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Resources at CBS

Posted By Tommi Raij

For Patients and Healthy Volunteers Participating as Research Subjects

For Researchers

How to prepare for a magnetic resonance imaging (MRI) visit

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Most TMS studies require that you have an MRI scan before the first TMS session. MRI is non-invasive and safe for most people. However, if you have any metal or medical implants in your body or on your skin, you should not participate in a MRI study, because the strong magnetic fields in the MRI may interfere with or damage the devices, or move and heat up metal. For example, cardiac pacemakers or other medical implants are unsafe to bring into the MRI. Metal dental fillings are acceptable. You should let the investigators know if you think you might have any reasons why you should not participate in an MRI scan. They will thoroughly screen you before the scan to make sure that you can participate in the MRI scan safely. To see our MRI safety screening questions, see here.

The MRI procedure consists of changing into hospital clothes in the laboratory, filling a safety screening form, going through a metal detector, and lying on a bed that slides into a tunnel ("bore") inside the magnet. Those who suffer from claustrophobia (fear of enclosed spaces) may find being in the MRI machine uncomfortable. Because the scans are very sensitive to motion, your head will be firmly supported inside a helmet-shaped device, and you will be asked to lay very still without moving during the scans. The MRI makes loud sounds associated with its operation, but you will wear ear plugs so the sounds should not be bothersome. If you have a respiratory infection with cough or sneezing, please call at least 24 hours before your scan to re-schedule the MRI for a later time when you are better. This is because coughing or sneezing moves the head so much that the MRI scan will fail.

You cannot take your own eyeglasses or any metal inside the MRI. If the experiment requires that you need to see clearly, we will provide MRI-compatible glasses, or you may wear your own (non-colored) contact lenses. If you have any removable dental devices such as metal dentures, removable bridges, or retainers, you will be asked to remove them. If you have non-removable dental devices other than typical fillings, let the investigators know and they will determine if you can safely participate in a scan. It is recommended that women who are pregnant do not participate in MRI research, unless there is potential for direct clinical benefit to the participant.

Since the MRI magnetic fields are strong enough to wipe credit cards, you cannot bring your wallet in the MRI room. You also cannot wear any metal jewelry or make-up. We will provide a secure place to store your clothes and valuables during the scan.

We will try to make you feel comfortable during the scan. If you feel pain or become uncomfortable at any point during the visit, let the investigators know. They will try to make you more comfortable, and if that does not succeed, they will stop the scan. You may ask to stop the session at any time for any reason.

If you have any questions or concerns about participating in an MRI scan, do not hesitate to ask the study investigators or staff, or contact the CBS Director Tommi Raij.

How to prepare for a transcranial magnetic stimulation (TMS) visit

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Transcranial magnetic stimulation (TMS) is a safe and noninvasive technique for brain stimulation used for clinical and research purposes in thousands of centers worldwide. Currently, the Food and Drug Administration (FDA) has approved TMS applications for treatment of depression and migraine; other therapeutic applications are being investigated. TMS also has a unique role in understanding how the normal brain works, because it can be used to either disengage or activate a brain area for a fraction of a second, allowing scientists to understand its functional role.

To prepare for a TMS scan, make sure to have a good night's sleep before the scan. Do not use any alcoholic beverages for at least 24 hours before the scan. You may be asked to remove your make-up before TMS. The investigators may give you additional instructions. If you were unable to follow any of these instructions, let the investigators know. The purpose of these instructions is to make the TMS scan as safe as possible for you.

The TMS procedure consists of changing into hospital clothes in the laboratory, filling a safety screening form, and sitting in a chair or lying on a bed while one or several TMS coils are placed over your head. The coils send brief magnetic field pulses that induce weak electric currents in the brain. The coils make a clicking sound associated with their operation - you will wear ear plugs so the clicks should not be bothersome. You will wear frames fitted on your head that allow us to localize the stimulated areas in your brain.

Subjects and patients that consider participating in a TMS study should know that TMS is not suitable for everyone. To see a list of our TMS screening questions, click here. People who have electrically, magnetically, or mechanically activated implants (such as cardiac pacemakers or deep brain stimulation devices) should not have TMS because these devices may malfunction as a result of the TMS pulses. Also, those with metal or magnetic pieces in their head (such as clips on blood vessels in the brain or other metal fragments) should not have TMS because the magnetic pulses may cause the metal to move and/or heat up. However, persons with metal dental fillings may have TMS. It is recommended that women who are pregnant do not participate in TMS research, unless there is potential for direct clinical benefit to the participant.

As an extremely rare side effect (less than 1 in 10,000 sessions) even healthy individuals can experience a seizure during TMS. This likelihood is somewhat elevated in subjects with epilepsy and some other clinical conditions. When TMS has been operated within the international safety guidelines, there have not been seizures in healthy subjects. In the unlikely event that a seizure would occur we are prepared to manage the situation. All subjects that have experienced a seizure during TMS have recovered fully. Personnel trained in managing any potential problems will be present throughout the experiment to make sure that you are safe. 

You will be required to keep your head still during TMS for up to 30 minutes at a time. After TMS, some subjects have experienced a headache that may be related to keeping the head still and/or stimulation of the scalp muscles and nerves. If present, this headache it is typically mild and resolves by itself in a few hours, and if needed, responds well to over-the-counter mild analgesics. The study staff will help you find a comfortable head position to make it less likely that you will experience any headache.

You will not be able to wear your own eyeglasses during TMS. If the study requires that you read or view images and you require vision correction, you should inform the investigator when you sign up for the study, and you may be fitted with special eye glasses. It is OK to wear contact lenses during TMS, but if you tend to have dry eyes and/or blink a lot, then the provided special glasses may be more comfortable. Generally, if EEG is recorded with TMS, we ask our subjects to blink as little as possible, because blinking disturbs the EEG recordings.

Since the TMS magnetic fields are strong, you should not bring any electrical devices or credit/debit cards near the TMS equipment. You may be asked to remove metal jewelry or makeup. We will provide a secure place to store your clothes and valuables during the scan.

We will try to make you feel comfortable during TMS. If you feel pain or become uncomfortable at any point during the visit, let the investigators know. They will try to make you more comfortable, and if that does not succeed, they will stop stimulation. You may ask to stop the session at any time for any reason.

If you have any questions or concerns about participating in an a TMS experiment, please do not hesitate to ask the study investigators or staff, or contact the CBS Director Tommi Raij.

How to prepare for an electroencephalography (EEG) visit

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There are no known risks associated with EEG recordings. It is a silent, non-invasive technique. In our center EEG is often recorded simultaneously with TMS.

On the day of the EEG scan, we ask that you wash your hair before arriving at the laboratory with shampoo only (no conditioner) and do not wear any make-up.

The EEG preparation consists of changing into hospital clothes in the laboratory, filling a safety screening form, and sitting in a chair while an EEG cap with many electrodes is fitted to your head. Additional electrodes may be placed close to your eyes, muscles in different body parts, and over your heart. To record the signals, the skin needs to be cleaned and slightly scratched under each electrode, after which EEG electrode paste is applied. This process may be somewhat bothersome. If you cannot tolerate this, we recommend that you do not participate in an EEG scan.

The EEG procedure consists of sitting in a chair or lying on a bed while your brain activity is recorded with the electrodes attached to your skin. You will be required to keep your head still during EEG. The scan usually takes place in a quiet electrically shielded room (ESR). Because EEG is very sensitive to disturbances, you cannot bring any electrical devices such as cell phones, pagers, cameras, or flashlights into the ESR. You may be asked to remove your shoes before entering the ESR.

You may not be able to wear your own eyeglasses during EEG. If the study requires that you read or view images and you require vision correction, you should inform the investigator when you sign up for the study, and you may be fitted with suitable eye glasses. It is OK (and often preferable) to wear contact lenses during EEG. Note that we ask our EEG subjects to blink as little as possible, because blinking disturbs the EEG recordings.

After the study you need to wash your hair to remove the EEG electrode paste.

We will try to make you feel comfortable during the EEG. If you feel pain or become uncomfortable at any point during the visit, let the investigators know. They will try to make you more comfortable, and if that does not succeed, they will stop the scan. You may ask to stop the session at any time for any reason.

If you have any questions or concerns about participating in an EEG experiment, please do not hesitate to ask the study investigators or staff, or contact the CBS Director Tommi Raij.

Gaining Investigator Access to CBS

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Our instruments, laboratory space, and personnel are available for academic investigators to conduct research that requires TMS instrumentation and skills. Our modest user fees (NU login) are strongly subsidized by RIC and the NU Core at Feinberg School of Medicine / Northwestern University. The fees include access to all instruments at CBS and a skilled TMS/EEG Tech.

We encourage any investigator considering to buy their own TMS stimulators, coils, navigators, and compatible EEG/fMRI devices, to talk with us. We can offer cutting-edge equipment, laboratory space, highly trained personnel, and TMS safety support at a fraction of the cost of purchasing and maintaining your own.

To gain access to CBS resources, we require that all investigators conducting research at CBS take our 1-Day TMS Safety Course. This is because TMS is an interventional technique that has a (rare) potential for adverse effects, most notably a seizure. The risk can be effectively mitigated by excluding unsuitable subjects and using safe TMS parameters. The course is offered 4 times per year at no cost to the participants, and covers basic TMS physics and physiology, safety, FDA and IRB issues, and hands-on training. In addition, any investigator participating in a TMS session is required to have an active Basic Life Support (BLS) certificate.

For simple step-by-step instructions on starting a new TMS project at CBS, see our Standard Operating Procedure (SOP) Manual (NU login). For new CBS users outside the Northwestern University, email the CBS Director to receive a copy of the SOP Manual.

Equipment at CBS

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TMS Stimulators

3 x MagPro X100 with MagOption (MagVenture, Farum, Denmark)

2 x Nexstim NBT 1.2 (Nexstim, Helsinki, Finland)

1 x Nexstim NBS 4.3

1 x Nexstim NBS 3.1

1 x Magstim Rapid2 (Magstim, Carmarthenshire, UK)

2 x Magstim Bistim2  = 4 x Magstim 2002

 

TMS Navigators

LOCALITE (Localite GmbH, St Augustin, Germany) - customized for multi-coil support

Nexstim navigators integrated in each Nexstim stimulator

BrainSight (Rogue Research Inc., Montreal, Quebec, Canada)

 

TMS Coils

MagPro: 1 x MC-125 / 1 x MCF-B65 / 2 x C-B60 / 2 x MC-B70 / 1 x MC-B35 / 2 x Cool-B65 / 1 x Cool-B65 A/P / 3 x Cool-B35 (HO, HP) / 1 x Cool-D50 / 1 x Cool-DB80 double-cone coil / 2 x MC-P-B70 / 1 x MCF-P-B65 / 1 x MRi-B91

Magstim: 1 x 70-mm figure-of-eight (9925), 2 x double-cone coil, 2 x 60-mm figure-of-eight branding iron coils, 1 x custom batwing 90-mm figure-of-eight coil

Nexstim: 4 x 70-mm figure-of-eight

TMS Coil Coolers

MagPro: 3 x Cooler for Cool Coils with High-Performance Option (circulating liquid cooling with refrigerator stage)

Other

MagPro: MRI Coil Holder for MagPro MRi-B91 (for simultaneous TMS-MRI)

EEG equipment (TMS- and MRI-compatible)

NeurOne 64 (Mega Electronics, Kuopio, Finland). Allows 64 EEG and 16 bipolar channels, AC and DC recording modes, sampling frequency up to 20 kHz. Includes Synchronization Unit for unaliased TMS-EEG and TMS-MRI recordings (Mega Electronics, Kuopio, Finland). EasyCap 64-channel EEG caps S/M/L with TMS-compatible electrodes (Brain Products GmbH, Gilching, Germany).

Stimulus computers and programs

A stimulus PC desktop running Presentation (Neurobehavioral systems) is available for delivery or auditory and visual stimuli and for recording behavioral responses. You may also use your own stimulus laptop.

MRI access

MRI Siemens 3T Prisma at RIC/Abilitylab (starting 3/2017) or Northwestern University Center for Translational Imaging (CTI). 

TMS Safety Training

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TMS is safe when used correctly, but is an interventional technique with potential for adverse events. Safety training is a prerequisite for access to TMS at CBS. Currently there exist no nationally accepted certification or accreditation for TMS users. At CBS, we recognize two levels of TMS training and accreditation: Basic and Advanced.

Basic level training (1-Day Basic TMS Safety Course) is open to everyone planning TMS studies at CBS. The course prepares you for planning and executing TMS experiments. It allows you to run TMS experiments with on-site support from the CBS TMS/EEG Tech. Specifically, this course will teach you what TMS is, what it can and cannot do, give you basic tools for designing and conducting safe and efficient TMS studies, educate about local policies and FDA regulations, and explain IRB requirements for TMS studies. The focus of this course is on safety; advanced TMS research/clinical applications and techniques are beyond its scope. Everyone involved in planning and delivering TMS must have passed the Basic level training. This includes the PIs that are ultimately responsible for correct TMS parameters and subject safety. The course takes one full day and includes both lectures and hands-on exercises. This course is offered about once every 3 months. Prior to accreditation, all candidates must show Basic Life Support (BLS) certification or corresponding medical training. To request Basic TMS training, contact the course director Tommi Raij. Advance registration is required.

CBS 1-DAY BASIC SAFETY COURSE – PROGRAM (Next date: NN December 2016)

Lectures 8:00 am – 12:00 pm (open to all registered participants)

TMS Physics and Physiology

Equipment: Stimulators, Coils, Navigators, EMG, EEG/fMRI

Safety, FDA and IRB regulations

CBS policies, operations, and lab etiquette

Setting up a TMS study at CBS

Demonstration of a TMS session

 

Hands-on sessions 1:00 – 4:30 pm (limit 10 students per session, repeated on later dates as needed)
MagPro X100 w/MagOption stimulator interface and programming

Single pulse, paired pulse, rTMS settings; Waveform options

TMS coil selection

Motor and phosphene threshold measurement

TMS Navigator/EMG interface and recordings

Auditory/visual stimulus systems and trigger setups

Data transfer

TMS seizure plan

Before the course, participants are expected to read the international TMS safety consensus: Rossi S, Hallet M, Rossini PM, Pascual-Leone A (2009) Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol 120(12):2008-39.

ADVANCED TRAINING

Advanced training is required to run experiments without CBS Tech support (during off-hours and weekends). Each group conducting TMS studies at CBS must include at least one Advanced level member. Moreover, at least one Advanced level person is required to be present in the CBS during every session. Advanced level accreditation may be obtained by participating in advanced TMS fellowship courses, or for users with extensive prior TMS training and experience, by providing the CBS Laboratory Committee proof thereof. Regardless of prior expertise, all Advanced level candidates must have (i) Basic Life Support (BLS) or corresponding training, and (ii) participated in the lecture portion of the CBS Basic course that describes local regulations, policies, operations, lab etiquette, and instrument specific issues. 

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