -tion of the hu man mo tor cor tex con trol ling the up perlimbs with a large cor ti cal rep re sen ta tion, and also inthe stim u la tion of spi nal nerve roots. To date cir cu larcoils with a mean di am e ter of 80-100mm have re -mained the most widely used in mag netic stim u la tion.

A 3D rep re sen ta tion of the mag netic field pro ducedon the sur face of a 90mm cir cu lar coil (Type 9784 inTa ble 1) is shown in Fig ure 6. In the case of cir cu larcoils it is im por tant to note that the in duced tis suecur rent is zero or near zero on the cen tral axis of thecoil and in creases to a max i mum in a ring ap prox i -

mately un der the mean di am e ter of the coil. Stim u la tion, there fore, is most likely to oc cur un der the wind ing andnot un der the coil cen tre. Dur ing the stim u lat ing phase,when the mag netic field is in creas ing from zero to itsmax i mum, the in duced tis sue cur rent flows in the op po -site di rec tion to the coil cur rent. In the case of theMagstim 200, all sin gle cir cu lar coils are marked withSide A and Side B. With the coil placed on the body andSide A vis i ble, the in duced tis sue cur rent flows in theclock wise di rec tion. With Side B vis i ble in duced tis suecur rent flows in the anti-clock wise di rec tion. The use ofthe cor rect coil side is par tic u larly im por tant in cor ti calstim u la tion as the hu man mo tor cor tex ap pears to bemore sen si tive when the in duced cur rent is flow ing from pos te rior to an te rior. Hence, with the coil placed cen -trally on the ver tex and Side A vis i ble, the in duced cur -rent pre dom i nantly stim u lates the left mo tor cor tex.With Side B vis i ble the ef fect is re versed.

Al though the 90mm cir cu lar coil is a very use ful gen eralpur pose coil, the site of stim u la tion is not well de -fined. The most no ta ble coil ad vance has been that ofthe dou ble coil (also termed but ter fly or fig ure ofeight coil). Dou ble coils uti lise two wind ings nor mallyplaced side by side. A 3D rep re sen ta tion of the mag -netic field pro duced on the sur face of a 70mm dou blecoil (Type 9925 in Ta ble 1) is shown in Fig ure 7.Typically dou ble coils range from very small flat coilsfor brain map ping work to large con toured ver sions


Figure 6: The 3D magnetic fieldprofile is shown below for the

circular 90mm coil (P/N 9784-00) shown on the left. The highestfield strength occurs near the

inner turn (2.0 Tesla peak field).

mm

Figure 7: The 3D magnetic fieldprofile is shown below for the

double circular 70mm coil (P/N9925-00) showing the interaction

between the two windings (2.2Tesla peak field).

MagneticField

Strength

mm

MagneticField

Strength

to stim u late deeper neu -ral struc tures in the brain.The main ad van tage ofdou ble coils over cir cu larcoils is that the in ducedtis sue cur rent is at its max -i mum di rectly un der itscen tre, where the twowind ings meet.

Two com mer cial coils, asin gle cir cu lar coil with a90mm mean di ame terwind ing (Type 9784 inTa ble 1) and a dou ble coilwith two 70mm mean di -ame ter wind ings (Type9925 in Ta ble 1), havebeen used to il lus trate themain dif fer ences be tweencir cu lar and dou ble coils.In Fig ure 8 the cal cu latedin duced elec tric field10mm be low the coil sur -face is plot ted against dis -tance from the coil cen tre. This shows that in thecase of the cir cu lar coilthe two peaks are sym met -ri cal about the cen tre andare of the same am pli tude.In the case of the dou blecoil, how ever, there is a cen tral peak with over twice theam pli tude of its pe riph eral peaks. That en ables the coilto pre domi nantly stimu late neu ral struc tures un der itscen tre.

How ever, the hy poth e sis that the dou ble coil onlystim u lates un der its cen tre should be viewed with cau -tion. As shown in Fig ure 8, there are also smaller pe -riph eral peaks of ap prox i mately half the am pli tude ofthe cen tral peak on ei ther side of the wind ing. Thesecal cu la tions re fer to an avail able com mer cial coilwhere prac ti cal re stric tions in con struc tion have beentaken into ac count. The chances of only stim u lat ingun der the cen tral axis can be in creased by stim u lat ingat, or just above, the thresh old level, but this can notbe guar an teed. In the case of cor ti cal stim u la tion,many neu ral fibres have to be stim u lated be fore a suf -fi cient de scend ing vol ley is gen er ated. The readi ness,and hence the stim u la tion thresh old, of in di vid ualnerve fibres in the mo tor cor tex var ies sig nif i cantlyfrom one re gion to the next. Thus nerve fibres un der

other parts of the coil wind ing ex posed to lower in ducedcur rents may also be stim u lated. With the dou ble coilplaced flat, how ever, the nat u ral cur va ture of the headhelps keep the outer edges of the wind ings away fromother area of the cor tex fur ther im prov ing the ac cu racyof the dou ble coil.

The Dou ble Cone Coil (Type 9902 in Ta ble 1; also seeFig ure 9) is a de vel op ment where two large cup shapedwind ings are po si tioned side by side with a flat cen tralsec tion and an gled sides closely fit ting the pa ti ent’s head. The ad van tage of this coil is that its ge ome try al lows forbet ter mag netic cou pling, giv ing sig nifi cantly higher in -duced cur rent in the cen tral fis sure (70% higher thanwith the 90mm cir cu lar coil). This coil is es pe cially use ful in the stimu la tion of the mo tor cor tex ar eas con trol lingthe mus cles of the lower torso and limbs.

Stim u lat ing coil con struc tion: The stim u lat ing coil is the only part of a mag netic nerve stimulator whichneeds to come close to, or into con tact with, the pa -


Figure 8: The induced electric field profile of single and double coils differ widely because oftheir geometry. The induced electric field of a circular coil is zero directly under its centre and reaches maximum approximately under the mean diameter. In the case of double coils it is at amaximum directly under the coil centre and has two smaller characteristic peaks on either side.

See Table 1 for winding details.

tient. Dur ing the dis charge of the mag netic pulse thecoil wind ing is sub jected to high volt ages and cur rents.Al though the pulse gen er ally lasts for less than 1ms, theforces act ing on the coil wind ing are sub stan tial and de -pend on the coil size, peak en ergy and con struc tion.Care ful coil de sign is, there fore, a very im por tant as pectin the con struc tion of a mag netic stimulator. Large coilsuti lise more cop per mass than a small coil and gen er allyhave a lower elec tri cal re sis tance. As a re sult less heat isdis si pated in their wind ings and be cause of their higherheat ca pac ity they re main us able for much lon ger pe ri -ods of time with out be com ing warm.

Cop per has been used as the high cur rent con duc tor incoil wind ings due to its low elec tri cal re sis tance, highheat ca pac ity, avail abil ity and a fair ten sile strength. Sil -ver has a lower re sis tance than cop per and hence therewould be less heat dis si pated within the coil dur ing thedis charge phase as a re sult of I2R re sis tive losses. Thebene fits are, how ever, off set by the sig nifi cantly lowerheat ca pac ity of sil ver re sult ing in the coil warm ing upmore quickly than cop per even though less heat hasbeen gen er ated.

Mag netic Field Strength vs. Stimu lus Strength

The most widely quoted fig ure re gard ing the out putof mag netic stimu la tors is the mag netic field strength.Al though it is an im por tant pa ram e ter, mag netic fieldstrength alone is a poor mea sure of mag neticstimulator per for mance. Mag netic field strength is de -fined as the mag netic flux den sity and does not re flectthe to tal mag netic flux pro duced by the stim u lat ingcoil over its to tal area. In a small coil where the mag -netic flux is con cen trated in a small area, the mag neticfield in ten sity will be higher than in a larger coil, butthe field falls off much more rap idly with dis tance.

Hence a small coil is some what more pow er ful in thestim u la tion of su per fi cial nerves and a large coil is moresuit able for struc tures at depth. The am pli tude, wave -form and spa tial char ac ter is tics of the in duced cur rent all play a role in mag netic nerve stim u la tion.

A more ac cu rate in di ca tor of the stimu lat ing power out -put is the in duced charge den sity per phase de fined asthe in te gral of the in duced cur rent den sity dur ing the rise time of the mag netic field. It pro vides a bet ter in di ca torof out put by tak ing into ac count the ef fects of both am -pli tude and du ra tion of the in duced stimu lat ing cur rent.It does not, how ever, take into ac count the ef fects of thenodal time con stant of the mye li nated nerve fi bre. Un -for tu nately the ac tual value of the in duced charge den -sity per phase is dif fi cult to cal cu late ac cu rately due tothe com plexi ties of the struc ture be ing stimu lated. Dif -fer ent ar eas, such as bone, fat, grey mat ter and whitemat ter with dif fer ing con duc tivi ties all af fect the in -duced cur rent and its path.

As well as bas ing a choice of coil on mag netic fieldstrength and in duced cur rent, the suit abil ity of a coil forits in tended ap pli ca tion must also be taken into ac count.As ex am ples the 90mm coil is very ef fec tive in bi lat eralstimu la tion of the phrenic nerve roots, the dou ble70mm is used for mono- hemispheric tran scra nial stimu -la tion, the cir cu lar 40mm coil is well suited to stimu la -tion at the Erb’s point, and the dou ble cone coil is mostpow er ful in cor ti cal stimu la tion of the lower ex tremi ties.


Magnetic Field Flow

Coil Cross Section

Coil Winding

Figure 9. The Double ConeCoil utilizes two angled

windings to improvecoupling to the head. Thissignificantly improves its

effective stimulating power. The coil is useful for

cortical stimulation of thelower limb areas.

Mag netic stimu la tion’s main abil ity is safely and eas ily tostimu late most neu ral struc tures, un im peded by fat andbone and with out dis com fort.The ma jor ity of the clini -cal ap pli ca tions for the tech nique are for the noninvasive stimu la tion of the pe riph eral and cen tral mo torpath ways. Other uses in clude stimu la tion of the left andright pre fron tal cor tex, vis ual cor tex, lan guage cen tre,cere bel lum and pe riph eral sen sory nerves.These ap pli -ca tions cover uses for di ag no sis, prog no sis, moni tor ingand ther apy. The fol low ing sec tions give an out line ofhow re sponses are ob tained and how their char ac ter is -tics are meas ured, to gether with sev eral sam ple ap pli ca -tions from op er at ing room moni tor ing to urol ogy.There is also a sec tion on safety with a con clud ing sec -tion of ref er ences.

Mo tor Evoked Po ten tials (MEPs)

Mag neti cally evoked mo tor po ten tials can be ob tainedby stimu lat ing neu ral tis sue such as the mo tor cor tex,spi nal nerve roots and pe riph eral nerves. Re sponses canbe re corded in the nor mal man ner us ing EMG orevoked po ten tial equip ment. In the case of mus cle ac -tion po ten tials av er ag ing is not gen er ally nec es sary be -cause of the size of the re sponse. De pend ing on there sponse size, nerve ac tion po ten tials may re quire av er -ag ing. Mag netic stimu la tion of a pe riph eral nerve, in thiscase the ul nar nerve, was pre vi ously shown in Fig ure 1.Us ing a more ac cu rate fig ure of eight coil the re sponsesin Fig ure 10 dem on strate the use of the Mag stim 200 tomeas ure the pe riph eral mo tor nerve con duc tion ve loc ity (NCV).

It is the stimu la tion of deeper and less ac ces si ble nerves,how ever, where the tech nique of mag netic stimu la tionex cels over con ven tional elec tri cal stimu la tion. Mo torevoked po ten tials from the left First Dor sal In teros se -ous (FDI) in re sponse to mag netic stimu la tion of head,neck, Erb’s point and the mo tor cor tex are shown in Fig -ure 11. Meas ure ments usu ally ob tained from the wave -forms tend to in clude con duc tion la tency, re sponseam pli tude (ei ther baseline to first peak, or peak to peakvalue), thresh old of stimu la tion. Other pa rame ters alsonoted, which are per haps used less fre quently in clude,mor phol ogy (number of re sponse phases), re sponsearea, power spec trum, si lent pe ri od, fa tigue and cen tralre cov ery time.

Fa cili ta tion: In the case of the cen tral nerv ous sys tem itis pos si ble to re duce the stimu la tion thresh old by ap -

proxi mately 25%, in crease the re sponse am pli tude 2-5times and re duce re sponse la tency by some 1- 3msthrough preactivation of the tar get mus cle (see Fig ure11 not ing the changes in scales). This tech nique, re ferred to as fa cili ta tion, has been de scribed in con sid er able de -tail by oth ers [e.g. Roth well et al. Re view ar ti cle. ExpPhysiol 1991, 76: 159- 200]. Where the pa tient is able tocon tract the tar get, the cli ni cian has the choice of re duc -ing the power level re sult ing in in creased pa tient com -fort. Ta bles of nor mal data are, how ever, avail able forboth re laxed and fa cili tated mus cles. The meas ure mentof con duc tion la tency with fa cili ta tion re quires sev eralsu per im posed re sponses to al low the de ter mi na tion ofex act take- off point.


Part 2: Clini cal As pects

5mV/Div

Stimulation atthe Elbow

Stimulation at the Wrist

5ms/Div

2ms/Div

1mV/Div

Stimulation atthe Elbow

Stimulation at the Wrist

3.20ms 7.36ms

Expanded View

Figure 10: Typical responses to peripheral magneticnerve stimulation are shown above and were recorded

over the first dorsal interosseous (FDI) muscle in the left hand. The ulnar nerve was stimulated at the elbow and

wrist using a double 30mm coil giving conductionlatencies of 7.36ms and 3.20ms respectively. The

distance between the two sites of stimulation was 24.5cm giving a healthy nerve conduction velocity of 59m/s. Thelower traces show expanded waveforms (note scales) to

highlight the take-off points.

MEP vari abil ity: From the very early days of cor ti calmag netic stimu la tion a con sid er able amount of re sponse vari abil ity has been noted, un like in pe riph eral stimu la -tion where re sponses are ac cu rately re peat able. Ini tiallythese were thought to be as a re sult of changes in coil po -si tion ing and power level varia tion from pulse to pulse.Care ful ex peri ments have, how ever, shown the vari abil -ity to be a real neu ro logi cal phe nome non as a re sult ofcon tinu ally chang ing ex cit abil ity of the cor tex. In factthe meas ure ment of this vari abil ity may also prove use -ful clini cally in cer tain dis or ders.

Cen tral Mo tor Con duc tion Time (CMCT): An es ti -ma tion of the cen tral mo tor con duc tion la tency can bemade by sub tract ing the cor ti cal to mus cle con duc tion la -tency from the pe riph eral con duc tion la tency. The pe -riph eral con duc tion la tency can be mea sured ei ther bymag netic stim u la tion of the spi nal nerve roots or by us ingcon ven tional F-wave tech niques where ap pli ca ble (seeFig ures 11 and 19 for ex am ple wave forms). The CMCT isab nor mal in many dis or ders of the ner vous sys tem and,to gether with the other pa ram e ters mea sured, forms theba sis for di ag no sis and as sess ment. There are nu mer ousnor ma tive and pa tient data avail able for many hu man


Figure 11: The set-up shown below allows the recording of motor evoked potentials. The example responses

shown on the right have all been recorded over the leftdorsal interosseous (FDI). From top to bottom: (a)

Stimulation at Erb’s point using the circular 40mm coil(see Table 1); (b) Stimulation at the neck with the 90mm

circular coil centred over C7; (c), (d) and (e)Stimulation of the motor cortex with the 90mm circularcoil placed centrally on the vertex - three superimposedresponses each. Responses (d) and (e) are facilitated byslight preactivation of the target muscle. Note that there

is a silent period after the compound motor potentiallasting over 100ms.

Magstim200

Interconnecting Lead

EMGInstrument

Stimulating Coil

mus cles or, if re quired, us ers can ob tain their own ta blesof data to suit their cir cum stances. Typically if theCMCT is out side mean plus two stan dard de vi a tions thecon duc tion is con sid ered ab nor mal.

Thresh old: The thresh old of stim u la tion (nor mally de -scribed as a per cent age of the max i mum power level of apar tic u lar stimulator man u fac turer and model) is gain ingpop u lar ity. It is also a sen si tive in di ca tor of ab nor mal ity incer tain dis or ders, es pe cially where CMCT can be nor mal,for ex am ple in stroke (tests for this dis or der are de scribedlater). Thresh old can be de fined as the power level atwhich a re sponse can be de tected 50% of the time and itcan be mea sured for both fa cil i tated and re laxed mus cles.Note that due to the vari a tions ex plained ear lier it is nec -es sary to re peat the stim u la tion a few times - three re -sponses out of six stim uli has been sug gested as astan dard. Mea sure ment of the thresh old of stim u la tion in

the dis or ders of the cen tral ner vous sys tem has the ad -van tage of re quir ing low power lev els and no pe riph eralstim u la tion. Its re peat abil ity and com fort eases lon gerterm as sess ment, for ex am ple in re ha bil i ta tion and drugther apy mon i tor ing.

Re sponse am pli tude: Whereas in pe riph eral stimu la -tion a su pra maxi mal stimu lus is gen er ally a re quire ment,a dif fer ent ap proach is taken for the stimu la tion of thecen tral nerv ous sys tem. Since it is not pos si ble to ob tainsu pra maxi mal re sponses evoked by cor ti cal stimu la tion,the am pli tude tends to be noted ei ther on its own or as ara tio of su pra maxi mal pe riph eral re sponse. In nor malsub jects this ra tio is above 50% for fa cili tated hand mus -cles but can be 5% or less in sev eral dis or ders such asstroke and mul ti ple scle ro sis.


Cortical Stimulation

Cortical Stimulation

Peripheral Response

Relaxed Muscle:Example CMCT = 23.8ms - 17.4ms = 6.4ms

Contracted Muscle:Example CMCT = 22.6ms - 17.4ms = 5.2ms

Figure 12: The central motor conduction time (CMCT)is typically measured by first stimulating the motor

cortex (top right) and then the relevant peripheral nerveas it exits the spine (right). The difference is the time ittakes for the impulse to travel from the motor cortex to

the spinal vertebral foramen. This time is commonlyreferred to as the CMCT. The responses shown abovewere obtained from the first dorsal interosseous (FDI)

muscle in the hand.

Coil Current

Stimulating Coil

Descending Nerve

Impulse

Lim i ta tions: It should be noted that the tech nique ofmag netic stim u la tion has cer tain lim i ta tions. It hasnot yet proved pos si ble di rectly to stim u late the spi nal cord al though this may be come pos si ble through thede vel op ment of new spe cial ised coils and puls ing ar -range ments. It is thought that the bone and car ti lagesur round ing the cord im pedes in wards cur rent flowfrom the out side and that the spi nal cav ity it self doesnot have a large enough area to al low suf fi cient in -duced cur rent. Cor ti cal and spi nal root stim u la tion,how ever, over come this lim i ta tion in most clin i caluses (as an ex am ple see sec t ion on cer vi calspondylosis).

While the Dou ble 25mm Coil does not re place all thestan dard MCV and SNCV tests, mag netic stim u la tionhas be come a s r e l i ab l e a s con ven t iona le l e c t roneurog raphy in the a s s e s s men t o fdemyelinating neuropathies, with less dis com fort anda shorter ex am i na tion time. Mag netic stim u la tion isof par tic u lar use in the non-in va sive stim u la tion ofdeep nerves and es pe cially spi nal nerve roots such asthe phrenic nerve where elec tri cal stim u la tion is bothvery pain ful and some times un re li able.

Mag netic Pulse Pairs with a timed stim u lus in ter valcan be ef fected ei ther through a sin gle coil or throughtwo in de pend ent coils. There are a num ber of op tionspro vided to match most needs.

A Magstim Model 250 unit can de liver two in di vid ualpulses through one coil at a pre de ter mined interstimulus in ter val from 1.0ms to 99.9ms in 0.1ms steps, with bothpulses at the same power level. The re sult ing MEP’swill show a fa cil i tated re sponse. The pulses can besummated to pro vide a sin gle high power pulse.

The BiStim set-up pro vides the flex i bil ity to evoke ei -ther an in hib ited or a fa cil i tated re sponse, or to de liver two pulses through one or two coils. The set-up uti -lises two Magstim Model 200 units and a BiStim Mod -ule.

De livering two pulses through one coil main tains thesame in duced cur rent flow (see Fig ure 13). Using theBiStim Mod ule it is pos si ble to ad just both the powerlevel and the tim ing of each pulse in de pend ent of each other. In the case of cor ti cal stim u la tion the site ofstim u la tion may not re main the same, as the first pulse can ac ti vate both in hib i tory and facilitatory mech a -nisms and mod ify the thresh old and readi ness ofother sites to stim u la tion by the sec ond pulse. Forthis rea son most stud ies us ing mag netic pulse pairs

have used dou ble coils for se lec tive stim u la tion. TheBiStim Mod ule is al low ing the de tailed study of the in -hib i tory and facilitatory mech a nisms of the brain andspi nal cord.


Figure 13: Magnetic pulse pairs can be produced usingthe BiStim Module which routes the output pulses from two

individual Magstim 200 units into one stimulating coil.Typically a time interval of between 1ms and 50ms is

chosen. Depending on the inter-pulse spacing and powerlevel magnetic pulse pairs applied to the central nervoussystem may produce inhibitory or facilitatory effects. The

responses below show the facilitatory effects of pulse pairs when stimulating cortically. Both responses were recorded from the left tibialis anterior using the Double Cone Coil(see Table 1 for details) placed at the vertex (50% power

level).

200µV/Div

10ms/Div

Single StimulusResponse

Dual StimulusResponse

4ms PulseSeparation

Right TibialisAnterior

30.4ms

200µV/Div

Sen sory Evoked po ten tials (SEPs)

Mag netic stimu la tion can also be used to stimu late sen -sory nerve fi bres. The re sponse can be re corded oversen sory nerves and av er aged in the nor mal man ner. Thead van tage of mag netic stimu la tion over elec tri cal is thatof com fort. The dis ad van tage is the fact that stimu lat ingcoils may warm up bef ore the end of the data ac qui si -tion. Mag netic sen sory evoked po ten tials, so far rela -tively un com mon, are gain ing popu lar ity as coilsim prove and pulse repe ti tion rates in crease. A typi calsen sory re sponse to mag netic stimu la tion at the wrist isshown in Fig ure 14. Ow ing to the small sig nal size care -ful ar range ment of re cord ing elec trodes is nec es sary toavoid stimu lus ar te fact in ter fer ence.

Sam ple Ap pli ca tions

The fol low ing sec tions pro vide a va ri ety of sam ple ap -pli ca tions cov er ing pe riph eral, spi nal nerve root andcor ti cal stim u la tion. For fur ther in for ma tion on thesam ple ap pli ca tions and other ar eas not cov ered in thisguide the reader is also re ferred to the ref er ence sec tion start ing on Page 27.

Op er ating Room Mon i toring

The stan dard method of op er at ing room (O.R.) mon i -tor ing, where the cen tral ner vous sys tem or spi nalnerve roots are at risk, has so far been that of sen soryevoked po ten tials (SEPs). The tech nique of re cord ingSEPs can not, how ever, be used to mon i tor the cen tralmo tor path ways di rectly. As a re sult dam age to the mo -tor sys tem may go un no ticed leav ing the pa tient at ahigher risk of post-op er a tive dis abil ity. O.R. mon i tor -

ing of mo tor path ways has, there fore, be come anim por tant goal.

With the pain as pects of stim uli be ing largely un im por -tant dur ing sur gery, where pos si ble elec tri cal stimu la tion has been used to stimu late mo tor nerves. This tech niquehas proved quite suc cess ful in the case of some pe riph -eral nerves and is al ready in wide spread use dur ing ap -pro pri ate sur gi cal pro ce dures. One ex am ple is fa cialnerve moni tor ing dur ing acous tic neu roma brain tu -mour sur gery.

Di rect elec tri cal stim u la tion of the cen tral ner vous sys -tem, how ever, poses im por tant prob lems be cause ofbone and the depth of tis sue to be stim u lated. These ob -sta cles mean that large cur rents are re quired to stim u latewith po ten tial for elec trode burns. In ad di tion the needfor di rect elec tri cal con tact with the pa tient in creases therisk of elec tric shock through the mal func tion of thestimulator and/or other equip ment in con tact with thepa tient. Mag netic stim uli on the other hand have no


20µV/Div 2.40ms

Stimulus Artefact

1ms/Div

Figure 14: Responses from sensory nerves can also berecorded using magnetic stimulation. The above averagedresponse (8 sweeps) is recorded over the index finger after

magnetic stimulation of the median nerve at the wristusing a Double 20mm Coil with the Magstim set at 75%

power level.

• A sin gle pulse train is all that is needed for bi lat -eral lower limb re sponses; no av er ag ing is re -quired. Re sponses can be ob tained regu larly.

• Un like with SEPs the mo tor tract is moni tored.The pro cess is noninvasive and can be car ried out at regu lar in ter vals.

• The set- up is sim ple and fast us ing con ven tionalsur face pick- up elec trodes. Epidural elec trodes,prone to mis place ment, are not re quired.

• The stimu lat ing coil, un like elec tri cal stimu la -tion, makes no elec tri cal con tact with the pa tientmini mis ing risk of elec tric shock or burns.

• Ad di tion ally mag netic stimu la tion can be usedpre- operatively for base line data and di ag no sisand post- operatively for prog no sis.

• When used to gether with SEPs the spi nal cord ismoni tored in both di rec tions by two in de pend entsys tems in creas ing re li abil ity.

Why Take the Mag netic Train Route in O. R. Moni tor ing?


O.R. Monitoring

Deep Per oneal Nerve

Figure 15: The above drawing shows one of the many possible O.R. monitoring set-ups during spinal surgery. Th e DoubleCone Coil, specifically designed to obtain good lower limb responses, is centred over the motor cortex and is used to deliver

the magnetic pulse. The coil can either be fixed into position using a variety of clamping arrangem ents or brought intocontact as and when monitoring is required. In this case recordings are made from Tibialis Anterior where clear signals ofup to 1mV p/p may be expected. Hand responses can also be recorded to act as controls. Although the painless aspects of

magnetic stimulation are no longer important with the patient under anaesthesia, it is possible to directly compare responses with pre- and post-operative data obtained using the magnetic stimulator. Additionally the lack of direct contact with the

patient eliminates the risk of electrode burns possible with high power electrical stimulators.

Figure 16: Example Responses obtained using the Magstim QuadroPulse, Train of Four Magnetic Stimulator, together withthe set-up shown in the previous figure. Single or double pulses produced no responses (when using propofol based

anaesthesia) whereas three and four pulses produced large amplitude motor evoked potentials. The advantage of three pulsesover two are clear-cut whereas the advantage of four pulses over three becomes apparent only in the more difficult cases.

Waveform reproduced with the kind permission of Dr. Lavern Gugino.


Fig ure 16a: The above draw ing shows a pos si ble set-up for mon i tor ing up per limbs dur ing cer vi cal sur gery. In con trast to themon i tor ing of lower limbs where the dou ble cone coil was used, the most suit able coil for re c ord ing up per limb re sponses isthe curved round coil. The use of epidural elec trodes is not nec es sary but is shown here to dem on strate al ter na tive re cord ing

tech niques. Re sponses can be re corded us ing con ven tional evoked po ten tial equip ment.

Fig ure 16b: Re sponses ob tained us ing the Magstim QuadroPulse, Train of Four Mag netic Stimulator, to gether with the set-upshown in the pre vi ous fig ure. Re sponses re pro duced with the kind per mis sion of Dr. Lavern Gugino. The two se quence of

traces show the sta bil ity of re sponses from one stim u lus train to the next and over a pe riod of 30 min utes. The in ter laced traces show al ter nate re sponses ob tained with the po lar ity of the mag netic pulse re versed from one pulse to the next.

Surgery

diffi culty pass ing through bone an use much lower cur -rent lev els of around 20mA/cm2, in stead of the 1A/cm2

of elec tri cal cor ti cal stimu la tors. Ad di tionally mag neticstim u la tion’s non-in va sive and more com fort able char -ac ter is tics give the ad van tage of al low ing a pre-op er a tive base line to be es tab lished and a post-op er a tive as sess -ments to be car ried out. This en ables mean ing ful com -par i sons to be made be fore, dur ing and af ter sur gery.

Cor ti cal mag netic stim u la tion in the awake sub ject typ i -cally pro duces a de scend ing vol ley con sist ing of sev eralin di rect waves (I-waves) with 1-3ms sep a ra tion. The de -scend ing vol ley summates and trig gers the spi nal al phamotoneurone with the im pulse lead ing to the mus clewhere the mus cle ac tion po ten tial (MAP) is re corded inthe nor mal man ner. With most an aes the sia, how ever,the I-waves are sig nif i cantly re duced in num ber or are

elim i nated com pletely. With the ad vent of shortinterpulse mag netic pulse trains it has be come pos si bleto mimic the nat u ral de scend ing vol ley even dur ing de -pres sive an aes the sia which would nor mally re duce orelim i nate the I-waves. The tech nique uti lises tem po ralsum ma tion at the spi nal al pha motoneurone to pro ducethe MAP in dis tal mus cles. This en ables the use of morecom mon an aes thetic agents, such as propofol, and pos -si bly even with in ha la tion agents.

Work by Tay lor et al. [J. Neu rol, Neu ro surg & Psy chiat,1993, 56: 104- 106] dem on strated the bene fits of us ingelec tri cal pulse pairs for spi nal MEPs. Tem po ral sum -ma tion at the spi nal level sig nifi cantly en hanced theMEP re sponse al low ing the use of “good sur gi cal an aes -the sia”. This tech nique was then ex tended suc cess fullyto the use of the BiS tim Mod ule with a Dou ble Cone


Figure 17: Block diagram of the Magstim QuadroPulse 500. Two independent charger systems feed four capacitor banks.These capacitors can be fired in a sequence to produce closely spaced trains of up to four pulses, or in combination to produce

very high power levels. Control of the instrument can either be via the hand-held unit or from an external source such as acomputer. There are a selection of stimulating coils to perform different tasks all of which can be held in position using the

supplied floor standing coil clamp. The instrument can be used pre-, intra- and post-operatively to establish baseline, monitorand then assess outcome.

• Con ven tional sin gle pulse mag netic stimu la torscan only be used for re li able mo tor tract moni tor -ing if spe cial an es thetic regi men are used (e.g.based on eto mi date and/or keta mine). More com -mon an es the sia such as pro po fol tend to oblit er -ate lower limb re sponses. Ex peri ments show thatthe D- wave re mains in tact but the I- waves are re -duced in number and am pli tude. Epidural elec -trodes can, there fore, be used to rec ord theD- wave di rectly.

• Tem po ral sum ma tion can be used with trains oftwo or more pulses to get mus cle re sponses withmore com mon an es the sia. The Mag stim Quad ro -Pulse is unique in that it is ca pa ble of very closelyspaced trains (1ms+). Us ing a train of four, in ter -pulse spac ings of around 3ms ap pear to be op ti mal giv ing ro bust MEPs with pro po fol based an es the -sia. Large am pli tude bi lat eral re sponses are ob -tain able with sin gle stim uli trains with outav er ag ing.

Op tions for Op er at ing Room Moni tor ing

Coil (see Ta ble 1) [Tay lor et al. 5th Int. Symp. on Spi nalCord Moni tor ing, Lon don 1992. In Press]. A pulse sepa -ra tion of 2ms was used with pro po fol as the main an aes -thetic. Large mo tor evoked po ten tial re sponses(~1mVp/p) were pres ent when us ing mag netic pulsepairs and ab sent with a sin gle pulse, clearly dem on strat -ing the bene fit of us ing paired stim uli. The stimu la tionand re cord ing sites were over the ver tex and tibi alis an te -rior mus cle re spec tively. An ex am ple of the fa cili ta tionpos si ble in an awake sub ject was shown in Fig ure 13.

As a re sult of the work with the BiS tim Mod ule, a newgen era tion of mag netic stimu la tor ca pa ble of longertrains with higher out put power was de vel oped. This in -stu ment, Mag stim Quad ro Pulse, is ca pa ble of very closein ter val (1ms+) trains of up to four pulses. With theO.R. set- up shown in Fig ure 15, it has proven pos si ble to ob tain clear, sta ble and large re sponses bef ore, dur ingand af ter spi nal sur gery. Ex am ple re sponses are shownin Fig ure 16. The block dia gram is shown in Fig ure 17.

Mag netic stimu la tors are also used for the pur pose ofO.R. pe riph eral nerve moni tor ing of cer tain cra nial andpe riph eral nerves (e.g. fa cial nerve), where an aes theticef fects are less im por tant [Thum fart WF et al. Ann. Otol. Rhin. Laryng, 1992, 101: 629- 634]. The ad di tional depthof pene tra tion in mag netic stimu la tion of ten al lows thestimu la tion of nerves not read ily ac ces si ble to con ven -tional elec tri cal stimu la tion. Fur ther in for ma tion re gard -ing the stimu la tion of fa cial nerve can be found on Page21.

Cer vi cal Spondylosis

Mag netic stimu la tion is also used in the early di ag no sisand as sess ment of spi nal dis or ders such as Cer vi calSpon dy lo sis. The test ing pro ce dure is sim ple, takes lessthan 45 min utes to carry out in the ma jor ity of cases, andis vir tu ally pain less.

The tests are based on the fact that the mus cles in theshoul ders and arms are fed from dif fer ent cer vi cal nerveroots and that the ana tomi cal con nec tions are well un -der stood. Hence, by look ing at the re sponses af ter cor ti -cal and pe riph eral stimu la tion from care fully cho senmus cle groups, the prog ress of the im pulse can be moni -tored through the brain, spe cific nerve roots and nervetrunks.

The mus cles used in this ex am ple are the Bi ceps, typi -cally fed by C5, C6, and C7 nerve roots, and First Dor salIn teros se ous (FDI), typi cally fed by C8 and T1 nerve

roots (see Fig ure 18). This choice al lows the dif fer en tia -tion be tween up per and lower cer vi cal dis or ders.

The stimu lat ing coil is used cor ti cally and re sponses areob tained from the left and right Bi ceps and FDI. Thecoil is then po si tioned over the cer vi cal nerve roots andat the Erb’s point and re sponses are once again re cordedfrom the left and right mus cles. In the case of the FDImus cles con ven tional F- wave re cord ings can also beused to dif fer en ti ate be tween cen tral and spi nal nerveroot le sions. Ex am ple re sponse wave forms are shown in Fig ure 19.

With cor ti cal stimu la tion the la ten cies from the Bi cepsand FDI com prise the Cen tral, nerve Root and Periph -eral con duc tion times (C+R+P). With the coil placedover the cer vi cal roots the meas ured la ten cies re late to


StimulatingCoil

Musculocutaneous Nerve

Biceps

Ulnarnerve

First DorsalInterosseous

C5, C6, C7C8, T1

Figure 18: In the above example responses can berecorded from the biceps and first dorsal interosseous to differentiate between upper and lower cervical disorders (see text below).For cortical stimulation the 90mm coilis placed directly over the vertex. For the stimulation of

cervical nerve root exits, the coil is positioned on themidline at the back of the neck at a height suitable for

the nerve root of interest.

the Periph eral seg ment of the mo tor path way (P) ex -clud ing the nerve root.

Sub trac tion of the sec ond la tency (P) from the first(C+R+P) gives the time taken for the im pulse to travelfrom the mo tor cor tex to the exit of the mo tor rootsfrom the in ter ver te bral fo ra men (C+R). This is re ferredto as the cen tral motor con duc tion time.

F- wave meas ure ments which in clude the spi nal nerveroots and the re flex cen tre can be com bined with mag -netic stimu la tion to cal cu late the ac tual cen tral mo torcon duc tion time and also to sepa rate out con duc tiontimes in the spi nal nerve roots. As an ex am ple, sub trac -tion of twice the dis tal con duc tion la tency, ob tained us -ing mag netic stimu la tion at the neck, from the sum ofthe F- wave and M- wave la ten cies gives the time takenfor the im pulse to travel through the spi nal nerve rootsand the re flex cen tre.

The la tency, am pli tude and wave form mea sure mentsare sen si tive in di ca tors of lo ca tion and se ver ity of cer vi -cal spine dis or ders. In ad di tion, com par i son of the re -sponses from left and right hand sides al lows thede ter mi na tion of the laterality of the ab nor mal ity. The test is used to in di cate, quan tify and mon i tor the prog ress ofthe spi nal dis or der, con firm ra dio log i cal and clin i cal find -ings, and also to in di cate the level of in volve ment of mo -tor path ways in pa tients with soft tis sue in jury.

Phrenic Nerve Stim u la tion

The Magstim is used for bi lat eral or uni lat eral phrenicnerve stim u la tion. Its ad van tages over elec tri cal stim u la -tion are ease of po si tion ing, re peat abil ity and much im -proved pa tient tol er ance. It is used re li ably to as sess thefunc tion of re spi ra tory mus cles by mea sur ing the di a -phrag matic re sponse and strength. The ease of ap pli ca -tion and pa tient com fort makes it pos si ble to also carryout lon gi tu di nal mon i tor ing stud ies. Mag netic stim u la tion can be used to ob tain re sponses even when the phrenicnerve can not be lo cated us ing con ven tional elec tri calstim u la tion.

The tech nique de scribed here has been used by theKings Col lege and Bromp ton Hos pi tals in Lon don.With the neck flexed the stan dard stim u lat ing coil is po -si tioned over the spineous pro cesses of C6/7 and themag netic stim u lus is given with the pa tient at FRC (seeFig ure 20). This al lows for bi-lat eral phrenic nerve stim -u la tion. The coil is moved up or down the midline un tilthe max i mum re sponse is ob tained. Oe soph a geal andgas tric pres sures are re corded from la tex bal loon cath e -

ters. Twitch di a phrag matic pres sure is then com putedby the sub trac tion of oe soph a geal from gas tric pres sure,us ing Pdi at FRC as the ref er ence point.

Uni lat eral phrenic nerve stimu la tion can also beachieved by us ing a small fig ure of eight coil placed at the side of the neck. Dia phrag matic mus cle ac tion po ten tials can then be re corded us ing sur face elec trodes placed inthe 7th and 8th in ter cos tal spaces. Re sponses ob tainedwhen us ing a dou ble small coil are shown in Fig ure 20dem on strat ing su pra maxi mal stimu la tion.

A de vel op ment is with two in di vid ual fig ure of eightcoils con nected to a BiS tim set- up al low ing al most si -mul ta ne ous dis charge for bi lat eral stimu la tion. The ad -van tage of this ap proach over a sin gle coil placed at theback of the neck is less cur rent spread and bet ter pa tientcom fort. The slight dis ad van tage is that the two coils


(a) Responses to supramaximalelectrical stimulation of the

ulnar nerve at the wrist.

(c) Responses tomagnetic stimulation atthe Erb’s point using the

Small 40mm Coil.

(d) Response to magneticstimulation at the C7 level using

the High Power 90mm Coil.

(b) As in (a) but with the verticalscale expanded to highlight the

F-wave response.

Figure 19: The example waveforms shown here have allbeen recorded over the left first dorsal inerosseous (FDI).Since the FDI muscle is fed by the ulnar nerve supplied bythe C8 and T1 nerve roots, the above measurements allowfor the assessment of lower cervical roots. Vertical Scale:5mV/Div for responses (a), (c) and (d) and 0.5mV/Div for

response (b). Horizontal scale: 5ms/Div.

need to be po si tioned in di vidu ally as is the case withelec tri cal stimu la tion.

Twitch Pdi meas ure ment may be used to con firm or re -fute the di ag no sis of bi lat eral or uni lat eral dia phragmweak ness. In pa tients with neu ro mus cu lar dis easeTwitch Pdi may per mit ac cu rate clini cal as sess ment ofdis ease prog ress. On go ing de vel op ments in clude the ad -ap ta tion of mag netic stimu la tion for use with neo natesor chil dren. Ad di tion ally, by meas ur ing pres surechanges in the mouth (Twitch Pmo) it is now pos si ble to ob tain a non- volitional meas ure of dia phragm strength. Urol ogy

Re cent ad vances in the di ag no sis and mon i tor ing of uro -gen i tal tract dys func tion have be come of in ter est to theUrol o gist, Neuro-Urol o gist and Urosurgeon alike. Thecon tri bu tion of the so matic fibres to the innervation ofthe lower gen i to uri nary tract is mar ginal com pared tothat of the au to nomic nerves. Mag netic stim u la tion al -

lows the in ves ti ga tion of cen tral mo tor path ways andau to nomic nerve func tion along side the more tra di -tional tech niques which look at so matic path ways only.

Pel vic floor mo tor evoked po ten tials (MEPs), in re -sponse to ei ther cor ti cal or pe riph eral stim u la tion, canbe re corded on stan dard EMG or evoked po ten tialequip ment. Re sponses can be picked up by con cen tricnee dle elec trodes from the mus cles con cerned (e.g.anal or periurethral sphincter, bulbocavernosus mus -cles, or detrusor mus cle), or by sphincter plugs con tain -ing sil ver plated elec trodes. Stim u la tion of the mo torcor tex gives an over all re sponse which in cludes con -duc tion along both the cen tral and pe riph eral por tionsof the mo tor path ways. As an ex am ple stim u la tion oflumbosacral nerves and roots, as shown in Fig ure 21, isalso pos si ble.

By sub tract ing the re sponse la tency to pe riph eral stim u -la tion from the re sponse la tency to cor ti cal stim u la tion,


10cmH2O

0.1 sec.

Poes

Pgas

Pdi

MagneticStimulation

PhrenicNerves

BilateralMagnetic

Stimulation

Latex BalloonCatheters

Poes

Pgas Pdi

EMGElectrodes

Figure 20: Above Right: Respiratory muscle responsescan be recorded using pressure measurements, EMGevoked potentials and ultrasound scans. In order to

stimulate the phrenic nerve roots the circular 90mm coilis centred over C7.

Above: Twitch responses resulting from electrical andmagnetic stimulation are shown above. These responses

were recorded using Validyne MP4-1 differentialpressure transducers (Validyne Co, Northbridge, CA).

Waveforms supplied courtesy of Professor John Moxham and Dr. Malcolm Green, Royal Brompton Hospital,

London, U.K.

Right: Supramaximal twitch response to unilateralmagnetic stimulation is obtained using a figure of eightcoil (Double 40mm Coil) placed at the side of the neck.Bilateral stimulation of the phrenic nerve can also beachieved using two Magstim units each feeding one

figure of eight coil.

200µV/Div

60%

70%

80% & 90%

10ms/Div

the cen tral mo tor con duc tion and spi nal root con duc -tion time is ob tained. The re sults can then be com -pared to ta bles of nor mal re sponses for in ter pre ta tion.Both con gen i tal and ac quired dis or ders such asmenigomyeloceles, mul ti ple scle ro sis, Parkinsons dis -ease, pel vic floor dis or ders in clud ing le sions of the sa cral cord, corda equina, the mo tor branch of the pudendalnerve, and frac tures of the pel vic bones, can be eval u -ated by this method. Re cent re search is re veal ing ex cit -ing pros pects for non in va sive con trol over blad deremp ty ing and blad der train ing.

Ad di tionally mag netic stim u la tion of the lum bar spinecan be used to re cord sen sory evoked po ten tials, for ex -am ple from the sen sory cor tex. The main ad van tage isthat of pa tient com fort where con ven tional elec tri calstim u la tion may be un bear able [Tsuji S, et al. Cor ti calSomatosensory Po ten tials Evoked by Mag netic Stim u la -tion of Tho racic and Lum bar Roots. Neu rol ogy, 1993,43: 391-396].

Stroke

The tech nique of mag netic stim u la tion is be ing used forthe prog no sis and mon i tor ing of stroke af fect ing thecen tral mo tor ner vous sys tem. When ap plied soon af terthe on set of stroke - within 7 days - it pro vides im por tant early data re gard ing the pros pects of re cov ery, es pe ciallymove ment. It is a quick test to con duct and its non-in va -sive na ture al lows for re peated use to mon i tor prog resswith out pa tient dis com fort.

Ac cu rate di ag no sis of stroke is cur rently achievedthrough clin i cal ex am i na tion and scan ning tech niques. It is, how ever, dif fi cult to de ter mine the pros pects for re -cov ery. Such in for ma tion is im por tant to de ter mine pa -tient need, ar range phys io ther apy where ap pro pri ate,and give rel a tives a more ac cu rate in di ca tor of re cov ery.

In its sim plest form mo tor evoked re sponses pres -ent on the pa retic side pre dict good re cov ery andan ab sence of any re sponse in di cates poor re cov -ery.

The test is sim ple and quick to carry out and whenneeded other pa ram e ters such as re sponse am pli tude,stim u la tion thresh olds and con duc tion la tency are alsode ter mined to al low finer prog nos tic dis tinc tions to beper formed. These mea sure ments also form the base -line data for long term mon i tor ing.

Stim u la tion: The ini tial ex am i na tion should be car ried out soon af ter the on set of stroke, pref er a bly within 7

days. Cor ti cal stim u la tion can be achieved through theuse of a va ri ety of coils. A cir cu lar coil is gen er ally used to re cord up per limb re sponses and the Dou ble Cone Coil(see Ta ble 1 for de tails) for lower limb re sponses.Typically coils are placed cen trally over the ver tex andthe stim u lat ing power is grad u ally in creased un til a re -sponse is ob tained. Typically two or more mus cles arestud ied in the hands and the legs for both the pa retic andnon-pa retic sides.

Thresh old: With the coil placed over the ver tex and thetar get mus cle re laxed, the thresh old of stimu la tion isnoted. The re sults are com pared ei ther with re sponsesfrom the non- paretic side or ta bles of nor mal data orboth. If it is not pos si ble to ob tain a re sponse from thetar get mus cle at high power lev els the pa tient is asked toat tempt to con tract the tar get mus cle to fa cili tate a re -sponse. Where col labo ra tion is dif fi cult to ob tain, fa cili -ta tion can be achieved by us ing the con tral lat eral side,the fa cial mus cles, or by us ing paired mag netic stim uli toin clude a fa cili ta tory pulse. In a number of pa tients nore sponse will be ob tain able even at maxi mum powerlevel. In such cases prog no sis will be poor.

Re sponse Am pli tude: Once the pres ence of a re -sponse has been es tab lished re sponse am pli tude, whichis also a sen si tive in di ca tor, is meas ured. Larg est re -sponses are ob tained with slight con trac tion of the tar get mus cle at around 20% above thresh old. Re sponse am -pli tudes, how ever, are quite vari able and de pend onother fac tors such as elec trode po si tion ing. Paired mag -netic stim uli can be used to halve the co ef fi cient of varia -


SciaticNerve

Pudendalnerve

Stimulating Coil

Site ofStimulation

Figure 21: The Magstim can be used for thestimulation of lumbosacral nerve roots. Here the

Double 70mm Coil (see Table 1 for details) is used to provide improved accuracy of stimulation.

tion of am pli tude, par ticu larly in con di tions where nocol labo ra tion is pos si ble. As bef ore, this meas ure mentcan be com pared ei ther with re sponses from the non- paretic side or ta bles of nor mal data or both.

The cen tral mo tor con duc tion time (CMCT) is cal cu -lated by sub tract ing pe riph eral la tency from the cor ti calto mus cle con duc tion la tency. Short est CMCTs aremeas ured with fa cili tated mus cles. There are nu mer ouspub lished ta bles of CMCT avail able for many mus clesthrough out the body. The CMCT is typi cally nor mal inthe case of cere bral stroke but can be ab nor mal withnon- cerebral stroke.

In ter pre ta tion of Re sults: A nor mal re sponse pre dictsgood and com plete re cov ery. Ab sence of a re sponse in -di cates poor re cov ery. Al though in some 5-10% of pa -tients with out an ini tial re sponse some de gree ofre cov ery is pos si ble, com plete re cov ery re mains un -likely. Ab nor mal thresh olds, small re sponse am pli tudesor a long CMCT all in di cate mo tor nerve in volve ment.The prog no sis is vari able to good de pend ing on thenumber of pa rame ters which are ab nor mal. Where mag -netic stimu la tion is car ried out in the first few days, there sults form the ba sis of a very early prog nos tic in di ca tor of mo tor re cov ery.

Other re lated ap pli ca tions: The abil ity of mag neticstimu la tion to non- invasively stimu late the mo tor cor tex al lows it to be used for a va ri ety of other cen tral mo tordis or ders and in ju ries to com ple ment other tech niques.

Coma: Simi lar meas ure ment tech niques to that de -scribed in this sec tion also ap ply in co ma tose pa tients,with the ex cep tion of vol un tary ef fort to fa cili tate re -sponses. Sev eral fa cili ta tion tech niques have beenshown to also work with un con scious pa tients. These in -clude the use of ten don vi bra tor and mag netic pulsepairs and pulse trains to pro duce tem po ral sum ma tion.In a case study it proved pos si ble to ob tain dis tinct re -sponses from the pa tient in full coma and se dated withflunitrazepam.

Fa cial Nerve

Mag netic stim u la tion has been used for across-the-le -sion test ing of the fa cial nerve func tion. It com ple -ments MRI by look ing at the func tion in stead of theanat omy of the nerve. Both cor ti cal and pe riph eral mo -tor ar eas as well as the intracranial part of the fa cialnerve can be as sessed. Coil po si tion ing for pe riph eralstim u la tion of the fa cial nerve and typ i cal re sponses are shown in Fig ure 22 us ing the cir cu lar 50mm coil (see

Ta ble 1). The ac tual site of pe riph eral nerve stim u la tionwas shown to be in the lab y rin thine seg ment of the fa cialca nal [Rösler et al. EEG, 1991, Suppl 43: 362-368]. Cor ti -cal stim u la tion can also be achieved through the use ofthe same coil placed over the contralateral mo tor cor texal low ing the cal cu la tion of the cen tral mo tor con duc tion time. This method makes it pos si ble to as sess the mo torroutes to the fa cial mus cles over dis tinct seg ments and to pro vide ev i dence of fa cial nerve le sions lo cated in the fa -cial ca nal at an early stage, such as in Bell’s Palsy.Transcranial cen tral stim u la tion of the trigeminal,hypoglossal and ac ces sory mo tor path ways andextracranial stim u la tion is also pos si ble. Clin i cal uses forthese tech niques in clude the pre-op er a tive as sess mentof fa cial nerve in volve ment in pa tients with acous ticneurinomas which can be de tected by transcranial mag -


Stimulating Coil Position forPeripheral

Stimulation ofthe Facial nerve

4.56ms

2ms/Div

200µV/Div

Figure 22: Peripheral stimulation of the facial nervecan be achieved at low power levels by the placing thecoil centred above the ear. This technique can be usedfor diagnosis as well as for intra-operative monitoringpurposes where anaesthetic effects are less important

than with the stimulation of the central nervous system.Typical responses recorded over the frontalis muscle

using the Small 50mm Coil are shown below.

netic stim u la tion even in pa tients with small and me -dium sized tu mours but with clin i cally nor mal fa cialfunc tion.

Rapid- Rate Mag netic Stim u la tion

Warn ing: Rapid rate cor ti cal stim u la tion can in duce sei -zures even in healthy sub jects! See guide lines by Was ser -mann EM. Electroencephalogr Clin Neurophysiol, 1998,108:1-16.

Fol low ing on from ear lier re search with re pet i tivetranscranial mag netic stim u la tion (rTMS) in 1990, one ofthe first pa pers to draw at ten tion to the po ten tial of thistech nique was “In duc tion of speech ar rest and count inger rors with rapid transcranial stim u la tion”, Pascual-Le -one et al. Neu rol ogy,1991;41:697-712 Trains of stim uli of25Hz last ing up to 10 sec onds were used to de ter mine thelaterality of the speech cen tres prior to neu ro sur gery as an al ter na tive to the wada test. More re cent pro to cols haveevolved us ing much slower rep e ti tion rates. The use ofrapid-rate stim u la tion has been ex tended to other cog ni -

tive stud ies and treat ment pro ce dures for psy chi at ricdis or ders such as de pres sion, schizo phre nia, ep i lepsy,Par kin son’s dis ease and pain re lief. Re pet i tive stimu la -tors are also pro vid ing a role for pe riph eral stim u la tionfor the re lief of spasticity in both stroke and mul ti plescle ro sis, in mus cle stim u la tion to sim u late a cough inspi nally in jured pa tients, to look at mus cle strength, fa -tigue and re cov ery, and aid ing in the maintainance ofmus cle bulk dur ing a pe riod of in ca pac ity. With Urol -ogy it may be an aid in the as sess ment and mon i tor ingof uri nary tract disfunction with the faster rates re duc -ing data ac qui si tion times, al low ing fa tigue stud ies, andper form ing mus cle ther a pies. New clin i cal pa pers areemerg ing which point the way to ad vanced ap pli ca -tions for re pet i tive stim u la tion both in di ag no sis andther apy.

At this stage it is im por tant to re mem ber that ef fects ofstim u lat ing the cor tex with re pet i tive stim u la tion mayhave im por tant safety con sid er ations and re sults maynot be as an tic i pated even if es tab lished pro to cols arebe ing used [Pascual-Le one et al. Lan cet, 1992, 997].Con sid er able work is, how ever, be ing put into quan ti -


Figure 23: Modern day rapid-rate magnetic stimulators are capable of up to 50Hz and custom devices can reach 1 00Hz oreven 1000Hz for brief trains. Risks, in particular that of inducing a seizure, have increased in line with stimulus repetitionrates. Fortunately the benefits have also increased now including potential treatment for various debilitating disorders. In

order to ensure that the correct ‘dose’ is delivered at least one of the rapid-rate equipment allows predetermined power level,frequency, train duration and, last but not least, the interval between trains. The computer screen shown above allows directcontrol over these parameters. In the case of the above software, the minimum interval between trai ns has been set to three

times the train duration or 3 seconds minimum. This can be adjusted as clinical details emerge.

fy ing the risk and de vel op ing treat ment strat e gieswhich mini mise the risk of sei zures and other pos si bleside-ef fects. (See also sec tion on Safety and Pre cau tions)

Of course sei zures are in duced dur ing treat ment of de -pres sion us ing ECT (elec tro con vul sive ther apy) andmany de part ments have the means of cop ing with a sei -zure. It has al ways re mained pos si ble that, given a suf fi -cient number of mag netic stim uli at a high stimu lusstrength and repe ti tion rates, a sei zure can be in duced.Thus, if the po ten tial bene fit of a par ticu lar treat mentout weighs the risk, then the risk of in duc ing a sei zure can be re duced by each or a com bi na tion of the fol low ingmeas ures:

(a) Stimu late at 90% or less than mo tor thresh old,(b) Stimu late at the low est fre quency pos si ble,(c) Stimu late away from mo tor cor tex ar eas,(d) Use a fo cal coil for less cur rent spread,(e) Stimu late for as brief a pe ri od as is pos si ble,(f) Al low suf fi cient re cov ery time af ter each train.

Re peti tive stimu la tion equip ment is now avail able fromall ma jor mag netic stimu la tion manu fac tur ers some ofwhom have safety fea tures built into their con trol pro -grammes, and al low ac cu rate dos age to be de ter mined,with the three main pa rame ters be ing : power level,fre -

quency and train du ra tion (or pulse number). A com -puter screen from one of the rapid- rate in stru ments isshown in Fig ure 23. Fur ther de vel op ments in the in ter -est of op era tional use and safety per mit pro to cols to bein stalled or writ ten to speci fi ca tion and pre cisely de liv -ered. These pro to cols will auto mati cally be up- datedwith safety pa rame ters built into the pro gramme. The in -for ma tion about sub ject, date, time, fre quency, powerlev els, train du ra tion etc. is auto mati cally logged ontohard disc for later re call and analy sis, or can be printed tohard copy if re quired. A con trol screen of the Ses sionSoft ware pro to col con trol ler is shown in fig ure 24.

The high level of in ter est now shown in TMS and rTMShas led to the for ma tion of the In ter na tional So ci ety forTran scra nial Stimu la tion, ISTS, which will be come arep re sen ta tive and sup por tive body, co- ordinating de -vel op ments at both the sci en tific and regu la tory level.The In ter na tional Fed era tion of Clini cal Neu ro physi ol -ogy has ap pointed a Spe cial Com mis sion to make rec -om men da tions for the world- wide use of TMS and theAmeri can Ac adamy of Neu rol ogy has ap pointed a Com -mis sion to evalu ate the clini cal use ful ness of TMS and to de velop a po si tion state ment for the AAN on the is sueof rec om men da tions for the tech nol ogy.


Figure 24: Magstim Rapid Session Software. The software allows the user to define, compile, edit and deliver a magneticnerve stimulation protocol specifically configured for individual needs. Up to 999 session files can be produced and monitored

either by number or by file name.This system gives total control and flexibility to create, store and recall or incorporate,patient specific or established protocols.


SheffieldMagstim

90mm Coil

Circular 50mm

Type 9999



Double 70mm Type 9925

Magnetic Field Strength (T) 1.4 2.8 2.0 1.5 1.6

Electric Field (V/m) 260 360 400 410 540

Induced Current Density PerPhase (mΑ/cm2/ph)

9 13 14 14 19

Induced Charged DensityPer Phase (µC/cm2/ph)

0.8 0.71 0.85 0.94 1.1

Energy Deposited Per Phase(µJ/cm3)

1.8 2.3 3.0 3.5 5.3

Table 2: Estimated maximum exposure of the human brain to magnetic and electric fields, induced current and charge

Re lated Web Sites

http://www.ists.unibe.ch

http://www.musc.edu/tmsmir ror/TMSresrc.html

http://www.psy com.net/de pres sion.cen tral.tran scra nial.html

http://info.utas.edu.au/docs/healthsci/inro/lay in tro.html

http://info.utas.edu.au/docs/healthsci/ar ti cles.html

http://www.psych.hel sinki.fi128.214.75.169/mag stim.html

http://mem bers.aol.com/mag stim/

http://www.magstim- us.com (Starts June 1998)

Safety Pre cau tions & Is sues

The pres ence of pace mak ers and other elec tronic im -plants must be con sid ered as a con tra in di ca tion in caseof in ter fer ence due to the in duced elec tric fields and cur -rents re sult ing from the mag netic pulse. Al though thestimu lat ing coil does not have much ef fect on small me -tal lic ob jects, such as stain less steel an eu rysm clipsplaced a few inches away, it could ex ert a more sig nifi -cant physi cal force on larger metal ob jects within 20cmof the coil. Much de pends on the size of the ob ject, itscon duc tiv ity and whether or not it is fer ro mag netic.Data on mag netic ma te ri als such as credit cards andcom puter floppy discs can be ac ci den tally erased andcath ode ray tubes, es pe cially those with a col our mask,could be af fected if they were brought within some50cm of the stimu lat ing coil.

Stud ies with very pow er ful mag netic stimu la tors withen er gies of 10kJ or more, giv ing an or der of mag ni tudein crease in stimu lat ing power over con ven tional stimu -la tors, have shown that it is pos si ble to in duce an ec topicbeat in a dog’s heart [Bour land, et al. Med Biol Eng &Com put, 1990, 28: 196- 198]. It is not pos si ble, how ever,to di rectly af fect the hu man heart with any of to day’scom mer cial mag netic stimu la tor units due to their lim -ited dis charge en ergy, the dis tance from the coil to theheart and also the rela tively fast pulse rise time of themag netic field wave form. Clini cal mag netic de fi bril la -tors, how ever, re mains a pos sib lity for the fu ture.

Kin dling is a phe nome non whereby a per ma nent epi lep -tic fo cus is in duced by very many re peti tive stim uli givento the brain us ing im planted elec trodes. God dard et al.[God dard et al. Exp Neu rol, 1969, 25: 295- 330] were un -

able to in duce kin dling in ani mals at fre quen cies of lessthan 10Hz, ir re spec tive of the number of stim uli given.Us ing mag netic stimu la tors, with a maxi mum dis chargerepe ti tion rate of less than 1Hz, no risk of kin dlingshould ex ist. In ad di tion, the number of stim uli given toany one sub ject is very low com pared to the mini mumre quired to cause kin dling in ani mals. The risk of kin -dling in the case of fast re peti tive mag netic stim uli(10Hz) re mains un known.

In Ta ble 2 the cal cu lated fig ures of mag netic and elec -tric field strengths, in duced cur rent, charge den sity,and de pos ited tis sue en ergy are pro vided for theMagstim 200 to gether with the orig i nal Shef fieldMagstim. In the cal cu la tion of these pa ram e ters, usedfor con sid er ing the phys i o log i cal ef fects of the mag -netic stimulator on hu mans, it has been as sumed thatthe brain does not lie closer than 5mm to the coil sur -face. Other than in the case of ex posed brain thisshould nor mally be the case. A uni form con duc tiv ityvalue of 0.35S/m, that of grey mat ter in hu mans[Geddes & Baker, Med Bio Eng, 1967, 5: 271-293], hasbeen used in the cal cu la tion of in duced cur rent, chargeden sity per phase and en ergy de pos ited per pulse. Itshould be noted that these cal cu la tions are car ried outto es ti mate the max i mum ex po sure lev els and are likelyto be over-es ti mates.

There is lit tle ev i dence to sug gest that mag netic fieldsof the or der of 2T can have any harm ful ef fect. The cur -rent U.K. guide lines for whole body ex po sure to staticmag netic fields dur ing mag netic res o nance im ag ing is2.5T [NRPB, Ra dio graph 1984, 50: 220]. In ad di tion itshould be re mem bered that, in most cases, the out putfrom a mag netic stimulator lasts only 1ms and there isno ob vi ous rea son why purely mag netic ef fects fromsuch a pulse should be greater than from a static field.

The fig ures in Ta ble 2 show that the max i mum elec tricfield and in duced cur rent den sity are 540V/m and19mA/cm2 re spec tively. As ex pected these lev els ofex po sure are sim i lar to con ven tional elec tri cal stim u la -tion us ing sur face or nee dle elec trodes which haveproven quite safe. In ad di tion the in duced stim u lusfrom the mag netic stimulator is in her ently charge bal -anced, elim i nat ing the pos si bil ity of elec tro lytic celldam age in cases of pro longed stim u la tion. The fig ureof charge den sity per phase of 1.1µC/cm2/phase iswell be low the min i mum fig ure of 40µC/cm2/phase atwhich ev i dence of neu ral dam age has been found when stim u lat ing for long pe ri ods at 50Hz [Agnew et al.Neurosurg, 1987, 20: 143-147]. In ad di tion the to talcharge de liv ered is less than 0.1% of that used for


ECT. The max i mum cal cu lated fig ure of 5.3µJ/cm3

for the en ergy den sity per pulse dis si pated in tis sue isex tremely small, giv ing a tem per a ture rise of only 10-6Cin the tis sue. At a rep e ti tion rate of 1Hz, the to tal power dis si pa tion of less than 1mW for the whole brain ismore than four or ders of mag ni tude lower than theadult brain base met a bolic rate.

It has been sug gested by Coun ter et al. [Neu rol ogy,1990, 40: 1159-1162] that the dis charge click noise pro -duced by a 5cm stim u lat ing coil causes hear ing loss inal bino and chin chilla rab bits with the coil placed overthe ex ter nal au di tory meatus. The sound out put fromthe coil was mea sured to be as much as 157dB peakSPL. Barker and Stevens [Phys i ol ogy Soc, Lon don,1991, 19: 14P] mea sured sound out put from the stan -dard com mer cial coil (Type 9784 in Ta ble 1) sup pliedto gether with the Magstim 200 and found it to be amax i mum of 124dB(A) on the coil sur face fall ing to117dB(A) 50mm away from the coil sur face. These val -ues are within that re quired by the U.K. Noise at WorkReg u la tions (1989) as long as the num ber of dis chargesat the max i mum power level does not ex ceed 4000stim uli per day - clearly an un likely event. It should benoted that the dis charge click noise de pends on the coilsize (small coils are louder than larger ver sions), powerlevel and most im por tantly the man u fac tur ing method.

Low Fre quency Stim u la tion

Since 1985 many tens of thou sand of sub jects havebeen ex am ined us ing low rep e ti tion rate (<1Hz) mag -netic stimu la tors to as sess mo tor func tion of the pe -riph eral and cen tral ner vous sys tem. There is now acon sid er able vol ume of data sup port ing the safety ofmag netic stim u la tion. There have been no ill ef fects re -ported with mag netic stim u la tion of the pe riph eral ner -vous sys tem and in the case of cor ti cal stim u la tion thein ci dence of side ef fects has been ex tremely low andwell within that ex pected by avail able sta tis tics for var i -ous pa tient groups [Kandler R, Lan cet, 1990, 335, 1:469-70]. An area of con cern has been the trig ger ing ofepileptiform ac tiv ity in in di vid u als at a high risk to ep i -lepsy [Hömberg & Netz, 1989, 2: 113]. Nev er the lessone of the ar eas where mag netic stimu la tors have beensuc cess fully used has been in the study of ep i lepsy andthe de ter mi na tion of the site of the ep i lep tic fo cus[Hufnagel et al. Ann Neurol, 1990, 27: 49-60]. Over allmag netic stim u la tion has proved to be a very safe andef fec tive clin i cal tool.

High Fre quency Stim u la tion Guide lines

A r e cent pa pe r by Was se r mann EM[Electroencephalogr Clin Neurophysiol, 1998,108:1-16.] is rec om mended read ing as it de scribes thede vel op ment of a set of guide lines cov er ing the safety ofre pet i tive transcranial mag netic stim u la tion.

Copy Right No tice: Cop ies of this guide can be madeso long as the com plete guide is re pro duced with out al -tera tion and that it is not sup plied for any fi nan cial gain.Please note that this docu ment is up dated ap proxi mately once every year. For modi fi ca tions and cor rec tion please con tact:Reza Jali nous, Ph.D.E- mail: rjali nous@compu serve.comThe Mag stim Com pany Lim ited, U.K.Tel: +44 -1994- 240798Fax: + 44- 1994- 240061Re vi sion: March 1, 1998


1. Anaesthesia

2. Anaesthesia, Primate Studies

3. A.L.S. Disease

4. Ataxias

5. Audiology

6. Basic Principles, Technical Aspects

7. Basic Principles, Clinical Aspects

8. Bends (Decompression Sickness)

9. Brain Mapping

10. Brainstem stimulation

11. Cerebellum

12. Cerebral Ischemia

13. Cerebral Palsy

14. Clinical Applications and Reviews

15. Coil Configuration

16. Colorectal Disease

17. Coma

18. Computer Modelling

19. Diabetes

20. Dystonia

21. Electrical Versus Magnetic Stimulation

22. Electroconvulsive therapy

23. Epilepsy

24. Experimental Research

25. Facial Nerve

26. Facilitation

27. Gastroenterology

28. Guillain-Barré Syndrome

29. Hereditary Spastic Paraparesis

30. History and Background

31. Huntington’s Disease

32. Hysteria

33. Inhibition

34. Kallmann’s Syndrome

35. Locked-in-syndrome

36. Magnetic Pulse Pairs

37. Mirror Movements

38. Miscellaneous Diseases

39. Motor Cortical Inhibition

40. Motor Evoked Potentials

41. Motoneuron Disease

42. Multiple Sclerosis

43. Myoclonus

44. Neuropathy

45. Operating Room Monitoring

46. Pediatrics

47. Pain

48. Paraplegia

49. Parkinson’s Disease

50. Peripheral Stimulation

51. Plasticity

52. Psychiatry

53. Pulmonary Medicine

54. Rehabilitation and Therapy

55. Repetitive Transcranial Magnetic Stimulation

56. Research

57. Respiratory Medicine

58. Rett’s Syndrome

59. Safety

60. Silent Period

61. Sleep

62. Somatosensory Evoked Potentials

63. Speech - Wada Test

64. Spinal Disorders and Injuries

65. Stroke

66. Thoracic Medicine

67. Urology

68. Visual Cortex/Opthalmics

69. Wilson’s Disease


Part 3: Ref er ence List Or gan ised by Dis ci pline

What's New!

The following is a list of selected new papers added fromAugust 1996 through to December 1997. The same papers are also organised by discipline in some 69 sectionstogether with earlier selected papers. Where more recentpapers have been available, the majority of paperspublished before 1995 have been removed.

Abbruzzese G, Marchese R, Trompetto C. Sensory andMotor Evoked Potentials in Multiple System Atrophy: AComparative Study with Parkinson's Disease. MovementDisorders, 1997;12:315-321.

Alfonsi E, Merlo IM, Monafo V, Lanzi G, Ottolini A,Veggiotti P, Moglia A. Electrophysiological Study ofCentral Motor Pathways in Ataxia-Telangiectasia. J. ChildNeurol, 1997;12: 327-331.

Ashridge E, Walsh V, Cowey A. Temporal aspects of visual search studied by transcranial magnetic stimulation.Neuropsychologia, 1997;35:1121-1131.

Basting EP,Rapisada G, Pennisi G, Maertens de Noordhout A, Lenaerts M, Good DC, Delwaide PJ. Mechanisms ofhand motor recovery after strokes: An electrophysiologicalstudy of central motor pathways. J. Neuro Rehab1997;11:97-108.

Beckung E, Uvebrant P. Hidden dysfunction in childhoodepilepsy. Developmental Medicine and Child Neurology,1997;39:72-78.

Belmaker RH, Grisaru M, Ben-Shahar D, Klein E. TheEffects of TMS on Animal Models of Depression,ß-Adrenergic Receptors, and Brain Monoamines. CNSSpectrums, 1997;2:26-30.

Boroojerdi B, Diefenbach K, Ferbert A.Transcallosalinhibition in cortical and subcortical cerebral vascularlesions. Journal of the Neurological Sciences, 1996;144:160-170.

Brouwer B, Smits E. Corticospinal imput onto motorneurons projecting to ankle muscles in individuals withcerebral palsy. Developmental Medicine and ChildNeurology, 1997;38:787-796.

Brouwer B, Hopkins-Rosseel DH. Motor cortical mappingof proximal upper extremity muscles following spinal cordinjury. Spinal Cord, 1997;35:205-212.

Caramia MD, Gigli G, Iani C, Desiato MT, Diomedi M,Palmieri MG, Bernardi G. Distinguishing forms ofgeneralised epilepsy using magnetic brain stimulation.Electoenc. Clin. Neurophysiology, 1996; 98:14-19.

Caramia MD, Iani C, Bernardi G. Cerebral plasticity afterstroke as revealed by ipsilateral responses to magneticstimulation. Neuroreport, 1996;7:1756-1760.

Carr LJ. Development and reorganisation of descendingmotor pathways in children with hemiplegic cerebral palsy.Acta Paediatrica, 1996;85:53-57.

Carter N, Zee DS. The anatomical location of saccadesusing functional imaging studies and transcranial magneticstimulation. Current Opinion in Neurology, 1997;10:10-17.

Catano A, Houa M, Noel P. Magnetic transcranialstimulation: dissociation of excitatory and inhibitorymechanisms in acute strokes. Electroencephalography andclinical Neurophysiology, 1997;105:29-36.

Catano A, Noel P. Transcranial magnetic stimulation:Interest of the excitation threshold. Acta NeurologicaBelgica, 1997;97:61-61.

Cantello R, Gianelli M, Civardi C, Mutani R. Focalsubcortical reflex myoclonus: A clinical andneurophysiological study. Archives of Neurology,1997;54:187-196

Chen J, Hanusaik L, Ramses P, Schipp D, Anderson J,MacLean A, Nedzelski J. Comparative psychophysicalevaluation in cochlear implantation: Electrical andmagnetic stimulation. American Journal of Otology, 1997;18:39-43.

Chen R, Gerloff C, Hallett M, Cohen LG. Involvement ofthe Ipsilateral Motor Cortex in Finger Movements ofDifferent Complexities. Ann Neurol, 1997;41:247-254.

Chen R, Classen J, Gerloff C, Celnik P, Wassermann EM,Hallet M, Cohen LG. Depression of motor cortexexcitability by low frequency magnetic stimulation.Neurology, 1997;48:1398-1403.

Classen J, Schnitzler A, Binkofski F, Werhan K, Kim YS,Kessler KR, Benecke R. The motor syndrome associatedwith exaggerated inhibition within the primary motorcortex of patients with hemiparetic stroke. Brain,1997;120:605-619.

Cohen L, Brazin B, Sirigu A, Meininger V,Pierrot-Deseilligny C. Progressive upper limb monoparesis:a form of primary lateral sclerosis? Two cases withmetabolic brain imaging and transcranial magneticstimulation. European Journal of Neurology,1997;4:294-296.


Cohen LG, Celnik P, Pascual-Leone A, Corwell B, Faiz L,Danbrosla J, Honda M, Sadato N, Gerloff C, M.Dolores C,Hallett M. Functional Relevance of cross-modal plasticityin blind humans. Nature,1997;389:180-183.

Curt A, Diez V. Prognosis of spinal cord injury. Themeaning of clinical and electrophysiological findings.Nervenarzt, 1997;68:485-495. (German)

Craggs MD, Dinner L, Lovell AT, Knight SL, GoldstoneJC. Diaphragm function assessed by multipulse magneticstimulation of phrenic nerves in man. Journal ofPhysiology, 1997;501:53.

Davey NJ, Murphy K, Maskill DW, Guz A, Ellaway PH.Site of facilitation of diaphragm EMG to corticospinalstimulation during inspiration. Respiration Physiology,1996; 106: 127-135.

Davey NJ, Puri BK, Lewis HS, Lewis SW, Ellaway PH.Effects of antipsychotic medication on electromyographicresponses to transcranial magnetic stimulation of the motor cortex in schizophrenia. Journal of NeurologyNeurosurgery and Psychiatry, 1997;63:468-473.

Desioto MT, Caramia MD. Toward a neurophysiologicalmarker of amyotropic lateral sclerosis as revealed bychanges in cortical excitability. Electroenceph. clin.Neurophysiol., 1997;105:1-7.

Detsch C, Kochs E. Effects of Ketamine on central nervous system function. Anaesthetist, 1997;46:S20-S29. (German)

Edgley SA, Eyre JA, Lemon RN, Miller S. Comparison ofactivation of corticospinal neurons and spinal motorneurons by magnetic and electrical transcranial stimulation in the lumbosacral cord of the anaesthetized monkey.Brain, 1997;120:839-853.

Epstein CM, Lah JJ, Meador K, Weissman JD, Gaitan LE,Dihenia B. Optimum stimulus parameters for lateralizedsuppression of speech with magnetic brain stimulation.Neurology, 1996;47:1590-1593.

Feistner H, Awiszus F, Sailer M, Hinrichs H, Heinze HJ.A method for rapid response estimation of single humanmotorneurones to transcranial magnetic and peripheralelectrical stimulation. Z. EEG-EMG, 1996;27:80-84.(German)

Flor H, Elbert T, Knecht S, Weinbruch C, Pantev C,Birbaumer N, Larbig W, Taub E. Phantom limb pain as aperceptual correlate of cortical reorganization followingarm amputation. Nature, 1995;375:482-484.

Gaillard WD, Bookheimer SY, HertzPannier L, BlaxtonTA. The noninvasive identification of language function:Neuroimaging and rapid transcranial magnetic stimulation. Neurosurgery Clinics of North America, 1997;8:321.

George M, Wassermann EM, Prost RM. TranscranialMagnetic Stimulation: A Neuropsychiatric Tool for the21st Century. Journal of Neuropsychiatry and ClinicalNeurosciences, 1996;8:373-382.

Gerloff C, Corwell B, Chen R, Hallett M, Cohen LG.Stimulation over the human supplementary motor areainterferes with the organization of future elements incomplex motor sequences. Brain, 1997;120:1587-1602.

Greenberg BD, George MS, Martin JD, Benjamin J,Schlaepfer T, Altemus M, Wasserman EM, Post RM,Murphy DL. Effect of prefrontal repetitive transcranialmagnetic stimulation in obsessive-compulsive disorder: Apreliminary study. American Journal of Psychiatry,1997;154:867-869.

deHaan P, Kalkman CJ, deMol BA, Ubags LH, VeldmanDJ, Jacobs MJHM. Efficacy of transcranial motor-evokedpotentials to detect spinal chord ischemia duringoperations for thoracoabdominal aneurysms. Journal ofThoracic and Cardiovascular Surgery, 1997;1:87-100.

Hamdy S, Aziz Q, Rothwell J, Singh KD, Barlow J, HughesD, Tallis R, Thompson DG. The cortical topography ofhuman swallowing musculature in health and disease.Nature Medicine, 1996;11:1217-1224.

Hamdy S, Aziz Q, Rothwell JC, Crone R, Hughes D, TallisR, Thompson DG. Explaining oropharyngeal dysphagiaafter unilateral hemispheric stroke. The Lancet,1997;350:686-692.

Hamnegard CH, Wragg S, Mills G, Kyroussis D, PolkeyMI, Bake B, Moxham J, Green M. Clinical assessment ofdiaphragm strength by cervical magnetic stimulation of the phrenic nerves. Thorax, 1996;51:1239-1242.

Harashima F, Yokoto T. Influence of peripheral nervestimulation on human cortical excitability in patients withventrolateral thalamic lesion. Archives of Neurology,1997;54:619-624.

Harris ML, Moxham J. Measuring respiratory and limbmuscle strength using magnetic stimulation. Brit J. Intensive Care, 1998; 8:(1) 21-28.

Hendricks HT, Hageman G, VanLimbeek J. Prediction ofrecovery from upper limb extremity paralysis after stroke by measuring evoked potentials. Scandinavian Journal ofRehabilitation Medicine, 1997;29:155-159.


Heinen F, Korinthenberg R. Does Transcranial MagneticStimulation Allow Early Diagnosis of Rett Syndrome?Neuropaediatrics, 1996; 27: 223-224.

Hendricks HT, Hageman G, VanLimbeek J. Prediction ofrecovery from upper limb extremity paralysis after stroke by measuring evoked potentials. Scandinavian Journal ofRehabilitation Medicine,1997;29:155-159.

Hiraizumi Y, Transfelt EE, Kawahara N, Yamada H.Differences in sensitivity between magnetic motor evokedpotentials and somatosensory evoked potentials inexperimental spinal cord lesions. Spine,1996;19:2190-2196.

Jones SJ. Harrison R. Koh KF, Mendoza N, Crockard HA.Motor evoked potential monitoring during spinal surgery:responses of distal limb muscles to transcranial corticalstimulation with pulse trains. Electroencephalography andClin Neurophysiol,1996;100:375-383.

Kamen G, Caldwell GE. Physiology and Interpretation ofthe Electromyogram. Journal of Clinical Neurophysiology,1996;13:366-384.

van der Kamp W, Zwinderman AH, Ferrari MD, vanDijk.Cortical excitability and response variability of transcranial magnetic stimulation. Journal of ClinicalNeurolophysiology, 1996;13:164-171.

van der Kamp W, VandenBrink AM, Ferrari MD, vanDijk. Interictal cortical hyperexcitability in migraine patientsdemonstrated with transcranial magnetic stimulation.Journal of the Neurological Sciences, 1996;139:106-110.

van der Kamp W, VandenBrink AM, Ferrari MD, vanDijk. Interictal cortical excitability to magnetic stimulation infamilial hemiplegic migraine. Neurology, 1997;48:1462-1464.

Kamen G, Caldwell GE. Physiology and Interpretation ofthe Electromyogram. Journal of Neurophysiology, 1996;13:366-384.

Kaneko K, Fuchigami Y, Morita H, Ofuji A, Kawai S.Effect of coil position and stimulus intensity in transcranialmagnetic stimulation on human brain. Journal ofNeurological Sciences, 1997;147:155-159.

Kaneko K, Kawai S, Fuchigama Y, Shiraishi G, Ito T.Intracortical facilitation after transcranial magnetic doublestimulation. Muscle and Nerve, 1996;19:1043-1045.

Kaneko K, Kawai S, Taguchi T, Fuchigami Y, Shiraishi G.Coexisting peripheral nerve and cervical cord compression. Spine,1997;22:636-640.

Kanouchi T, Yokoto T, Isa F, Ishii K, Senda M. Role ofipsilateral motor cortex in mirror movements. Journal ofNeurology Neurosurgery and Psychiatry, 1997;62:629-632.

Kanouchi T, Yokata T, Kamata T, Ishii K, Senda M.Central pathway of photic reflex myoclonus. Journal ofNeurology, Neurosurgery, and Psychiatry, 1997;62:414-417.

Karlsborg M, Smed A, Jesperson H, Stephenson S, Cortsen M, Jennum P, Herning M, Korfitsen E Werdelin L. A prospective study of 39 patients with whiplash injury.Acta Neurol Scand, 1997;95:65-72.

Kew JJM, Halligan P, Marshall JC, Passingham RA,Rothwell JC, Riddind MC, Marsden CD, Brooks DJ.Abnormal access of axial vibrotactile input intodeafferinated somatosensory cortex in human upper limbamputees. J. Neurophysiol. 1997;77:2753-2764.

Keirs L. Magnetic stimulation of the motor cortex: Clinical applications. Journal of Clinical Neuroscience, 1997;4:3-8.

Kirkcaldie M, Pridmore S, Reid P. Bridging the skull:Electroconvulsive therapy (ECT) and repetitivetranscranial magnetic stimulation (rTMS) in psychiatry.Convulsive Therapy, 1997;13:83-91.

Kirkaldie MTK, Pridmore SA, Pascual-Leone A.Transcranial magnetic stimulation as a therapy fordepression and other disorders. Australian and NewZealand Journal of Psychiatry, 1997;31:264-272.

Kotterba S, Tegenthoff M, Malin JP. Perioperative lesionsof the facial nerve: follow-up investigations usingtranscranial magnetic stimulation. Eur ArchOtorhynolaryngol, 1997;254:140-144.

Krams M, Quinton R, Mayston MJ, Harrison LM, DolanRJ, Bouloux PMG, Stephens JA, Frakckowiak RSJ,Passingham RE. Mirror movements in X-linked Kallman'ssyndrome. 2. A PET study. Brain, 1997;120:1217-1228.

Krings T, Buchbinder B, Butler W, Chiappa K, Jiang H,Cosgrove G, Rosen B. Functional magnetic resonanceimaging and transcranial magnetic stimulation:complementary approaches in the evaluation of corticalmotor function. Neurology, 1997;5:1406-1416.

Kyroussis D, Polkey MI, Mills GH, Hughs PD, Moxham J,Green M. Simulation of Cough in Man by MagneticStimulation of the Thoracic Nerve Roots. Am J. RespirCrit Care Med, 1997;156:1696-1699.



Laghi F, Tobin MJ. Relationship betweentransdiaphramatic and mouth twitch pressures atfunctional residual capacity. European Respiratory Journal, 1997;10:530-536.

Lin VWH, Wolfe V, Frost Fs, Perkash I. Micturition byfunctional magnetic stimulation. Journal of Spinal CordMedicine, 1997;20:218-226.

Lin VWH, Hsiao I, Perkash I. Micturition by functionalmagnetic stimulation in dogs: A preliminary report.Neurourology and Urodynamics, 1997;16:305-313.

Lissons MA, Vanderstraeten GG. Motor evoked potentialsof the respiratory muscles in tetraplegic patients. SpinalCord, 1996;34:673-678.

Ljubsavljevic M, Milanovic S, Radovanovic S, Vukcevic I,Kostic V, Anastasijevic R. Central changes in musclefatigue during sustained submaximal isometric voluntarycontraction as revealed by transcranial magneticstimulation. Electroencephalography Clin Neurophysiol, 1996;101:298-303.

McFarlane JP, Foley SJ, De Winter P, Shah JPR, CraggsMD. Suppression of detruser instability by magneticstimulation of the sacral nerve roots. British Journal ofUrology, 1997;80:734-741.

Maegaki Y, Maeoka Y, Ishii S, Shiota M, Takeuchi A,Yoshino K, Takeshita K. Mechanisms of central motorreorganisation in pediatric hemiplegic patients.Neuropediatrics, 1997;28:168-174.

Maloney SR, Bastings EP, Blair D, Quinlevan L, Good DC. The course of cortico-hypoglossal projections in the human brainstem: functional testing using transcranial magneticstimulation. Brain, 1997;120:1910-1911.

Mathis J, Hess CW. Motor-evoked potentials frommultiple target muscles in multiple sclerosis and cervicalmyelopathy. European Journal of Neurology 1996;3:567-573.

Mathis J, Gurfinkel VS, Struppler A. Facilitation of motorevoked potentials by postcontraction response (Konstammphenomenon). Electroencephalogr Clin Neurophysiol, 1996;101:298-303.

Mayston MJ, Harrison LM, Quinton R, Stephens JA,Krams M, Bouloux PMG. Mirror movements in X-linkedKallman's syndrome. 1. A neurophysiological study. Brain,1997;120:1199-1216.

Meyer B, Liebsch R, Roricht S. Tongue motor responsesfollowing transcranial magnetic stimulation of the motorcortex and the proximal hypoglossal nerve in man.Electroencephalography and clinical Neurophysiology,1997;105:15-23.

Mills GH, Kyroussis D, Hamnegard CH, Wragg S, PolkeyMI, Moxham J, Green M. Cervical magnetic stimulation of the phrenic nerves in bilateral diaphragm paralysis.American Journal of Respiratory and Critical CareMedicine, 1997;155:1565-1569.

Mills KR, Kimiskidis V. Motor cortex excitability duringballistic forearm and finger movements. Muscle & Nerve,1996;19:468-473.

Mills KR, Nithi KA. Motor cortex stimulation does notreset primary orthostatic tremor. Journal of Neurology,Neurosurgery & Psychiatry, 1997;63:553.

Mills KR, Nithi KA. Corticomotor threshold is reduced inearly sporadic amyotrophic lateral sclerosis. Muscle &Nerve, 1997;20:1137-1141.

Muellbacher W, Mamoli B. The course ofcortico-hyperglossal projections in the human brainstem:functional testing using transcranial magnetic stimulation.Brain, 1997;120:1909-1910.

Nakajima M, Eisen A, McCarthy R, Olney RK, AminoffMJ. Reduced corticomotoneuronal excitatory postsynapticpotentials (EPSPs) with normal la afferent EPSPs in amyotrophic lateral sclerosis. Neurology,1996;47:1555-1561.

Netz J, Lammers T, Homberg V. Reorganization of motoroutput in the non-affected hemisphere after stroke. Brain,1997;120:1579-1586.

Netzu A, Kimura S, Ohtsuki N, Tanaka M. Transcranialmagnetic stimulation in benign childhood epilepsy withcentro-temporal spikes. Brain and Development,1997;19:134-137.

Netzu A, Kimura S, Uehara S, Kobayashi T, Tanaka M,Saito K. Magnetic stimulation of the motor cortex inchildren: Maturity of the corticospinal pathway andproblem of clinical application. Brain and Development,1997;19:176-180


Nielson JF. Improvement of amplitudes variability of motor evoked potentials in multiple sclerosis patients and inhealthy subjects. Electroencephaloraphy and clinicalNeurophysiology, 1996;101:404-411.

Nielson JF. Logarythmic Distribution of Amplitudes ofCompound Muscle Action Potentials Evoked byTranscranial Magnetic Stimulation. Journal of ClinicalNeurophysiology, 1996;13:423-434.

Nielson JF, Sinkjaer T. Long-lasting depression of soleusmotoneurons excitability following repetitive magneticstimuli of the spinal cord in multiple sclerosis patients.Multiple Sclerosis, 1997;3:18-30.

Nielson JF. Frequency-dependent conduction delay ofmotor evoked potentials in multiple sclerosis. Muscle &Nerve, 1997;20:1264-1274.

Nielson JF. Treatment of spasticity with repetitivemagnetic stimulation; a double-blind placebo-controlledstudy. Multiple Sclerosis, 1996;2:227-232.

Neilson JF. Repetitive magnetic stimulation of the cerebralcortex in normal subjects. Journal of ClinicalNeurophysiology, 1996;13:69-76.

Nilsson J, Panizza M, Arieti P. Computer-AidedDetermination of the Silent Period. J.Clin. Neurophysiol.1997;14:136-143.

Nirkko AC, Rosler KM, Ozdoba C, Heid O, Schroth G,Hess CW. Human cortical plasticity: Functional recoverywith mirror movements. Neurology, 1997;48:1090-1093.

Olson JD, Li J, Anand S, Hotson JR. Rapid-ratetranscranial magnetic stimulation delivered focally overfrontal cortex evokes saccades. Neurology, 1996;46:S44.006.

Paus T, Jech R, Thompson CJ, Comeau R, Peters T, EvansAC. Transcranial magnetic stimulation during positronemission tomography: A new method for studyingconnectivity of the human cerebral cortex. Journal ofNeuroscience, 1997;17:3178-3184.

Polkey MI, Kyroussis D, Hamnegard CH, Mills GH, GreenM, Moxham J. Diaphragm Strength in ChronicObstructive Pulmonary Disease. American Journal ofRespiratory and Critical Care Medicine, 1996;154:1310-1317.

Polkey MI, Kyrouissis D, Hamnegard CH, Hughs PD,Rafferty GF, Moxham J, Green M. Paired phrenic nervestimuli for the detection of diaphragm fatigue in humans.Eur. Respir J, 1997;10:1859-1864.

Priori A. Clinical Applications of Silent PeriodMeasurements. Advances in Occupational Medicine andRehabilitation, 1996;2:91-97.

Puri BK, Lewis SW. Transcranial magnetic stimulation inpsychiatric research. British Journal of Psychiatry, 1996;169:675-677.

Puri BK, Davey NJ, Ellaway PH, Lewis SW. AnInvestigation of Motor Function in Schizophrenia usingTranscranial Magnetic Stimulation of the Motor Cortex.British Journal of Psychiatry, 1996;169:690-695.

Rapisarda G, Bastings E, deNoordhout AM, Pennisi G,Delwaide PJ. Can motor recovery in stroke patients bepredicted by early transcranial magnetic stimulation?Stroke, 1996;27:2191-2196.

Ravnborg M. The role of transcranial magneticstimulations and motor evoked potentials in theinvestigation of central motor pathways in multiplesclerosis. Danish Medical Bulletin, 1996;43:448-462.

Rijntjes M, Tegenthoff M, Liepert J, Leonhardt G,Kotterba S, Muller S, Kiebel S, Malin JP, Diener HC,Weiller C. Cortical reorganization in patients with facialpalsy. Annals of Neurology, 1997;41:621-630.

Roricht S, Irlbacher K, Petrow E, Meyer BU. Normativedata for callosally and corticospinally mediatedelectromyographic effects in hand muscles following ahemisphere-selective magnetic cortex stimulation in man.Z. EEG-EMG, 1997;28:34-38. (German)

Rose RD. Sensory component of cervically evoked motorpotentials. Medical Hypothesis, 1996;46:577-579.

Salerno A, Georgesco M. Interhemispheric facilitation andinhibition studied in man with double magneticstimulation. Electroencephalography and ClinNeurophysiol, 1996; 101: 395-403.

Samii A, Wassermann EM, Ikoma K, Mercuri B, et al.Decreased postexercise facilitation of motor evokedpotentials in patients with chronic fatigue syndrome ordepression. Neurology, 1996;47:1410-1414.

Schubert M. Clinical and Experimental aspects of magnetic stimulation. Z. EEG-EMG, 1997;28:114-118. (German)

Schulz U, Ferbert A. Variability of motor evokedpotentials: Comparison of three small hand muscles.Z. EEG-EMG, 1996;27:143-150.


Schulze-Bonhage, Knott K, Ferbert A. Effects ofcarbamezepine on cortical excitatory and inhibitoryphenomena: a study with paired transcranial magneticstimulation. Electroencephalography and ClinNeurophysiol, 1996;99:267-273.

Schwarz CM. Subconvulsive magnetic brain stimulation no replacement for ECT. American Journal of Psychiatry,1997;154:716-717.

Scott PV. Asystole from tetanic stimulation of theaccessory nerve. Anaesthesia, 1996;51:1148-1150.

Sheean GL, Murray NMF, Rothwell JC, Miller DH,Thompson AJ. An electrophysiological study of themechanism of fatigue in multiple sclerosis. Brain, 1997;120:299-315.

Sheriff MKM, Shah JPR, Fowler C, Mundy AR, CraggsMD. Neuromodulation of detrusor hyper-reflexia byfunctional magnetic stimulation. British Journal ofUrology, 1996;78:39-46.

Similowski T, Mehiri S, Duguet A, Attali V, Straus C,Derenne J-Ph. Comparison of magnetic and electricalphrenic nerve stimulation in assessment of phrenic nerveconduction time. Journal of Applied Physiology,1997;82:1190-1199.

Similowsky T, Catala M, Rancurel G, Derenne J-Ph.Impairment of Central Motor Conduction to theDiaphragm in Stroke. Am J. Respir Care Med, 1996;154:436-441.

Similowski T, Straus C, Attali V, Duguet A, Jourdain B,Derenne J-Ph. Assessment of the motor pathway to thediaphragm using cortical and cervical magnetic stimulation in the decision making process of phrenic pacing. Chest, 1996; 110: 1551-1557.

Similowski T, Straus C, Coic L, Derenne J-Ph.Facilitation-independent Response to the Diaphragm toCortical Magnetic Stimulation. Am J. Respir Care Med ,1996;154:1771-1777.

Spicer M, Hughes P, Green M. A non-invasive system toevaluate diaphragmatic strength in ventilated patients.Physiol. Meas. 1997;18:355-361.

Strafella A, Ashby P, Lozano A, Lang AE. Palliditomyincreases cortical inhibition in Parkinson's disease.Canadian Journal of Neurological Sciences,1997;24:133-136.

Strafella A, Ashby P, Lang AE. Reflex myclonus incortical-basal ganglionic degeneration involves atranscortical pathway. Movement Disorders, 1997;12:360-369.

Struppler A, Jakob C, Muller-Barna P, Schmid M,Lorenzen H-W, Paulig M, Prosiegal M. New method forearly rehabilitation in extreme palsies of central origin bymagnetic stimulation. Z. EEG-EMG, 1996;27: 151-157.(German with English Abstract)

Sue CM, Yiannikas C, Clouston PD, Lim CL, Graham S.Transcranial cortical stimulation in disorders of the central motor pathways. J. Clin. Neuroscience, 1997;4:19-25.

Tamer SK, Misra S, Jaiswal S. Central motor conductiontime in malnourished children. Archives of Disease inChildhood, 1997;77:323-325.

Tegenthoff M, Vorgerd M, Juskowiak F, Roos V, MalinJ.-P. Postexcitatory inhibition after transcranial magneticsingle and double brain stimulation in Huntington'sdisease. Electroencephalogr Clin Neurophysiol,1996;101:298-303.

Thompson ML, Thickbroom GW, Mastaglia FL.Corticomotor representation of the sternocleidomastoidmuscle. Brain, 1997;120:245-255.

Timmerhuis TPH, Hageman G, Oosterloo SJ, RozeboomAR. The prognostic value of cortical magnetic stimulationin acute middle cerebral artery infarction compared withother parameters. Clinical Neurology and Neurosurgery,1996;98:231-236.

Traversa R, Cicinelli P, Bassi A, Rossini PM, Bernadi G.Mapping of motor cortical reorganisation after stroke: Abrain stimulation study with focal magnetic pulses. Stroke, 1997;289:110-117.

Tokimura H, Ridding MC, Tokimura Y, Amassian VE,Rothwell JC. Short latency facilitation between pairs ofthreshold magnetic stimuli applied to the human cortex.Electroencephalogr Clin Neurophysiol, 1996;101:298-303.

Tokimura H, Tokimura Y, Oliviero A, Ascura T, RothwellJC. Speech-induced Changes in Corticospinal Excitability.Ann Neurol, 1996;40:628-634.

Turton A, Wroe S, Trepte N, Fraser C, Lemon RN.Contralateral and ipsilateral EMG responses to transcranial magnetic stimulation during recovery of arm and handfunction after stroke. Electroencephalogr ClinNeurophysiol, 1996;101:316-328.


Ubags LH, Kalkman CJ, Been HD, Porsius M, DrummondJC. The use of ketamine or etomidate to supplementsufentanil/N2O anesthesia does not disrupt monitoring ofmyogenic transcranial motor evoked responses. Journal ofNeurosurgical Anesthesiology, 1997;9:228-233.

Ubags LH, Kalkman CJ, Harris DNF, Drummond JC.Differential effects of nitrous oxide and propofol onmyogenic transcranial motor evoked responses duringsufentanil anaesthesia. British Journal of Anaesthesia,1997;79:590-594.

Uccioli L, Giacomini PG, Pasqualetti P, DiGirolamo S,Ferrigno P, et al. Contribution of central neuropathy topostural instability in IDDM patients with peripheralneuropathy. Diabetes Care, 1997;20:929-934.

Urban PP, Hopf HC, Zorowkar PG, Fleischer S, Andreas J.Dysarthria and lacunar stroke: Pathophysiologic aspects.Neurology, 1996;47:1135-1141.

Urban PP, Hopf HC, Connemann B, Hundemer HP,Koehler J. Technical considerations of electromyographictongue muscle recordings using transcranial magneticstimulation. Brain, 1997;120:1911-1914.

Urban PP, Hopf HC, Fleischer S, Zorowkar PG,MullerForell W. Impaired cortico-bulbar tract function indyarthria due to hemispheric stroke - Functional testingusing transcranial magnetic stimulation. Brain, 1997;120:1077-1084.

Vorgerd M. Tegenthoff M Juskowiak F. Roos V. Malin J.-P. Transcranial magnetic double stimulation: Methods andclinical studies. Z. EEG-EMG, 1996;27: 85-91. (Germanwith English Abstract)

Walsh V. Brain mapping: Faradization of the mind.Current Biology, 1998;8:R8-R11.

Wassermann EM, Grafman J. Combining transcranialmagnetic stimulation and neuroimaging to map the brain.Trends in Cognitive Sciences, 1997;6:199-201.

Wassermann EM. Repetitive transcranial magneticstimulation: An introduction and overview. CNS Spectrums, 1997;2:21-25.

Wasserman EM. Risk and safety of repetitive transcranialmagnetic stimulation: report and suggested guidelines from the International Workshop on the Safety or TranscranialMagnetic Stimulation, June 5-7, 1996. ElectroencephalogrClin Neurophysiol, 1998, 108:1-16.

Watson SRD, Colebatch JG. Pathophysiology of congenital mirror movements. Journal of Clinical Neuroscience,1997;4:69-74.

Wenning GK, Smith SHM. Magnetic brain stimulation inmultiple system atrophy. Movement Disorders,1997;12:452-453.

Wessel K, Teganthoff M, Vorgerd M, Otto V, NitschkeMF, Malin J.-P. Enhancement of inhibitory mechanisms inthe motor cortex of patients with cerebellar degeneration:a study of transcranial magnetic brain stimulation.Electroencephalogr Clin Neurophysiol, 1996;101:298-303.

Yokoto T, Yoshino A, Inaba A, Saito Y. Double corticalstimulation in amyotrophic lateral sclerosis. Journal ofNeurology Neurosurgery and Psychiatry, 1996;61:596-600.

Zaaroor M, Bleich N, Chistyakov A, Pratt H, Feinsod M.Motor evoked potentials in preoperative and postoperativeassessment of normal pressure hydrocephalus. Journal ofNeurology, Neurosurgery, and Psychiatry, 1997;62:517-521.

Ziemann U, Lönnecker S, Steinhoff BJ, Paulus W. Effectsof Antiepileptic Drugs on Motor Cortex Excitability inHumans: A Transcranial Magnetic Stimulation Study.Annals of Neurology, 1996;40:367-378.

Ziemann U, Paulus W, Rothenberger A. Decreasedinhibition in Tourette's disorder: Evidence fromtranscranial magnetic stimulation. American Journal ofPsychiatry, 1997;154:1277-1284.

Zifko UA, Hahn AF, Rentulla H, George CFP, WihlidalW, Bolton CF. Central and peripheral respiratoryelectrophysiological studies in myotonic distrophy. Brain,1996;119:1911-1922.


Ref er ences Or gan ised by Dis ci pline

1. An aes the sia

Detsch C, Kochs E. Effects of Ketamine on central nervous system function. Anaesthetist, 1997;46:S20-S29. (German)


Kitagawa H, Nakamura H, Kawaguchi Y, Tsuji H, SatoneT, Takano H, Nakatoh S. Magnetic-Evoked CompoundMuscle Action Potential Neuromonitoring in SpineSurgery. Spine, 1995;20:2233-2239.

Kong K, Ukachoke C, Mcguire G, Wong D, Ashby P. Theexcitability of human corticospinal neurons is depressed bythiopental. Canadian Journal of Neurological Sciences1995;22:218-222.

Ubags LH, Kalkman CJ, Been HD, Porsius M, DrummondJC. The use of ketamine or etomidate to supplementsufentanil/N2O anesthesia does not disrupt monitoring ofmyogenic transcranial motor evoked responses. Journal ofNeurosurgical Anesthesiology, 1997;9:228-233.

Ubags LH, Kalkman CJ, Harris DNF, Drummond JC.Differential effects of nitrous oxide and propofol onmyogenic transcranial motor evoked responses duringsufentanil anaesthesia. British Journal ofAnaesthesia,1997;79:590-594.

Watt JWH, Fraser MH, Soni BM, Sett PK, Clay R. Totaliv anaesthesia for transcranial magnetic evoked potentialspinal cord monitoring. British Journal of Anaesthesia,1996;76:870-871.

2. An aes the sia, Pri mate Stud ies

Baker SN, Olivier E, Lemon RN. Recording an IdentifiedPyramidal Volley Evoked by Transcranial MagneticStimulation in a Conscious Macaque Monkey. Exp BrainRes, 1994, 99: 529-532.

Ghaly RF, Stone JL, Levy WJ, Kartha RK, Aldrete JA,Brunner EB, Roccaforte P. The Effect of an AnestheticInduction Dose of Midazolam on Motor Potentials Evokedby Transcranial Magnetic Stimulation in the Monkey. J. Neurosurg Anesthesiol 1991, 3: 1-8.

Ghaly RF, Stone JL, Levy WJ, Kartha RK, Miles ML, Jaster HJ. The effect of Etomidate or Midazolam Hypnotic Doseon Motor Evoked Potentials in the Monkey. J. Neurosurg Anesthesiol, 1990, 2: 244.

Ghaly RF, Stone JL, Aldrete JA, Levy WJ. Effects ofIncremental Ketamine Hydrochloride Doses on MotorEvoked Potentials (MEPs) Following TranscranialMagnetic Stimulation: A Primate Study. J. Neurosurg Anesthesiology, 1990, 2: 79-85.

Ghaly RF, Stone JL, Levy WJ, Kartha RK, Aldrete JA. The Effect of Nitrous Oxide on Transcranial Magnetic-Induced Electromyographic Responses in the Monkey. J. Neurosurg Anesthesiol, 1990, 2: 175-181.

Ghaly RF, Stone JL, Levy WJ, Roccaforte P, Brunner EB.The effect of Etomidate on Motor Evoked PotentialsInduced by Transcranial Magnetic Stimulation in theMonkey. Neurosurg, 1990,Vol. 27, No. 6.

Gahly RF, Stone JL, Levy WJ, Kartha R, Brunner EA,Aldrete A, Laege R. The Effect of Neuroleptanalgesia(Droperidol-Fentanyl) on Motor Evoked Potentials Evoked by Transcranial Magnetic Stimulation in the Monkey. J. Neurosurg Anesthesiol, 1992, 3: 117-123.

3. A.L.S.

See section on Motor Neurone Disease.

4. Atax ias

Abele M, Burk K, Andres F, Topka H, Laccone F, Bosch S, Brice A, Cancel G, Dichgans J, Klockgether T. Autosomaldominant cerebellar ataxia type 1 - Nerve conduction andevoked potential studies in families with SCA1, SCA2 andSCA3. Brain 1997;120:2141-2148.

Alfonsi E, Merlo IM, Monafo V, Lanzi G, Ottolini A,Veggiotti P, Moglia A. Electrophysiological Study ofCentral Motor Pathways in Ataxia-Telangiectasia J. ChildNeurol 1997;12: 327-331.

Claus D, Harding AE, Hess CW, Mills KR, Murphy NMF,Thomas PK. Central Motor Conduction in DegenerativeAtaxic Disorders: A Magnetic Stimulation Study. Neurol,Neurosurg and Psychiat, 1988, 51: 790-795.

Murray NMF. Magnetic Stimulation of Cortex: ClinicalApplications. J. Clin Neurophysiol, 1991, 8: 66-76.

Murray NMF. Magnetic Transcranial Stimulation inDegenerative Ataxic Disorders. In: Clinical Applications of Magnetic Stimulation. Lissens M.A. (Ed.), Peeters Press,Belgium 1992: 209-217.


Nakashima K, Yang YP, Shimoda M, Sakuma K,Takahashi K. Prolonged silent periods produced bymagnetic cortical stimulation in patients with cerebellarataxia. Psychiatry and Clinical Neurosciences1995;49:143-146.

Scarpini C, Mondelli M, Guazzi GC, Federico A.Ataxia-Telangiectasia: Somatosensory, Brainstem Auditory and Motor Evoked Potentials in Six Patients.Developmental Medicine and Child Neurology,1996;38:65-73.

5. Au di ol ogy

Chen J, Hanusaik L, Ramses P, Schipp D, Anderson J,MacLean A, Nedzelski J. Comparative psychophysicalevaluation in cochlear implantation: Electrical andmagnetic stimulation. American Journal of Otology,1997;18:39-43.

Wang H, Wang X, Scheich H. LTD and LTP induced bytranscranial magnetic stimulation in auditory cortex.Neuroreport, 1996;7:521-525.

6. Ba sic Prin ci ples, Tech ni cal As pects

Cerri G, Deleo R, Moglie F, Schiavoni A. An accurate 3-D model for magnetic stimulation of the brain cortex. Journal of Medical Engineering & Technology 1995;19:7-16.

Feistner H, Awiszus F, Sailer M, Hinrichs H, Heinze HJ. A method for rapid response estimation of single humanmotorneurones to transcranial magnetic and peripheralelectrical stimulation. Z. EEG-EMG, 1996;27:80-84.(German)

Garnham C, Barker AT, Freestone IL. Measurement ofactivating function of magnetic stimulation usingcombined electrical and magnetic stimuli. Journal ofMedical Engineering & Technology, 1995;19:57-61.

Jalinous R. Technical and Practical Aspects of MagneticNerve Stimulation. J. Clin Neurophysiol, 1991, 8: 10-25.

Mouchawar GA, Bourland JD, Nyenhuis JA, Geddes LA,Foster KS, Jones JT, Grabar LA. Closed-chest CardiacStimulation with a Pulsed Magnetic Field. Med Biol EngComp, 1992, 162-168.


Wassermann EM, Grafman J, Combining transcranialmagnetic stimulation and neuroimaging to map the brainTrends in Cognitive Sciences, 1997;6:199-201.

7. Ba sic Prin ci ples, Clini cal As pects

Kamen G, Caldwell GE. Physiology and Interpretation ofthe Electromyogram. Journal of Clinical Neurophysiology,1996;13:366-384.



Mathis J, Hess CW. Motor-evoked potentials frommultiple target muscles in multiple sclerosis and cervicalmyelopathy. European Journal of Neurology 1996;3:567-573.



Röricht S, Irlbacher K, Petrow E, Meyer B. Normative data for callosally and corticospinally mediatedelectromyographic effects in hand muscles following ahemisphere-selective magnetic cortex stimulation in man.Z. EEG-EMG, 1997;28:34-38.(German)

8. Bends (De com pres sion Sick ness)

Murrison AW, Mostofi S, Banerjee T, Sedgwick EM.Central Motor Conduction Time in NeurologicalDecompression Illness. Electroenceph Clin Neurophys,1993, 89: 434-436.

9. Brain Map ping




Chen R, Cohen LG, Hallett M. Role of ipsilateral cortex in voluntary movement. Canadian Journal of NeurologicalSciences, 1997;24:284-291.



Ilmoniemi RJ, Virtanen J, Ruohonen J, Karhu J, AronenHJ, Naatanen R, Katila T. Neuronal responses to magnetic stimulation reveal cortical reactivity and connectivity.NeuroReport, 1997;8:3537-3540.


Krings T, Buchbinder BR, Butler WE, Chiappa KH, JiangHJ, Rosen B, Cosgrove GR. Stereotactic transcranialmagnetic stimulation: Correlation with direct electricalcortical stimulation. Neurosurgery, 1997;41:1319-1326.


Thompson ML, Thickbroom GW, Mastaglia FL.Corticomotor representation of the sternocleidomastoidmuscle. Brain, 1997;120:245-255.

Traversa R, Cicinelli P, Bassi A, Rossini PM, Bernadi G.Mapping of motor cortical reorganisation after stroke: Abrain stimulation study with focal magnetic pulses. Stroke,1997;289:110-117.

Walsh V. Brain mapping: Faradization of the mind.Current Biology, 1998;8:R8-R11.

Wassermann EM, Grafman J, Combining transcranialmagnetic stimulation and neuroimaging to map the brain.Trends in Cognitive Sciences, 1997;6:199-201.

10. Brain stem Stimu la tion

Ugawa Y, Uesaka Y, Terao Y, Hanajima R, Kanazawa I.Magnetic stimulation of the corticospinal pathways at theforamen magnum level in humans. Annals of Neurology1994;36:618-624.

11. Cere bel lum

Hashimoto M, Ohtsuka K. Transcranial magneticstimulation over the posterior cerebellum during visuallyguided saccades in man. Brain, 1995;118:1185-1193.

Ugawa Y, Uesaka Y, Terao Y, Hanajima R, Kanazawa I.Magnetic stimulation over the cerebellum in humans.Annals of Neurology, 1995;37:703-713.


12. Cere bral Ische mia

See section on Stroke.

13. Cere bral Palsy

Also see section on Paediatrics.

Carr LJ, Harrison LM, Evans AL, Stephens JA. Patterns ofCentral Motor Reorganization in Hemiplegic CerebralPalsy. Brain, 1993, 116: 1223-47.

Carr LJ, Harrison LM, Evans AL, Stephens JA. Patterns ofcentral Motor Reorganisation in children with HemiplegicCerebral Palsy. J. Physiol. 1992; 452: 107.


14. Clini cal Ap pli ca tions and Re views

Cantano A, Noel P. Transcranial magnetic stimulation:Interest of the excitation threshold. Acta NeurologicaBelgica, 1997;97:61-61.

Gaillard WD, Bookheimer SY, HertzPannier L, BlaxtonTA. The noninvasive identification of language function:Neuroimaging and rapid transcranial magnetic stimulation. Neurosurgery Clinics of North America, 1997;8:321.




Kamen G, Caldwell GE. Physiology and Interpretation ofthe Electromyogram. Journal of Neurophysiology,1996;13:366-384.


Kaneko K, Fuchigami Y, Morita H, Ofugi A, Kawai S.Effect of coil position and stimulus intensity in transcranialmagnetic stimulation of the human brain. Journal ofNeurological Sciences, 1997;147:155-159.

Keirs L. Magnetic stimulation of the motor cortex: Clinical applications. Journal of Clinical Neuroscience, 1997;4:3-8.



Mathis J, Hess CW. Motor-evoked potentials frommultiple target muscles in multiple sclerosis and cervicalmyelopathy. European Journal of Neurology1996;3:567-573.


Roricht S, Irlbacher K, Petrow E, Meyer BU. Normativedata for callosally and corticospinally mediatedelectromyographic effects in hand muscles following ahemisphere-selective magnetic cortex stimulation in man.Z. EEG-EMG, 1997;28:34-38. (German)

Rose RD. Sensory component of cervically evoked motorpotentials. Medical Hypothesis, 1996;46:577-579.



Sue CM, Yiannikas C, Clouston PD, Lim CL, Graham S.Transcranial cortical stimulation in disorders of the central motor pathways. J. Clin. Neuroscience, 1997;4:19-25.


Vorgerd M. Tegenthoff M Juskowiak F. Roos V. Malin J-P.Transcranial magnetic double stimulation: Methods andclinical studies. Z. EEG-EMG, 1996;27: 85-91. (Germanwith English Abstract)

Wassermann EM. Repetitive transcranial magneticstimulation: An introduction and overview. CNS Spectrums, 1997;2:21-25.

Wenning GK, Smith SHM. Magnetic brain stimulation inmultiple system atrophy. Movement Disorders,1997;12:452-453.

Wunderlich G, Knorr U, Herzog H, Kiwit JCW, FreundHJ, Seitz RJ. Precentral Glioma Location Determines theDisplacement of Cortical Hand Representation.Neurosurgery, 1998;42:18-27.

Zaaroor M, Bleich N, Chistyakov A, Pratt H, Feinsod M.Motor evoked potentials in preoperative and postoperativeassessment of normal pressure hydrocephalus. Journal ofNeurology, Neurosurgery, and Psychiatry,1997;62:517-521.

15. Coil Con figu ra tion

Benecke R. Magnetic stimulation in the assessment ofperipheral nerve disorders. Baillière’s Clinical Neurology1996; 5: 115-128.

Chiappa KH, Cohen D. Determination of the Direction ofCurrent Flow in the Circular Coils used in TranscranialMagnetic Stimulation. Neurology, 1991, 41: 1154-1155.


De Leo R, Cerri G, Balducci D, Moglie F, Scarpino O,Guidi M. Computer Modelling of Brain Cortex Excitationby Magnetic Field Pulses. J. Med Eng Tech 1992, 16:149-156.

Hess CW, Rosler KM, Heckmann RO, Ludin HP.Magnetic Stimulation of the Human Brain: Influence ofSize and Shape of the Stimulating Coil. In: MotorDisturbances II. Academic Press Limited, London, U.K.1990: 31-42.

Kraus KH, Gugino LD, Levy WJ, Cadwell J, Roth BJ. TheUse of a Cap-Shaped Coil for Transcranial MagneticStimulation of the Motor Cortex. J. Clin Neurophys, 1993,10: 353-362.

Macdonell RAL, Shapiro BE, Chiappa KH, Helmers SL,Cross D, Day BJ, Shahani BT, Phil D. HemisphericThreshold Differences for Motor Evoked PotentialsProduced by Magnetic Coil Stimulation. Neurology 1991,41: 1441-1444.

Mills KR, Boniface SJ, Schubert M. Magnetic BrainStimulation with a Double Coil: The Importance of CoilOrientation. Electroencephalog Clin Neurophysiol, 1992,85: 17-21.

Rosler KM, Hess CW, Heckmann RO, Ludin HP.Significance of Shape and Size of the Stimulating Coil inMagnetic Stimulation of the Human Motor Cortex.Neuroscience Letters, 1990, 100: 347-352.

Tofts PS. The Distribution of Induced Currents inMagnetic Stimulation of the Nervous System. Phys. Med.biol, 1990, 35: 1119-1128.

16. Co lo rec tal Dis ease

Also see sec tion on Urol ogy.

Herdmann J, Bielefeldt K, Enck P. Quantification of motor pathways to the pelvic floor. Am J. Physiol.,1991;260:G720-723.

Jost WH, Ecker KW, Schrimrigk K. Surface verses needleelectrodes in determination of motor conduction time tothe external anal sphincter. Int J. Colorect Dis1994;9:97-199.

Jost WH, Schrimrigk K. Magnetic stimulation of thepudendal nerve. Diseases of the Colon & Rectum1994;37:697-699.

Tomita R, Kurosu Y, Munakata K. ElectrophysiologicAssessments in Pudendal and Sacral Motor Nerves AfterIleal J-Pouch-Anal Anastomosis for Patients withUlcerative Colitis and Adenomatosis Coli. Diseases of theColon & Rectum 1996;39:410-415.

17. Coma

Firsching R, Wilhelms S, Csescei G. Pyramidal TractFunction during onset of Brain Death. EEG ClinNeurophysiol. 1992, 84: 321-324.

Firsching R. Clinical Applications of Magnetic TCS inComatose Patients. In: Clinical Applications of MagneticStimulation. Lissens M.A. (Ed.), Peeters Press, Belgium1992: 263-268.

Ying Z, Schmid UD, Schmid J, Hess CW. Motor andSomatosensory Evoked Potentials in Coma: Analysis andRelation to Clinical Status and Outcome. J. Neurol,Neurosurg and Psychiat, 1992, 55: 470-474.

Zentner J, Epner A. Prognostic value of somatosensory and motor evoked potentials in patients with non-traumaticcoma. Eur Arch Psychiat & Neurolog Sci, 1988, 237:184-187.

18. Com puter Mod el ling

Cerri G, Deleo R, Moglie F, Schiavoni A. An accurate 3-D model for magnetic stimulation of the brain cortex. Journal of Medical Engineering and Technology, 1995;1: 7-16.

De Leo R, Cerri G, Balducci D, Moglie F, Scarpino O,Guidi M. Computer Modelling of Brain Cortex Excitationby Magnetic Fields. J. Med Eng Tech, 1992 16: 149-156.

Roth BJ, Basser PJ. A Model of the Stimulation of a NerveFiber by Electromagnetic Induction. IEEE Transactions onBiomedical Engineering, 1990, 37: 588-596.

Tofts PS. The Distribution of Induced Currents inMagnetic Stimulation of the Nervous System. Phys. Med.biol, 1990, 35: 1119-1128.

19. Dia be tes

Bax G, Lelli S, Grandis U, Cospite AM, Paolo N, Fedele D. Early Involvement of Central Nervous System in Type 1Diabetic Patients. Diabetes Care, 1995;18:559-562.



20. Dysto nia

Ikoma K, Samii A, Mercuri B, Wassermann EM, HallettM. Abnormal cortical excitability in dystonia. Neurology1996:46;1371-1376.

Rona S, Berardelli A, Vacca L, Inghillaeri M, Manfredi M.Alterations of motor cortical inhibition in patients withdystonia. Movement Disorders, 1998;13:118-124.

21. Elec tri cal ver sus Mag netic Stimu la tion

Benecke R. Magnetic stimulation in the assessment ofperipheral nerve disorders. Baillière's Clinical Neurology1996;5:115-128.

Edgley SA, Eyre JA, Lemon RN, Miller S. Comparison ofactivation of corticospinal neurons and spinal motorneurons by magnetic and electrical transcranial stimulation in the lumbosacral cord of the anaesthetized monkey.Brain, 1997;120:839-853.

Laranne J, Rimpilainen I, Karma P, Eskola H, Hakkinen V, Laippala P. A comparison of transcranial magneticstimulation with electroneurogaphy as a predictive test inpatients with Bell's palsy. European Archives ofOto-Rhyno-Laryngology, 1995;252:344-347.


22. Elec tro con vul sive Ther apy

Also see sec tion on Psy chia try.

Belmaker RH, Grisaru N, Fleischman A. Effects on BrainNeurotransmission of Transcranial Magnetic Stimulation.Neuropsychopharmacology, 1994;10,No.3S/Part 1, 583.

George MS, Wassermann EM. Rapid-rate transcranialmagnetic stimulation and ECT. Convuls Ther, 1994;10:251-254.

Kirkcaldie M, Pridmore S, Reid P. Bridging the skull:Electroconvulsive therapy (ECT) and repetitivetranscranial magnetic stimulation (rTMS) in psychiatry.Convulsive Therapy, 1997;13:83-91.


Zyss T. Deep magnetic brain stimulation - The end ofpsychiatric electroshock therapy? Medical Hypotheses,1994;43:69-74.

23. Epi lepsy


Caramia MD, Gigli G, Iani C, Desiato MT, Diomedi M,Palmieri MG, Bernardi G. Distinguishing forms ofgeneralised epilepsy using magnetic brain stimulation.Electoenc. clin. Neurophysiology, 1996; 98:14-19 23.

Classen J, Witte OW, et al. Epileptic seizures triggereddirectly by focal transcranial magnetic stimulation.Electroencephalogr. Clin. Neurophysiol 1995;94:19-25.


Jennum P, Winkel H, et al. EEG changes followingrepetitive transcranial magnetic stimulation in patientswith temporal lobe epilepsy. Epilepsy Res. 1994;18:167-73.


Ziemann U, Lönnecker S, Steinhoff BJ, Paulus W. Effectsof Antiepileptic Drugs on Motor Cortex Excitability inHumans: A Transcranial Magnetic Stimulation Study.Annals of Neurology, 1996;40:367-378.

24. Ex peri men tal Re search

Baker SN, Olivier E, Lemon RN. Recording an IdentifiedPyramidal Volley Evoked by Transcranial MagneticStimulation in a Conscious Macaque Monkey. Exp BrainRes, 1994, 99: 529-532.


Chen R, Classen J, Gerloff C, Celnik P, Wassermann EM,Hallet M, Cohen LG. Depression of motor cortexexcitability by low frequency magnetic stimulation.Neurology, 1997;48:1398-1403.



Kitagawa H, Møller AR. Conduction Pathways andGenerators of Magnetic Evoked Spinal Cord Potentials: AStudy in Monkeys. Electroenceph Clin Neurophysiol,1994, 93: 57-67.




25. Fa cial Nerve

Ghezzi A, Callea L, Zaffaroni M, Zibetti A, Montanini R.Clinical Application of Magnetic Transcranial Stimulationin Facial Nerve Lesions. In: Clinical Applications ofMagnetic Stimulation. Lissens M.A. (Ed.), Peeters Press,Belgium 1992: 234-246.

Kandler RH, Jarratt JA. Magnetic Stimulation in Bell'sPalsy. J Neurol, Neurosurg and Psychiat, 1991, 54: 1022.

Kotterba S, Tegenthoff M, Malin JP. Perioperative lesionsof the facial nerve: follow-up investigations usingtranscranial magnetic stimulation. Eur ArchOtorhynolaryngol, 1997;254:140-144.

Kotterba S, Tegenthoff M, Malin J.-P. TranscranialMagnetic Stimulation after Perioperative Lesion of theFacial Nerve. Larngo Rhina Otologie, 1993, 72: 1-56.(German)

Laranne J, Rimpilainen I, Karma P, Eskola H, Hakkinen V, Laippala P. A comparison of transcranial magneticstimulation with electroneurogaphy as a predictive test inpatients with Bell's palsy. European Archives ofOto-Rhyno-Laryngology, 1995;252:344-347.

Meyer BU, Britton TC, Benecke R. Investigation ofUnilateral Facial Weakness: Magnetic Stimulation of theProximal Facial Nerve and of the Face-Associated MotorCortex. J. Neurology, 1989, 236: 102-107.

Rijntjes M, Tegenthoff M, Liepert J, Leonhardt G,Kotterba S, Muller S, Kiebel S, Malin JP, Diener HC,Weiller C. Cortical reorganization in patients with facialpalsy. Annals of Neurology, 1997;41:621-630 26.

Schmid UD, Moller AR. Schmid J. Transcranial MagneticStimulation Excites the Labyrinthine Segment of the Facial Nerve: An Intraoperative Electrophysiological Study InMan. Neuroscience Letters, 1991, 124: 273-276.

Tokimura H, Yamagami M, Tokimura Y, Asakura T,Atsuchi M. Transcranial Magnetic Stimulation Excites theRoot Exit Zone of the Facial Nerve. Neurosurgery, 1993,32: 414-416.

Wolf SR, Schneider W, Berg M, Hain CT, Wigand ME.Facial Nerve Involvement in Patients with AcousticNeurinomas. Examination with Magnetic Single andBi-Stimulation. Acta Otolaryngol (Stockh)1995;520:29-32.

26. Fa cili ta tion

Also see sec tion on Si lent Pe ri od.

Catano A, Houa M, Noel P. Magnetic transcranialstimulation: dissociation of excitatory and inhibitorymechanisms in acute strokes. Electroencephalography andclinical Neurophysiology, 1997;105:29-36.


Hiroshi Nakamura, Hideki Kitagawa, YoshiharuKawaguchi, Haruo Tsuji, Haruo Takano, ShinichiNakaton. Intracortical facilitation and inhibition afterpaired magnetic stimulation in humans under anaesthesia.Neuroscience Letters, 1995;199:155-157.

Izumi SI, Findley TW, Ikai T, Andrews J, Daum M, ChinoN. Facilitatory Effect of Thinking about Movement onMotor-Evoked Potentials to Transcranial MagneticStimulation of the Brain. American Journal of PhysicalMedicine & Rehabilitation, 1995;74:207-213.

Kaneko K, Kawai S, Fuchigama Y, Shiraishi G, Ito T.Intracortical facilitation after transcranial magnetic doublestimulation. Muscle and Nerve, 1996;19:1043-1045





27. Gas tro en ter ol ogy

Also see Stroke.

Aziz Q, Rothwell JR, Barlow J, Thompson DG. Modulation of Esophageal Responses to Magnetic Stimulation of theHuman Brain by Swallowing and by Vagal Stimulation.Gastroenterology, 1995;109:1437-1445.


28. Guillain- Barré Syn drome

Boniface S, Mills K. Clinical Applications of TranscranialStimulation in Hereditary Motor and Sensory Neuropathyand in Inflammatory Neuropathies. In: ClinicalApplications of Magnetic Stimulation. Lissens M.A. (Ed.),Peeters Press, Belgium 1992: 255-262.

Kandler RH, Jarratt JA. Magnetic Stimulation inGuillain-Barré Syndrome. J. Clin Neurophysiol. 1992, 22:1, 145s.

29. Here di tory Spas tic Para pare sis

Claus D, Waddy HM, Harding AE, Murray NMF, ThomasPK. Hereditary Motor and Sensory Neuropathies andHereditary Spastic Paraplegia: A Magnetic StimulationStudy. Ann Neurol, 1990, 28: 43-49.

Thompson PD, Day BL, Rothwell JC, et al. TheInterpretation of Electromyographic Responses toElectrical Stimulation of the Motor Cortex in Diseases ofthe Upper Motoneurone. J. Neurolog Sciences, 1987, 80:91-110.

30. His tory and Back ground

Barker AT, Jalinous R, Freeston IL. Non InvasiveMagnetic Stimulation of the Human Motor Cortex. Lancet 1985, 1: 1106-7.

Bickford RG, Fremming BD. Neural Stimulation by PulsedMagnetic Fields in Animals and Man. In: Digest of the 6thInternational Conference on Medical Electronics andBiological Engineering, 1965 (Tokyo), Paper 7-6.

D’Arsonval A. Dispositifs Pour la Mesure des CourantsAlternatifs de Toutes Frequences. CR Soc Biol (Paris)1896, May 2: 450-1.

Geddes LA. History of Magnetic Stimulation of theNervous System. J. Clin Neurophysiol. 1991, 8: 3-9.

Jalinous R, Barker R, Freeston IL. The DesignConsiderations and Performance of a Magnetic NerveStimulator In: IEEE Conf Mag Fields Med Biol 1985, 257:59-63.

Polson MJR, Barker AT, Freeston IL. Stimulation of Nerve Trunks with Time-varying Magnetic Fields. Med Biol EngComput 1982, 20: 243-4.

31. Hun ting don's Dis ease

Eisen AA, Bohlega S, Bloch M, Hayden M. Silent periods,long latency reflexes and cortical MEPs in Huntington'sDisease and at Risk Relative. Electroenceph & ClinNeurophys, 1989, 74: 444-449.

Hömberg V, Lange HW. Central Motor Conduction toHand and Leg Muscles in Huntington's Disease.Movement Disorders, 1990, 5: 214-418.

Meyer BU, Noth J, Herwig, et al. Motor Responses Evoked by Magnetic Brain Stimulation in Huntington's Disease.EEG & Clin Neurophys, 1992, 84: 321-324.

Meyer BU, Conrad B. Neurophysiological and DiagnosticApplication of Transcranial Brain Stimulation in BasalGanglia Disorders. In: Clinical Applications of MagneticStimulation. Lissens M.A. (Ed.), Peeters Press, Belgium1992: 185-201.

Priori A, Inghilleri M, Berardelli A. Transcranial BrainStimulation in Basal Ganglia Diseases. In: ClinicalApplications of Magnetic Stimulation. Lissens M.A. (Ed.),Peeters Press, Belgium 1992: 175-184.

Tegenthoff M, Vorgerd M, Juskowiak F, Roos V, Malin J.-P Postexcitatory inhibition after transcranial magnetic singleand double brain stimulation in Huntington's disease.Electroencephalogr Clin Neurophysiol, 1996;101:298-303.



32. Hys teria

Janssen BA, Theiler R, Grob D, Dvorak J. The role ofmotor evoked potentials in psychogenic paralysis. Spine1995;20:608-611.

Jellinek DA, Bradford R, Bailey I, Symon L. The Role ofMotor Evoked Potentials In The Management ofHysterical Paraplegia: Case Report. Paraplegia 1992, 30:300-302.

33. In hi bi tion

See also sec tion on Si lent Pe ri od.

Benecke R, Classen J. Inhibitory phenomena in individualmotor units induced by transcranial magnetic stimulation.Electroencephalogr Clin Neurophysiol: ElectromyogrMotor Contr. 1995;97:264-274.

Berardelli A, Rona S, Inghilleri M, Manfredi M. Corticalinhibition in Parkinson's disease - A study with pairedmagnetic stimulation. Brain 1996;119:71-77.

Boroojerdi B, Diefenbach K, Ferbert A. Transcallosalinhibition in cortical and subcortical cerebral vascularlesions. Journal of the Neurological Sciences,1996;144:160-170.

Catano A, Houa M, Noel P, Magnetic transcranialstimulation: dissociation of excitatory and inhibitorymechanisms in acute strokes. Electroencephalography andclinical Neurophysiology, 1997;105:29-36.


Hiroshi Nakamura, Hideki Kitagawa, YoshiharuKawaguchi, Haruo Tsuji, Haruo Takano, ShinichiNakaton. Intracortical facilitation and inhibition afterpaired magnetic stimulation in humans under anaesthesia.Neuroscience letters 1995;199:155-157.







Ziemann U. Lönnecker S, Paulus W. Inhibition of humanmotor cortex by ethanol. A transcranial magneticstimulation study. Brain 1995;118:1437-1446.

34. Kall man's Syn drome

Danek A, Heye B, Schroedter R. Cortically Evoked MotorResponses in Patients with Xp22.3-Linked Kallmann'sSyndrome and in Female Gene Carriers. Annals ofNeurology, 1992, 31: 3, 299 - 304.

Krams M, Quinton R, Mayston MJ, Harrison LM, DolanRJ, Bouloux PMG, Stephens JA, Frakckowiak RSJ,Passingham RE. Mirror movements in X-linked Kallman'ssyndrome. 2. A PET study Brain, 1997;120:1217-1228.

Mayston MJ, Harrison LM, Quinton R, Stephens JA,Krams M, Bouloux PMG. Mirror movements in X-linkedKallman's syndrome. 1. A neurophysiological study Brain,1997;120:1199-1216.

35. Locked- in Syn drome

Bassetti C, Mathis J, Hess CW. Multimodalelectrophysiological studies including motor evokedpotentials in patients with locked-in-syndrome: report ofsix patients. Journal of Neurology Neurosurgery andPsychiatry 1994;57:1403-1406.

36. Mag netic Pulse Pairs

Kaneko K, Kawai S, Fuchigama Y, Shiraishi G, Ito T.Intracortical facilitation after transcranial magnetic doublestimulation. Muscle and Nerve, 1996;19:1043-1045.



Nakamura H, Kitagawa H, Kawaguchi Y, Tsuji H, TakanoH, Nakatori S. Intracortical facilitation and inhibition after paired magnetic stimulation in humans under anaesthesia.Neuroscience Letters 1995;199:155-157.



Schulze-Bonhage, Knott K, Ferbert A. Effects ofcarbamezepine on cortical excitatory and inhibitoryphenomena: a study with paired transcranial magneticstimulation. Electroencephalography and ClinNeurophysiol, 1996;99:267-273 36.



Vorgerd M. Tegenthoff M. Juskowiak F. Roos V. Malin J-P. Transcranial magnetic double stimulation: Methods andclinical studies Z. EEG-EMG, 1996;27: 85-91. (Germanwith English Abstract)


Ziemann U, Winter M, Reimers CD, Reimers K, Tergau F,Paulus W. Impaired Motor cortex inhibition in patientswith amyotrophic lateral sclerosis - Evidence from pairedtranscranial magnetic stimulation. Neurology,1997;49:1292-1298.

37. Mir ror Move ments

Britton TC, Meyer BU, Benecke R. Central MotorPathways in Patients with Mirror Movements. J. Neurol.Neurosurg and Psychi 1991, 54: 505-510.

Cohen LG, Meer J, Tarkka I, Bierner S, Leiderman DB,Dubinsky RM, Sanes JN, Jabbari B, Branscum B, Hallet M. Congenital Mirror Movements. Brain, 1991, 114: 381-403.

Kanouchi T, Yokoto T, Isa F, Ishii K, Senda M. Role ofipsilateral motor cortex in mirror movements. Journal ofNeurology Neurosurgery and Psychiatry, 1997;62:629-632.

Rothwell JC, Colebatch J, Britton TC, Priori A, Thompson PD, Day BL, Marsden CD. Physiological Studies in apatient with Mirror Movements and Agenesis of theCorpus Callosum. J. Physiol 1991, 438: 34.

Nirkko AC, Rosler KM, Ozdoba C, Heid O, Schroth G,Hess CW. Human cortical plasticity:Functional recoverywith mirror movements. Neurology, 1997;48:1090-1093.

Van Der Linden C, Bruggeman R. Bilateral Small-HandMuscle Motor Evoked Responses in a Patient withCongenital Mirror Movements. Electromyogr ClinNeurophysiol 1991, 31: 361-364.

Watson SRD, Colebatch JG. Pathophysiology of congenital mirror movements. Journal of Clinical Neuroscience,1997;4:69-74.

38. Mis cel la ne ous Dis eases


Bassetti C, Mathis J, Hess CW. Multimodalelectrophysiological studies including motor evokedpotentials in patients with locked-in-syndrome: report ofsix patients. Journal of Neurology Neurosurgery andPsychiatry 1994; 57: 1403-1406.

Brown P, Ridding MC, Werhahn KJ, Rothwell JC,Marsden CD. Abnormalities of the balance betweeninhibition and excitation in the motor cortex of patientswith cortical myclonus. Brain 1996;119:309-317.

Del Carro U, Riva D, Comi GC, Locatelli T, Magnani G,Levati N, Viganó R, Sambruni I, Canal N.Neurophysiological Evaluation in Detrusor Instability.Neurourology and Urodynamics, 1993, 12: 455-62.

Endo C, Kakigi R, Tachikawa N, Miyahara M, Kuroda Y.Detection of Central Nervous System Lesion in a Patientwith Fisher's Syndrome. Internal Medicine, 1993, 32:722-24.


Ikoma K, Samii A, Mercuri B, Wassermann EM, HallettM. Abnormal cortical excitability in dystonia. Neurology1996:46;1371-1376.

Lazzaro VDi, Restuccia D, Fogli D, Nardone R, Mazza S,Tonali P. Central Sensory and Motor Conduction inVitamin B12 Deficiency. Electroencephalog ClinNeurophysiol, 1992, 84: 433-439.

Mano Y, Nakamuro T, Ikoma K, Sugata T, Morimoto S,Takayanagi T, Mayer RF. Central Motor Conductivity inAged People. Internal Medicine, 1992, 31: 1084-1087.

Meyer BU, Britton TC, Benecke R, Bischoff C, MachetanzJ. Conrad B. Motor Responses Evoked by Magnetic BrainStimulation in Psychogenic Limb Weakness: DiagnosticValue and Limitations. J. Neurol 1992, 239: 251-255.

Mills KR, Nithi KA. Motor cortex stimulation does notreset primary orthostatic tremor. Journal of Neurology,Neurosurgery & Psychiatry, 1997;63:553 38.


Zaaroor M, Bleich N, Chistyakov A, Pratt H, Feinsod M.Motor evoked potentials in the preoperative andpostoperative assessment of normal pressurehydrocephalus. Journal of Neurology, Neurosurgery andPsychiatry, 1997;62L517-521.

Yokota T, Yoshino A, Hirashima F, Komori T, Myatake T.Increased central motor tract excitability inCreutzfeldt-Jakob disease. Journal of the NeurologicalSciences 1994;123:33-37.


39. Mo tor Cor ti cal In hi bi tion

See section on Inhibition.

40. Mo tor Evoked Po ten tials





Jennum P, Winkel H, Fuglsang-Fredriksen A. Repetitivemagnetic stimulation and motor evoked potentials.Electroencephalogr Clin Neurophysiol 1995;97:96-101.

Kamen G, Caldwell GE. Physiology and Interpretation ofthe Electromyogram. Journal of Neurophysiology,1996;13:366-384




Maloney SR, Bastings EP, Blair D, Quinlevan L, Good DC. The course of cortico-hypoglossal projections in the human brainstem: functional testing using transcranial magneticstimulation. Brain, 1997;120:1910-1911.

Mathis J, Gurfinkel VS, Struppler A. Facilitation of motorevoked potentials by postcontraction response (Konstammphenomenon). Electroencephalogr Clin Neurophysiol,1996;101:298-303.




Muellbacher W, Mamoli B. The course ofcortico-hyperglossal projections in the human brainstem:functional testing using transcranial magnetic stimulation.Brain, 1997;120:1909-1910.


Nielson JF. Improvement of amplitude variability of motorevoked potentials in multiple sclerosis patients and inhealthy subjects. Electroencephalography and clinicalNeurophysiology, 1996;101: 404-411.

Ravnborg M. The role of transcranial magneticstimulations and motor evoked potentials in theinvestigation of central motor pathways in multiplesclerosis. Danish Medical Bulletin, 1996;43:448-462 40.

Roricht S, Irlbacher K, Petrow E, Meyer BU. Normativedata for callosally and corticospinally mediatedelectromyographic effects in hand muscles following ahemisphere-selective magnetic cortex stimulation in man.Z. EEG-EMG, 1997;28:34-38.

Samii A, Wassermann EM, Ikoma K, Mercuri B, et al.Decreased postexercise facilitation of motor evokedpotentials in patients with chronic fatigue syndrome ordepression. Neurology, 1996;47:1410-1414.

Schulz U, Ferbert A. Variability of motor evokedpotentials: Comparison of three small hand muscles.Z. EEG-EMG, 1996;27:143-150.

Urban PP, Hopf HC, Connemann B, Hundemer HP,Koehler J. Technical considerations of electromyographictongue muscle recordings using transcranial magneticstimulation. Brain, 1997;120:1911-1914.

Zaaroor M, Bleich N, Chistyakov A, Pratt H, Feinsod M.Motor evoked potentials in the preoperative andpostoperative assessment of normal pressurehydrocephalus. Journal of Neurology, Neurosurgery andPsychiatry, 1997;62:517-521.

41. Mo tor Neu rone Dis ease

Cohen L, Brazin B, Sirigu A, Meininger V,Pierrot-Deseilligny C. Progressive upper limb monoparesis:a form of primary lateral sclerosis? Two cases withmetabolic brain imaging and transcranial magneticstimulation. European Journal of Neurology,1997;4:294-296.

Desioto MT, Caramia MD. Toward a neurophysiologicalmarker of amyotropic lateral sclerosis as revealed bychanges in cortical excitability. Electroenceph. clin.Neurophysiol., 1997;105:1-7.

Eisen A, Entezaritaher M, Stewart H. Cortical projectionsto spinal motoneurones: Changes with aging andamyotrophic lateral sclerosis. Neurology1996;46:1396-1404.

Feistner H, Awiszus F, Sailer M, Hinrichs H, Heinze HJ. A method for rapid response estimation of single humanmotorneurones to transcranial magnetic and peripheralelectrical stimulation.Z. EEG-EMG, 1996;27:80-84. (German)

Mano Y, Morita Y, Tamura R, Morimoto S, Takayanagi T,Mayer R. The Site of Action of Magnetic Stimulation ofHuman Motor Cortex in a Patient with Motor NeuronDisease. Journal of Electromyography and Kinesiology,1993, 3: 245-250.

Mills KR, Nithi KA. Corticomotor threshold is reduced inearly sporadic amyotrophic lateral sclerosis. Muscle &Nerve, 1997;20:1137-1141.

Nakajima M, Eisen A, McCarthy R, Olney RK, AminoffMJ. Reduced corticomotoneuronal excitatory postsynapticpotentials (EPSPs) with normal la afferent EPSPs inamyotrophic lateral sclerosis. Neurology,1996;47:1555-1561.


Ziemann U, Winter M, Reimers CD, Reimers K, Tergau F,Paulus W. Impaired Motor cortex inhibition in patientswith amyotrophic lateral sclerosis - Evidence from pairedtranscranial magnetic stimulation. Neurology,1997;49:1292-1298.


42. Mul ti ple Scle ro sis

Boniface SJ, Schubert M, Mills KR. Suppression and LongLatency Excitation of Single Spinal Motoneurons byTranscranial Magnetic Stimulation in Health, MultipleSclerosis, and Stroke. Muscle and Nerve, 1994, 17:642-646.

Kandler RH, Jarratt JA, Davies-Jones GAB, Gumpert EJW, Sager HJ, Venables GS. The Role of Magnetic Stimulationin the Diagnosis of Multiple Sclerosis. J. NeurologicalSciences, 1991, 106: 31-34.

Kandler RH, Jarratt JA, Davies-Jones GAB, Gumpert EJW, Sager HJ, Venables GS, Zeman A. The Role of MagneticStimulation as a Quantifier of Motor Disability in Patientswith Multiple Sclerosis. J. Neurological Sciences 1991, 106: 25-30.


Nielsen JF, Klemar B, Hansen HJ, Sinkjaer T. A newtreatment with repetitive magnetic stimulation in multiplesclerosis. Journal of Neurology, Neurosurgery andPsychiatry, 1995;58:254-255.

Nielson JF, Improvement of amplitude variability of motorevoked potentials in multiple sclerosis patients and inhealthy subjects. Electroencephalography and ClinNeurophysiol, 1996;101: 404-411.

Nielson JF, Sinkjaer T. Long-lasting depression of soleusmotoneurons excitability following repetitive magneticstimuli of the spinal cord in multiple sclerosis patients.Multiple Sclerosis, 1997;3:18-30.

Nielson JF. Frequency-dependent conduction delay ofmotor evoked potentials in multiple sclerosis. Muscle &Nerve, 1997;20:1264-1274.


Ravnborg M. The role of transcranial magneticstimulations and motor evoked potentials in theinvestigation of central motor pathways in multiplesclerosis. Danish Medical Bulletin, 1996;43:448-462.

Roricht S, Meyer BU. Responses of single motor units inrelaxed hand muscles following magnetic motor cortexstimulation in patients with multiple sclerosis.Z. EEG-EMG, 1997;28:130-135.

Sheean GL, Murray NMF, Rothwell JC, Miller DH,Thompson AJ. An electrophysiological study of themechanism of fatigue in multiple sclerosis. Brain,1997;120:299-315.

43. Myo clo nus

Also see sec tion on Epi lepsy.

Brown P, Ridding MC, Werhahn KJ, Rothwell JC,Marsden CD. Abnormalities of the balance betweeninhibition and excitation in the motor cortex of patientswith cortical myoclonus. Brain 1996;119:309-317.

Cantello R, Gianelli M, Civardi C, Mutani R. Focalsubcortical reflex myoclonus: A clinical andneurophysiological study. Archives of Neurology,1997;54:187-196.

Kanouchi T, Yokata T, Kamata T, Ishii K, Senda M.Central pathway of photic reflex myoclonus. Journal ofNeurology, Neurosurgery, and Psychiatry,1997;62:414-417.

Reutens DC, Puce A, Berkovic SF. Corticalhyperexcitability in progressive myclonus epilepsy.Neurology, 1993;43:186-192.

Rothwell JC, Brown P. The spread of myoclonic activitythrough sensorimotor cortex in cortical reflex myoclonus.Advances in Neurology, 1995;67:143-155.

Strafella A, Ashby P, Lang AE. Reflex myclonus incortical-basal ganglionic degeneration involves atranscortical pathway. Movement Disorders,1997;12:360-369.

44. Neu ro pa thy

Also see section on Peripheral Stimulation.

Benecke R. Magnetic stimulation in the assessment ofperipheral nerve disorders. Baillière's Clinical Neurology1996;5:115-128.

Chistyakov AV, Soustiel JF, Hafner H, Feinsod M. Motorand Somatosensory Conduction in Cervical Myelopathyand Radiculopathy. Spine 1995;20:2135-2140.





Valls-Sollé J, Martinez AC, Graus F, Saiz A, Arper J, GrauJM. Abnormal sensory nerve conduction in multifocaldemyelinating neuropathy with persistent conductionblock. Neurology 1995;45:2024-2028.

Yokota T, Inaba A, Yuki N, Ichikawa T, Tanaka H, SaitoY, Kanouchi T. The F wave disappears due to impairedexcitability of motor neurons or proximal axons ininflammatory demyelinating neuropathies. Journal ofNeurology Neurosurgery and Psychiatry, 1996;60:650-654.

45. Op er at ing Room Moni tor ing

Also see section on Anaesthesia.

Anderson LC, Hemler DE, Luethke JM, Latchaw RE.Transcranial Magnetic Evoked Potentials Used to Monitorthe Spinal Cord During Angiography of the Spine. Spine,1994, 19: 613-616.


Herdmann J, Deletis V, Harvey L, Edmonds Jr, Morota N.Spinal Cord and Nerve Root Monitoring in Spine Surgeryand Related Procedures. Spine, 1996;21:879-885.

Jones SJ. Harrison R. Koh KF, Mendoza N, Crockard HA.Motor evoked potential monitoring during spinal surgery:responses of distal limb muscles to transcranial corticalstimulation with pulse trains. Electroencephalography andClin Neurophysiol, 1996;100:375-383.


Kitagawa H, Nakamura H, Kawaguchi Y, Tsuji H, SatoneT, Takano H, Nakatoh S. Magnetic-Evoked CompoundMuscle Action Potential Neuromonitoring in SpineSurgery. Spine, 1995; 20: 2233-2239.

Moroto N, Deletis V, Constantini S, Kofler M, Cohen H,Epstein F. The role of motor evoked potentials duringsurgery for intermedullary spinal cord tumors.Neurosurgery, 1997;41:1327-1336.

Thumfart WF, Pototschnig C, Zorowka P, Eckel HE.Electrophysiologic Investigation of Lower Cranial NerveDiseases by Means of Magnetically StimulatedNeuromyography of the Larynx. Annal of OtologyRhinology and Laryngology, 1992, 101: 629-634.

Watt JWH, Fraser MH, Soni BM, Sett PK, Clay R. Totali.v. anaesthesia for transcranial magnetic motor evokedpotential spinal cord monitoring. British Journal ofAnaesthesia 1996;76:870-871.

Zaaroor M, Bleich N, Chistyakov A, Pratt H, Feinsod M.Motor evoked potentials in the preoperative andpostoperative assessment of normal pressurehydrocephalus. Journal of Neurology, Neurosurgery andPsychiatry, 1997;62:517-521.

46. Pae di at rics

Alfonsi E, Merlo IM, Monafo V, Lanzi G, Ottolini A,Veggiotti P, Moglia A. Electrophysiological Study ofCentral Motor Pathways in Ataxia-Telangiectasia. J. ChildNeurol 1997;12: 327-331.


Brouwer B, Smits E. Corticospinal imput onto motorneurons projecting to ankle muscles in individuals withcerebral palsy. Developmental Medicine and ChildNeurology, 1997;38:787-796.


Eyre JA, Miller S, Rash V. Constancy of CentralConduction Delays During Development in Man:Investigation of Motor and Somatosensory PathwaysInvolving the Upper Limb. J. Physiol, 1991, 434: 441-452.

Heinen F, Korinthenberg R. Does Transcranial MagneticStimulation Allow Early Diagnosis of Rett Syndrome ?Neuropaediatrics, 1996; 27: 223-224.

Maegaki Y, Maeoka Y, Ishii S, Shiota M, Takeuchi A,Yoshino K, Takeshita K. Mechanisms of central motorreorganisation in pediatric hemiplegic patients.Neuropediatrics, 1997;28:168-174.


Muller K, Kasslliyya F, Reitz M. Ontogeny of ipsilateralcorticospinal projections: A developmental study withtranscranial magnetic stimulation. Annals of Neurology,1997;42:705-711.


Netzu A, Kimura S, Uehara S, Kobayashi T, Tanaka M,Saito K. Magnetic stimulation of the motor cortex inchildren: Maturity of the corticospinal pathway andproblem of clinical application. Brain and Development,1997;19:176-180.

Scarpini C, Mondelli M, Guazzi GC, Federico A.Ataxia-telangiectasia: Somatosensory, brainstem auditoryand motor evoked potentials in six patients.Developmental Medicine and Child Neurology1996;38:65-73.


Unclés P, Lorente S. Electrophysiologic Measures ofDelayed Maturation in Attention-Deficit HyperactivityDisorder. Journal of Child Neurology, 1996;11:155-156.

47. Pain

Cruccu G, Frisardi G, Pauletti G, Romaniello A, ManfrediM. Excitability of the central masticatory pathways inpatients with painful temporomandibular disorders. Pain,1997;73:447-454.

van der Kamp W, VandenBrink AM, Ferrari MD, vanDijk. Interictal cortical hyperexcitability in migraine patientsdemonstrated with transcranial magnetic stimulation.Journal of the Neurological Sciences, 1996;139:106-110.

van der Kamp W, VandenBrink AM, Ferrari MD, vanDijk. Interictal cortical excitability to magnetic stimulation infamilial hemiplegic migraine. Neurology,1997;48:1462-1464.

Migita K, Tohru U, Arita K, Monden S. TranscranialMagnetic Coil Stimulation of Motor Cortex in Patientswith Central Pain. Neurosurgery, 1995;36:1-4.

48. Para plegia

See sec tions on Spi nal Dis or ders and Urol ogy.

49. Park in son's Dis ease

See also sec tion on Si lent Pe riod.


Berardelli A, Rona S, Inghilleri M, Manfredi M. Corticalinhibition in Parkinson's disease - A study with pairedmagnetic stimulation. Brain, 1996;119:71-77.

Cunnington R, Iansek R, Thickbroom GW, Laing BA,Mastaglia FL, Bradshaw JL, Phillips JG. Effects of magneticstimulation over supplementary motor area on movementin Parkinson's disease. Brain, 1996;119:815-822.

Ellaway PH, Davey NJ, et al. The relation betweenbradykynesia and excitability of the motor cortex assessedusing transcranial magnetic stimulation in normal andparkinsonian subjects. Electroencephalogr ClinNeurophysiol 1995;97:169-178.


Kandler RH, Jarratt JA, Sagar HJ, Gumpert E.J.W,Venables G.S, Davies-Jones G.A.B, Jordon N.Abnormalities of Central Motor Conduction in Parkinson's Disease. J. Neurol Sciences, 1990, 100: 94-97.

Pascual-Leone A, Valls-Solé J, Brasil-Neto JP, CammarotaA, Grafman J, Hallett M. Akinesia in Parkinson's Disease.Effects of Subthreshold Repetitive Motor CortexStimulation. Neurology, 1994, 44: 892-898.

Pascual-Leonè A, Valls-Solle J, et al. Resetting of essentialtremor and postural tremor in Parkinson's disease withtranscranial magnetic stimulation. Muscle and Nerve,1994;17:800-807.

Pascual-Leonè A, Alonso M, et al. Lasting beneficialeffects of rapid-rate transcranial stimulation on slowness inParkinson's disease. Neurology, 1995;45:550P, A315.

Ridding MC, Inzelberg R, Rothwell JC. Changes inexcitability of motor cortical circuitry in patients withParkinson's disease. Annals of Neurology,1995;37:181-188.



Tsai CH, Semmier JG, Kimber TE, Thickbroom G, Stell R, Mastaglia FL, Thompson PD. Modulation of primaryorthostatic tremor by magnetic stimulation over the motorcortex. Journal of Neurology, Neurosurgery and Psychiatry, 1998;64:33-36.

Young MS, Triggs WJ, Bowers D, Greer M, Friedman WA. Stereotactic pallidotomy lengthens the transcranialmagnetic cortical stimulation silent period in Parkinson'sdisease. Neurology, 1997:49:1278-1283.

50. Pe riph eral Stimu la tion

See also sections on Facial nerve, Thoracic Medicine andUrology.

Benecke R. Magnetic stimulation in the assessment ofperipheral nerve disorders. Baillière's Clinical Neurology,1996;5:115-128.



Struppler A, Jakob C, Muller-Barna P, Schmid M,Lorenzen H-W, Paulig M, Prosiegal M. New method forearly rehabilitation in extreme palsies of central origin bymagnetic stimulation. Z. EEG-EMG 27(1996) 151-157.(German with English Abstract)

51. Plas tic ity


Cohen LG, Celnik P, Pascual-Leone A, Corwell B, Faiz L,Danbrosla J, Honda M, Sadato N, Gerloff C, M.Dolores C,Hallett M. Functional Relevance of cross-modal plasticityin blind humans. Nature, 1997;389:180-183.

Flor H, Elbert T, Knecht S, Weinbruch C, Pantev C,Birbaumer N, Larbig W, Taub E. Phantom limb pain as aperceptual correlate of cortical reorganization followingarm amputation. Nature, 1995;375:482-484.


Kew JJM, Halligan P, Marshall JC, Passingham RA,Rothwell JC, Riddind MC, Marsden CD, Brooks DJ.Abnormal access of axial vibrotactile input intodeafferinated somatosensory cortex in human upper limbamputees. J. Neurophysiol. 1997;77:2753-2764.

Mano Y, Nakamuro T, Tamura R, Takayanagi T,Kawanishi K, Tamai S, Mayer RF. Central MotorReorganisation after Anastomosis of the Musculotaneousand Intercostal Nerves Following Cervical Root Avulsion.Annals of Neurology, 1995;38:15-20.


Nirkko AC, Rosler KM, Ozdoba C, Heid O, Schroth G,Hess CW. Human cortical plasticity:Functional recoverywith mirror movements. Neurology, 1997;48:1090-1093.

Rijntjes M, Tegenthoff M, Liepert J, Leonhardt G,Kotterba S, Muller S, Kiebel S, Malin JP, Diener HC,Weiller C. Cortical reorganization in patients with facialpalsy. Annals of Neurology, 1997;41:621-630.


Wunderlich G, Knorr U, Herzog H, KiwitJCW, Freund HJ, Seitz RJ. Precentral Glioma Location Determines theDisplacement of Cortical Hand Representation.Neurosurgery, 1998;42:18-27 52.

52. Psy chia try

Also see sections on Parkinson's Disease, Safety andSpeech.

Amassian VE, Cracco RQ, Maccabee PJ, Cracco JB HenryK. Some Positive Effects of Transcranial MagneticStimulation. Advances in Neurology, 1995;67:79-106.

Belmaker RH, Grisaru M, Ben-Shahar D, Klein E. TheEffects of TMS on Animal Models of Depression,ß-Adrenergic Receptors, and Brain Monoamines. CNSSpectrums, 1997;2:26-30.


Belmaker RH. Transcranial magnetic stimulation - apotential new frontier in psychiatry. Biol. Psychiatry1995;38:419-421.

Catala MD, Rubio B, Pascuel Leonè A. Lateralized effectof rapid-rate transcranial stimulation of dorsolateralprefrontal cortex on depression. Neurology1996;46:S28.005.


Davey NJ, Puri BK, Lewis HS, Lewis SW, Ellaway PH.Effects of antipsychotic medication on electromyographicresponses to transcranial magnetic stimulation of the motor cortex in schizophrenia. Journal of NeurologyNeurosurgery and Psychiatry, 1997;63:468-473.

Epstein CM, Figiel G, McDonald WM, Amazon-Leece J,Figiel L. Rapid rate transcranial magnetic stimulation inyoung and middle-aged refractory depressed patients.Psychiatric Annals, 1998;28:36.


George MS, Wassermann EM, Kimbrell TA, et al. Moodimprovement following daily left prefrontal repetitivemagnetic stimulation in patients with depression: Aplacebo-controlled crossover trial. Am J. Psychiatry,1997;154:1752-1756.

George MS, Wassermann EM, Wendol WA, Steppel J,Pascual-Leonè A, Basser P, Hallett M, Post RM. Changesin Mood and Hormone Levels After Rapid-RateTranscranial Magnetic Stimulation (rTMS) of thePrefrontal Cortex. The Journal of Neuropsychiatry andClinical Neurosciences, 1996;8:172-180.


Greenberg BD, George MS, Martin JD, Benjamin J,Schlaepfer T, Altemus M, Wasserman EM, Post RM,Murphy DL. Effect of prefrontal repetitive transcranialmagnetic stimulation in obsessive-compulsive disorder: Apreliminary study. American Journal of Psychiatry,1997;154:867-869.

Haag C, Padberg F, Moller HJ. Transcranial magneticstimulation (TMS). A diagnostic tool from neurology as atherapy in psychiatry? Nervenarzt, 1997;68:274-278.(German)

Hallett M, Post RM. Daily repetitive transcranial magneticstimulation (rTMS) improves mood in depression.NeuroReport, 1995;6:1853-1856.

Kolbinger HM, Hoflich et al. Transcranial magneticstimulation (TMS) in the treatment of major depression - a pilot study. Hum Psychopharm 1995;6:1853-1856.

Kirkcaldie MTK, Pridmore SA. Transcranial magneticstimulation in psychiatry. Open Mind 1996;14:7-8.

Kirkaldie MTK, Pridmore SA, Pascual-Leone A.Transcranial magnetic stimulation as a therapy fordepression and other disorders. Australian and NewZealand Journal of Psychiatry, 1997;31:264-272.

Kirkaldie M, Pridmore S, Reid P. Bridging the Skull:Electroconvulsive Therapy (ECT) and RepetitiveTranscranial Magnetic Stimulation (rTMS) in Psychiatry.Convulsive Therapy, 1997;13:83-91.

Markwort S, Cordes P, Aldenhoff J. Transcranial magneticstimulation as a therapeutic alternative toelectroconvulsive therapy in therapy-resistant depressions.Fortschr. Neurol. Psychiat., 1997;65:540-549. (German)

Pascual-Leonè A, Rubio B, Palladó F, Catalá MD.Rapid-rate transcranial magnetic stimulation of leftdorsolateral prefrontal cortex in drug-resistant depression.The Lancet, 1996;347:233-37.

Pascual-Leonè A, Catalá MD, Pascual APL. Lateralizedeffect of rapid-rate transcranial magnetic stimulation of the prefrontal cortex on mood. Neurology, 1996;46:499-502.

Puri BK, Lewis SW. Transcranial magnetic stimulation inpsychiatric research. British Journal of Psychiatry,1996;169:675-677.

Puri BK, Davey NJ, Ellaway PH, Lewis SW. AnInvestigation of Motor Function in Schizophrenia usingTranscranial Magnetic Stimulation of the Motor Cortex.British Journal of Psychiatry, 1996;169:690-695.

Samii A, Wassermann EM, Ikoma K, Mercuri B, GeorgeMS, et al. Decreased postexercise facilitation of motorevoked potentials in patients with chronic fatiguesyndrome or depression. Neurology, 1996;47:1410-1414.



Wassermann EM, Cohen LG, Flitman SS, Chen R, HallettM. Seizures in healthy people with repeated “safe” trains of transcranial magnetic stimuli. The Lancet,1996;347:825-826.


Williams WA, Steppel J, et al. Rapid transcranial magnetic stimulation (rTMS) in prefrontal cortex: mood andneurendocrine effects. Neurology, 1995;4568P,A178.

Ziemann U, Paulus W, Rothenberger A. Decreasedinhibition in Tourette's disorder: Evidence fromtranscranial magnetic stimulation. American Journal ofPsychiatry, 1997;154:1277-1284.

53. Pul mo nary Medi cine

See section on Thoracic Medicine.

54. Re ha bili ta tion and Ther apy


Kyroussis D, Mills G, Polkey MI, Hamnegard CH,Koulouris N, Green M, Moxham J. Abdominal musclefatigue after maximum ventilation in humans. Journal ofApplied Physiology, 1996;81(4):1-7.

Ljubsavljevic M, Milanovic S, Radovanovic S, Vukcevic I,Kostic V,Anastasijevic R. Central changes in musclefatigue during sustained submaximal isometric voluntarycontraction as revealed by transcranial magneticstimulation. Electroencephalogr Clin Neurophysiol,1996;101:298-303.

Mills KR, Kimiskidis V. Motor cortex excitability duringballistic forearm and finger movements. Muscle & Nerve,1996;19:468-473.

Mills KR, Thompson CCB. Human muscle fatigueinvestigated by transcranial magnetic stimulation.Neuroreport, 1995;6:1966-1968.


Nielson JF, Klemar B, Hansen HJ, Sinkjaer T. A newtreatment of spasticity with repetitive magnetic stimulation in multiple sclerosis. Journal of Neurology, Neurosurgeryand Psychiatry, 1995;58/2:254-255.

Polkey MI, Kyroussis D, Hamnegard CH, Mills GH, GreenM, Moxham J. Quadriceps strength and fatigue assessed bymagnetic stimulation of the femoral nerve in man. Muscle& Nerve, 1996; 19:549-55.

Struppler A, Jakob C, Muller-Barna P, Schmid M,Lorenzen H-W, Paulig M, Prosiegal M. New method forearly rehabilitation in extreme palsies of central origin bymagnetic stimulation.Z. EEG-EMG, 1996;27: 151-157. (German)

Struppler A, Havel P, Muller-Barna P, Lorenzen H-W, Anew method for rehabilitation of central palsy of arm andhand by peripheral magnetic stimulation. Neurol Rehabil,1997;3:145-158. (German )

55. Re peti tive Tran scra nial Mag netic Stimu la -tion

Also see sec tion on Safety.

Brandt SA, Ploner CJ, Meyer BU. Repetitive transcranialmagnetic stimulation. Potentials, limitations, and safetyaspects. Nervenarzt, 1997;68:778-784.


Meyer BU, Roricht S, Niehaus L, Brandt SA.Experimental, diagnostic, and therapeutic application ofrepetitive transcranial magnetic stimulation (rTMS) with a focus on motor cortex stimulation.Z. EEG-EMG, 1997;28:254-261.


Neilson JF. Repetitive magnetic stimulation of the cerebralcortex in normal subjects. Journal of ClinicalNeurophysiology, 1996;13:69-76.

Wassermann EM. Repetitive Transcranial Stimulation: An introduction and an overview.CNS Spectrums, 1997;2:21-25.


56. Re search

See sections on Experimental Research, ComputorModelling, Anaesthesia; Primate Studies, CoilConfiguration, etc.

57. Res pi ra tory Medi cine

See sec tion on Tho racic Medi cine.

58. Rett's Syn drome

Eyre JA, Kerr AM, Miller S, O’Sullivan MC, Ramesh V.Neurophysiological Observations on CorticospinalProjections to the Upper Limb in Subjects with RettSyndrome. J. Neurol, Neurosurg and Psychiat, 1990, 53:874-879.

59. Safety

Amassian VE, Henry K, Durkin H, Chice S, Cracco JB,Somasundaram M, Hassan N, Cracco RQ, Maccabee PJ,Eberle L. Magnetic Stimulation of Left Versus RightTemporo-Parieto-Occipital Cortex Acts Differently on theHuman Nervous Systems. J. Physiol, Kings College London Meeting, 1994, 30P, C17 (Abstract).

Andrews J, Reisman S, Johnson S, Findley W, DeLuca J,Daum M. Effects of Cortical Magnetic Stimulation onCognition and Upper Extremity Reaction Time. Proc 14Ann Int Conf IEEE Eng in Med & Biol Soc, 1992, p1420 -1421.

Barker AT, Stevens JC. Measurement of the AcousticOutput from Two Magnetic Nerve Stimulator Coils. JPhysiol, 1991, 431: 301P.

Bridgers SL. The safety of transcranial magneticstimulation reconsidered: evidence regarding cognitive and other cerebral effects. Magnetic motor stimulation: BasicPrinciples and Clinical Experience. (EEG Suppl. 43)1991;170-179.

Bridgers SL, Delaney RC. Transcranial MagneticStimulation: An Assessment of Cognitive and otherCerebral Effects. Neurology, 1989, 39: 417-419.

Boyd SG, Kandler RH, Stevens WR. A Comparison ofNoise Levels Produced By Different Magnetic Stimulators.J. Physiology, 1991, 438: 368.

Chokroverty S, Hening W, et al. Magnetic brainstimulation: safety studies. Electroencephalogr. Clin.Neurophysiol, 1995;97:36-42.

Classen J, Witte OW, et al. Epileptic seizures triggereddirectly by focal transcranial magnetic stimulation.Electroencephalogr. Clin. Neurophysiol, 1995;94:19-25.

Counter SA, Borg E, Lofqvist L, Brisma T. Hearing Lossfrom Acoustic Artifact of the Coil used in ExtracranialMagnetic Stimulation. Neurology, 1990, 40: 1159-1162.

Dhuna A, Gates J, Pascual-Leonè A. Transcranialmagnetic stimulation in patients with epilepsy. Neurology,1991;41:1067-1071.

Gates JR, Dhuna A, Pascual-Leone A. Lack of PathologicChanges in Human Temporal Lobes After TranscranialMagnetic Stimulation. Epilepsia, 1992, 33: 504-508.

Hömberg V, Netz J. Generalised Seizures Induced byTranscranial Magnetic Stimulation of Motor Cortex. TheLancet, 1989: 1223.

Jalinous R. Technical and Practical Aspects of MagneticNerve Stimulation. J. Clinical Neurophysiology, 1991, 8:10-25.

Jennum P, Winkel H, et al. EEG changes followingrepetitive transcranial magnetic stimulation in patientswith temporal lobe epilepsy. Epilepsy Res. 1994;18:167-73.

Kandler R. Letter: Safety of Transcranial MagneticStimulation. The Lancet, 1990, 335: 469.

Levy WJ, Oro J, Traad M. Motor Evoked Potentials: Issuesin Safety and Operative Monitoring. In: Spinal CordMonitoring and Electrodiagnosis. Shimoji et al. (eds),Springer Verlag Publisher, Berlin Heidelberg, Germany,1991: 273-283.

Matsumiya Y, Yamamoto T, Yarita M, Miyauchi S, KlingJW. Physical and Physiological Specification of MagneticPulse Stimuli that Produce Cortical Damage in Rats. J. Clin Neurophysiol, 1992, 9: 278-287.


Pascual-Leonè A, Dhuna A, Roth BJ, Cohen LG, HallettM. The danger of causing burns during rapid-rate magnetic stimulation in the presence of electrodes. The Lancet,1990;336:1195-1196.

Pascual-Leone A, Vals-Sole J, Brasil-Neto JP, Cohen LG,Hallett M. Seizure Induction and Transcranial MagneticStimulation. The Lancet, 1992, 339: 997.


Pascual-Leone A, Cohen LG, Shotland LI, Dang N, PikusA, Wassermann E.M, Brasil-Neto JP, Valls-Sole J, HallettM. No Evidence Of Hearing Loss In Humans Due ToTranscranial Magnetic Stimulation. Neurology, 1992, 42:647-652.

Pascual-Leone A, Houser CM, Reese K, Shotland LI,Grafman J, Sato S, Vall-Solé J, Brasil-Neto JP,Wassermann EM, Cohen LG, Hallett M. Safety ofRapid-Rate Transcranial Magnetic Stimulation in NormalVolunteers. Electroencephalog Clin Neurophysiol, 1993,89: 120-130.

Ravnborg M, Knudsen GM, Blinkenberg M. No Effect ofPulsed Magnetic Stimulation on the Blood-Brain Barrier in Rats. Neuroscience, 1990, 38: 277-280.

Roth BJ, Pascual-Leone A, Cohen LG, Hallett M. TheHeating of Metal Electrodes During Rapid Rate MagneticStimulation: A Possible Safety Hazard. Electromyogr. Clin.Neurophysiol, 1992, 85: 116-123.

Schüler P, Claus D, Hermann S. Hyperventilation andTranscranial Magnetic Stimulation: Two Methods ofActivation of Epileptiform EEG Activity in Comparision. J. Clin Neurophysiol 1993, 10: 111-115.


Tassinari CA, Michelucci R, Forti A, et al. TranscranialMagnetic Stimulation in Epileptic Patients: Usefulness and Safety. Neurology, 1990, 40: 1132-3.

Wassermann EM, Cohen LG, Flitman SS, Chen R, HallettM. Seizures in healthy people with repeated “safe “ trainsof transcranial magnetic stimuli. The Lancet1996;347:825-826.


60. Si lent Pe ri od

Also see section on Inhibition.

Berardelli A, Rona S, Inghilleri M, Manfredi M. Corticalinhibition in Parkinson's disease - A study with pairedmagnetic stimulation. Brain, 119;1996:71-77.

Brasil-Neto, Cammarota A, Valls-Solé, Pascual-Leonè A,Hallett M, Cohen LG. Role of intracortical mechanisms inthe late part of the silent period to transcranial stimulationof the human motor cortex. Acta Neurol Scand1995;92:383-386.

Braun HJ, Fritz C. Transcranial magneticstimulation-evoked inhibition of voluntary muscle activity(silent period) is impaired in patients with ischemichemispheric lesion. Stroke, 1995;26:550-553.

Braun HJ, Fritz C. Asymmetry of silent period evoked bytranscranial magnetic stimulation in stroke patients. ActaNeurol Scand, 1996;93:168-174.

Hallet M, et al. Transcranial Magnetic Stimulation -Negative Effects. Advances in Neurology,1995;67:107-113.

Haug BA, Kukowski B. Latency and Duration of theMuscle Silent Period Following Transcranial MagneticStimulation in Multiple Sclerosis, Cerebral Ischemia, andOther Upper Motoneuron Lesions. Neurology, 1994, 44:936-940.

Nilsson J, Panizza M, Arieti P. Computer-AidedDetermination of the Silent Period. J.Clin. Neurophysiol. 1997;14:136-143.

Priori A. Clinical Applications of Silent PeriodMeasurements. Advances in Occupational Medicine andRehabilitation, 1996;2:91-97.

Werhahn KJ, Classen J, Benecke R. The silent periodinduced by transcranial magnetic stimulation in musclessupplied by cranial nerves: normal data and changes inpatients. Journal of Neurology, Neurosurgery, andPsychiatry, 1995;59:586-596.

61. Sleep

Hess CW, Murray NM, Mills KR, Schriefer TN. MotorEvoked Potentials During Slow Wave Sleep and REMsleep. In: Non Invasive Stimulation of Brain and SpinalCord: Fundamentals and Clinical Applications. Alan R.Liss, Inc., 1988, 85-92.

Siao P, Day BJ, Fang J, Stakes J, Cros D, Shahani B,Merlino M, Moir M. Excitability of The Human MotorCortex During Sleep: A Magnetic Stimulation Study.Abstract Presented at the American NeurologicalAssociation Conference, 1991.


62. So ma to sen sory Evoked Po ten tials

Kalkman CJ, Drummond JC, U HS. Severe SensoryDeficits with Preserved Motor Function After Removal ofa Spinal Arteriovenous Malformation: Correlation withSimultaneously Recorded Somatosensory and MotorEvoked Potentials. Anesth Analg, 1994, 78: 165-168.

Misra UK, Kalita J. Somatosensory and motor evokedpotential changes in patients with Pott’s paraplegia. SpinalCord, 1996;34:272-276.

Pascual-Leone A, Torres F. Plasticity of the SensorimotorCortex Representation of the Reading Finger in BrailleReaders. Brain, 1993, 116: 39-52.

Tsuji S, Murai Y. Cortical Somatosensory PotentialsEvoked by Magnetic Stimulation: Effect of Body Height,Age and Stimulus Intensity. Electromyogr. Clin.Neurophysiol, 1991, 80: 32-38.

Tsuji S, Murai S, Yarita M. Cortical SomatosensoryPotentials Evoked by Magnetic Stimulation of Thoracicand Lumbar Roots. Neurology, 1993, 43: 391-396.

63. Speech - Wada Test

Claus D, Weis M, Treig T, Lang C, Eichhorn KF, Sembach O. Influence of Repetitive Magnetic Stimuli on VerbalComprehension. J. Neurol, 1993, 240: 149-150.

Epstein CM, Lah JJ, Meador K, Weissman JD, Gaitan LE,Dihenia B. Optimum stimulus parameters for lateralizedsuppression of speech with magnetic brain stimulation.Neurology, 1996;47:1590-1593.


Jennum P, Friberg L, Fuglsang-Frederiksen A, Dam M.Speech Localization Using Repetitive TranscranialMagnetic Stimulation. Neurology, 1994, 44: 269-273.

Kuchta J, Reuter B, Kurthen M, Kohler W, Linke DB.Magnetic stimulation of the speech associated areas in thebrain. Z. EEG-EMG, 1997;28:164-166.

Pascual-Leone A, Gates JR, Dhuna A. Induction of Speech Arrest and Counting Errors with Rapid-Rate TranscranialMagnetic Stimulation. Neurology, 1991, 41: 697-702.


64. Spi nal Dis or ders and In ju ries


Chang CW, Lin SM. Measurement of motor conduction in the thoracolumbar cord: A possible predictor of surgicaloutcome in cervical spondylotic mylopathy. Spine1996;21:485-491.

Chistyakov AV, Soustiel JF, Hafner H, Feinsod M. Motorand Somatosensory Conduction in Cervical Myelopathyand Radiculopathy. Spine, 1995;20:2135-2140.

Curt A, Diez V. Prognosis of spinal cord injury. Themeaning of clinical and electrophysiological findings.Nervenarzt, 1997;68:485-495. (German)

Curt A, Keck ME, Diez V. Functional outcome followingspinal cord injury: Significance of motor evoked potentialsand ASIA scores. Arch Phys Med Rehabil, 1998;79:81-86.

Herdman J, Deletis V, Edmonds HL, Morota N. Spinalcord and nerve root monitoring in spine surgery andrelated procedures. Spine, 1996;21:879-885.


Kaneko K, Kawai S, Taguchi T, Fuchigami Y, Shiraishi G.Coexisting peripheral nerve and cervical cord compression. Spine, 1997;22:636-640.

Karlsborg M, Smed A, Jesperson H, Stephenson S, Cortsen M, Jennum P, Herning M, Korfitsen E Werdelin L. Aprospective study of 39 patients with whiplash injury. ActaNeurol Scand, 1997;95:65-72.



Macdonell RAL, Donnan GA. Magnetic corticalstimulation in acute spinal cord injury. Neurology1995;45:303-306.



Misra UK, Kalita J. Somatosensory and motor evokedpotential changes in Pott's paraplegia. Spinal Cord1996;34:272-276.

Moroto N, Deletis V, Constantini S, Kofler M, Cohen H,Epstein F. The role of motor evoked potentials duringsurgery for intermedullary spinal cord tumors.Neurosurgery, 1997;41:1327-1336.

Wehling P, Cleveland S, Reinecke J, Schulitz KP.Magnetic Stimulation as a Diagnostic Tool in CervicalNerve Root Compression and Compression-InducedNeuropathy. Journal of Spinal Disorders, 1995;8:304-307.

65. Stroke

Basting EP,Rapisada G, Pennisi G, Maertens de Noordhout A, Lenaerts M, Good DC, Delwaide PJ. Mechanisms ofhand motor recovery after strokes: An electrophysiologicalstudy of central motor pathways. J. Neuro Rehab, 1997;11:97-108.

Binkofski F, Seitz RJ, Arnold S, Classen J, Benecke R,Freund HJ. Thalamic metabolism and cortical tractintegrity determine motor recovery in stroke. Annals ofNeurology, 1996;39:460-470.

Braun HJ, Fritz C. Transcranial magneticstimulation-evoked inhibition of voluntary muscle activity(silent period) is impaired in patients with ischemichemispheric lesion. Stroke, 1995;26:550-553.

Braun HJ, Fritz C. Asymmetry of silent period evoked bytranscranial magnetic stimulation in stroke patients. ActaNeurologica Scandanavia, 1996;93:168-174.


Catano A, Houa M, Noel P, Magnetic transcranialstimulation: dissociation of excitatory and inhibitorymechanisms in acute strokes. Electroencephalography andclinical Neurophysiology, 1997;105:29-36.



Hamdy S, Aziz Q, Rothwell JC, Crone R, Hughes D, TallisR, Thompson DG. Explaining oropharyngeal dysphagiaafter unilateral hemispheric stroke. The Lancet,1997;350:686-692.



Rapisarda G, Bastings E, deNoordhout AM, Pennisi G,Delwaide PJ. Can motor recovery in stroke patients bepredicted by early transcranial magnetic stimulation?Stroke, 1996;27:2191-2196.

Similowsky T, Catala M, Rancurel G, Derenne J-Ph.Impairment of Central Motor Conduction to theDiaphragm in Stroke. Am J. Respir Care Med,1996;154:436-441.

Stephan KM, Netz J, Homberg V. Prognostic value of MEP and SSEP in patients with chronic UMN lesions afterstroke. Cerebrovascular Diseases, 1995;5:407-412.


Timmerhuis TPH, Hageman G, Oosterloo SJ, RozeboomAR. The prognostic value of cortical magnetic stimulationin acute middle cerebral artery infarction compared withother parameters. Clinical Neurology and Neurosurgery,1996;98:231-236.


Turton A, Wroe S, Trepte N, Fraser C, Lemon RN.Contralateral and ipsilateral EMG responses to transcranial magnetic stimulation during recovery of arm and handfunction after stroke. Electroencephalogr ClinNeurophysiol, 1996;101:316-328.


Urban PP, Hopf HC, Zorowkar PG, Fleischer S, Andreas J.Dysarthria and lacunar stroke: Pathophysiologic aspects.Neurology, 1996;47:1135-1141.

Urban PP, Hopf HC, Fleischer S, Zorowkar PG,MullerForell W. Impaired cortico-bulbar tract function indyarthria due to hemispheric stroke - Functional testingusing transcranial magnetic stimulation. Brain,1997;120:1077-1084.


66. Tho racic Medi cine

Craggs MD, Dinner L, Lovell AT, Knight SL, GoldstoneJC. Diaphragm function assessed by multipulse magneticstimulation of phrenic nerves in man. Journal ofPhysiology, 1997;501:53.


Hamnegard CH, Wragg S, Mills G, Kyroussis D, PolkeyMI, Bake B, Moxham J, Green M. Clinical assessment ofdiaphragm strength by cervical magnetic stimulation of the phrenic nerves. Thorax, 1996;51:1239-1242.

Hamnegard CH, Wragg S, Mills G, Kyroussis D, Road J,Daskos G, Bake B, Moxham J, Green M. The effect of lung volume on transdiaphragmatic pressure. Eur Respir J,1995;8:1532-1536.

Hamnegard CH, Wragg S, Kyroussis D, Mills G, PolkeyMI, Moran J, Road J, Bake B, Green M , Moxham J.Diaphragm fatigue following maximal ventilation in man.Eur Respir J, 1996;9:241-247.

Hamnegard CH, Wragg S, Kyroussis D, Mills G, Bake B,Green M, Moxham J. Mouth pressure in response tomagnetic stimulation of the phrenic nerves. Thorax1995;50:620-624.

Harris ML, Moxham J. Measuring respiratory and limbmuscle strength using magnetic stimulation. Brit J. Intensive Care. 1998, 8:(1) 21-28.


Laghi F, Tobin MJ. Relationship betweentransdiaphramatic and mouth twitch pressures atfunctional residual capacity. European Respiratory Journal, 1997;10:530-536.

Laghi F, Harrison MJ, Tobin MJ. Comparison of magneticand electrical phrenic nerve stimulation in assessment ofdiaphragmatic contractility. J. Appl Physiol.1996;80(5):1731-1742.


Mador MJ, Rodis A, Diaz J. Diaphramatic fatigue following voluntary hyperpnea. American Journal of Critical CareMedicine 1996;154:63-67.

Mills GH, Kyroussis D, Hamnegard CH, Wragg S, PolkeyMI, Moxham J, Green M. Cervical magnetic stimulation of the phrenic nerves in bilateral diaphragm paralysis.American Journal of Respiratory and Critical CareMedicine, 1997;155:1565-1569.

Mills GH, Kyroussis D, Hamnegard CH, Wragg S,Moxham J, Green M. Unilateral Transcutaneous Magnetic Stimulation of the Phrenic Nerve. Thorax1995;50:1162-1172.

Mills GH, Kyroussis D, Hamnegard C, Wragg S, MoxhamJ, Green M. Unilateral Transcutaneous MagneticStimulation of the Phrenic Nerve. Thorax, 1995; 50:1162-1172.

Polkey MI, Kyroussis D, Hamnegard CH, Mills GH, GreenM, Moxham J. Diaphragm Strength in ChronicObstructive Pulmonary Disease. American Journal ofRespiratory and Critical Care Medicine,1996;154:1310-1317.

Polkey MI, Kyroussis D, Hamnegard CH, Hughs PD,Rafferty GF, Moxham J, Green M. Paired phrenic nervestimuli for the detection of diaphragm fatigue in humans.Eur. Respir J, 1997;10:1859-1864.

Polkey MI, Moxham J. The diaphragm in chronicobstructive pulmonary disease: How useful is it? EuropeanJournal of Clinical Investigation, 1997;27:881-884.

Polkey MI, Green M, Moxham J. Measurement ofrespiratory muscle strength. Thorax, 1995;50:1131-1135.

Similowski T, Straus C, Coic L, Derenne J-Ph.Facilitation-independent Response to the Diaphragm toCortical Magnetic Stimulation. Am J Respir Care Med,1996;154:1771-1777.


Similowski T, Straus C, Attali V, Duguet A, Jourdain B,Derenne J-Ph. Assessment of the motor pathway to thediaphragm using cortical and cervical magnetic stimulation in the decision making process of phrenic pacing. Chest,1996; 110: 1551-1557.


Similowski T, Duguet A, Straus C, Attali V, Boisteanu D,Derenne J-Ph. Assessment of the voluntary activation ofthe diaphragm using cervical and cortical magneticstimulation. Eur Respir J., 1996;9:1224-1231.

Similowski T, Fleury B, Launois S, Cathala HP, Bouche P,Derenne JP. Cervical Magnetic Stimulation: a NewPainless Method for Bilateral Phrenic Nerve Stimulation in Conscious Humans. American Physiological Society, 1989, Brief Review, 1311-1318.

Spicer M, Hughes P, Green M. A non-invasive system toevaluate diaphragmatic strength in ventilated patients.Physiol. Meas. 1997;18:355-361.

Travaline JM, Sudarshan S, Criner GJ. Recovery ofPdiTwitch following the introduction of diaphragm fatiguein normal subjects. Am J. of Respiratory and Critical CareMedicine, 1997;156:1562-1566.


Zifko UA. Electrophysiology of respiration.Nervenarzt, 1997;68:945-955. (German)

67. Urol ogy

Also see section on Colorectal Diseases.

Brodak PP, Bidair M, Joseph A, Szollar S, Saad J. Magnetic Stimulation of the Sacral Roots. Neurourology &Urodynamics, 1993, 12: 533-540.

Del Carro U, Riva D, Comi GC, Locatelli T, Magnani G,Levati N, Viganó R, Sambruni I, Canal N.Neurophysiological Evaluation in Detrusor Instability.Neurourology and Urodynamics, 1993, 12: 455-62.

Lin VWH, Wolfe V, Frost Fs, Perkash I. Micturition byfunctional magnetic stimulation. Journal of Spinal CordMedicine, 1997;20:218-226.

Lin VWH, Hsiao I, Perkash I. Micturition by functionalmagnetic stimulation in dogs: A preliminary report.Neurourology and Urodynamics, 1997;16:305-313.

McFarlane JP, Foley SJ, De Winter P, Shah JPR, CraggsMD. Acute suppression of detruser instability by magneticstimulation of the sacral nerve roots. British Journal ofUrology, 1997;80:734-741.

Sheriff MKM, Shah JPR, Fowler C, Mundy AR, CraggsMD. Neuromodulation of detrusor hyper-reflexia byfunctional magnetic stimulation. British Journal ofUrology, 1996;78:39-46.

68. Vis ual Cor tex/Op thal mics

Ashridge E, Walsh V, Cowey A. Temporal aspects of visual search studied by transcranial magnetic stimulation.Neuropsychologia, 1997;35:1121-1131.

Beckers G, Zeki S. The consequences of inactivating areasV1 and V5 on visual motion perception. Brain,1995;118:49-60.

Carter N, Zee DS. The anatomical location of saccadesusing functional imaging studies and transcranial magneticstimulation. Current Opinion in Neurology,1997;10:10-17.


Epstein CM, Zangaladze A. Magnetic coil suppression ofextrafoveal visual perception using disappearance targets.Journal of Clinical Neurophysiology, 1996;13:242-246.

Epstein CM, Verson R, Zangaladze A. Magnetic coilsuppression of visual perception at an extracalcarine site.Journal of Clinical Neurophysiology, 1996;13:247-252.

Hashimoto M, Ohtsuka K. Transcranial magneticstimulation over the posterior cerebellum during visuallyguided saccades in man. Brain, 1995;118:1185-1193.

Marg E, Rudiak D. Phosphenes Induced by MagneticStimulation Over the Occipital Brain: Description andProbable Site of Stimulation. Optometry and VisionScience, 1994, 71: 301-311.

Olson JD, Li J, Anand S, Hotson JR. Rapid-ratetranscranial magnetic stimulation delivered focally overfrontal cortex evokes saccades. Neurology, 1996;46:S44.006.


Pascual-Leone A, Gomez-Tortosa E, Grafman J, Alway D,Nichelli P, Hallett M. Induction of Visual Extinction byRapid-Rate Transcranial Magnetic Stimulation of ParietalLobe. Neurology, 1994, 44: 494-498.

69. Wil son's Dis ease

Berardelli A. et al. Involvement of Cortico-Spinal Tract inWilson’s Disease. Movement Disorders, 1990, 5: 363-347.

Chu NS. Motor Evoked Potentials in Wilson’s Disease:Early and Late Responses. J. Neurol Sci. 1990, 99: 259-269.

Meyer BU, Britton TC, Bischoff C, Machetanz J, BeneckeR, Conrad B. Abnormal Conduction in Cortico-SpinalPathways in Wilson’s Disease: Investigation of Nine caseswith Magnetic Brain Stimulation. Movements Disorders,1991, 6: 320-323.

Meyer BU, Conrad B. Neurophysiological and DiagnosticApplication of Transcranial Brain Stimulation in BasalGanglia Disorders. In: Clinical Applications of MagneticStimulation. Lissens M.A. (Ed.), Peeters Press, Belgium1992: 185-201.

Priori A, Inghilleri M, Berardelli A. Transcranial BrainStimulation in Basal Ganglia Diseases. In: ClinicalApplications of Magnetic Stimulation. Lissens M.A. (Ed.),Peeters Press, Belgium 1992: 175-184.

Last Updated RJ. Feb 28.1998.


Guide to Mag netic Stim u la tion - PSICOMAG.COM MagSrtim/mguide.pdf · Guide to Mag netic Stim u la tion ... ducted by Pascual-et al. Leone [Lan cet, 1996b, 348: 233- 238] ... plied

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